1
|
Rubulotta F, Blanch Torra L, Naidoo KD, Aboumarie HS, Mathivha LR, Asiri AY, Sarlabous Uranga L, Soussi S. Mechanical Ventilation, Past, Present, and Future. Anesth Analg 2024; 138:308-325. [PMID: 38215710 DOI: 10.1213/ane.0000000000006701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.
Collapse
Affiliation(s)
- Francesca Rubulotta
- From the Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Lluis Blanch Torra
- Department of Critical Care, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Kuban D Naidoo
- Division of Critical Care, University of Witwatersrand, Johannesburg, South Africa
| | - Hatem Soliman Aboumarie
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield Hospitals, London, United Kingdom
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom
| | - Lufuno R Mathivha
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, The Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
| | - Abdulrahman Y Asiri
- Department of Internal Medicine and Critical Care, King Khalid University Medical City, Abha, Saudi Arabia
- Department of Critical Care Medicine, McGill University
| | - Leonardo Sarlabous Uranga
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto
- UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Institut national de la santé et de la recherche médicale (INSERM), Université de Paris Cité, France
| |
Collapse
|
2
|
Seder DB. Implications of Structural Brain Injury in ARDS. Neurocrit Care 2024; 40:40-41. [PMID: 37667078 DOI: 10.1007/s12028-023-01824-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 09/06/2023]
Affiliation(s)
- David B Seder
- Department of Critical Care Services, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| |
Collapse
|
3
|
Damlakhy A, Barham H, Omar M, Khan Z, Elkholy M. Right-to-Left Intra-cardiac Shunt in a COVID-19 Patient Leading to Stroke and Poor Prognosis: A Case Report and Review of the Literature. Cureus 2024; 16:e54421. [PMID: 38510887 PMCID: PMC10954315 DOI: 10.7759/cureus.54421] [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] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
Coronavirus disease 2019 (COVID-19) often presents with a wide range of complications, including respiratory distress, acute respiratory distress syndrome (ARDS), and hypercoagulable states with resultant cerebrovascular incidents. Intra- and extra-pulmonological shunts can further complicate patient courses, leading to persistent hypoxemia and paradoxical emboli, resulting in potentially life-threatening consequences, necessitating a comprehensive, multidisciplinary approach to patient care. Here we present the case of a 73-year-old male who experienced severe persistent hypoxemic respiratory failure, superimposed methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, and stroke with a previously undiagnosed patent foramen ovale (PFO) contributing to his clinical presentation.
Collapse
Affiliation(s)
- Ahmad Damlakhy
- Internal Medicine, Detroit Medical Center/Sinai Grace Hospital/Wayne State University, Detroit, USA
| | - Husam Barham
- Internal Medicine, Balqa Applied University, Al-Salt, JOR
| | - Mohammad Omar
- Internal Medicine, Balqa Applied University, Al-Salt, JOR
| | - Zohaib Khan
- Internal Medicine, Detroit Medical Center/Sinai Grace Hospital/Wayne State University, Detroit, USA
| | - Montaser Elkholy
- Internal Medicine, Detroit Medical Center/Sinai Grace Hospital/Wayne State University, Detroit, USA
| |
Collapse
|
4
|
Sanchez F, Goudelin M, Evrard B, Vignon P. Prevalence and impact of Eustachian valve on the diagnosis of patent foramen ovale in patients ventilated for an acute respiratory distress syndrome. Crit Care 2023; 27:392. [PMID: 37817233 PMCID: PMC10566137 DOI: 10.1186/s13054-023-04670-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Florence Sanchez
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France
- Medical Intensive Care Unit, Brive Hospital, Brive-la-Gaillarde, France
| | - Marine Goudelin
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - Bruno Evrard
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France.
- Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France.
- Réanimation Polyvalente, CHU Dupuytren, 2 Ave. Martin Luther King, 87000, Limoges, France.
| |
Collapse
|
5
|
Lau VI, Mah GD, Wang X, Byker L, Robinson A, Milovanovic L, Alherbish A, Odenbach J, Vadeanu C, Lu D, Smyth L, Rohatensky M, Whiteside B, Gregoire P, Luksun W, van Diepen S, Anderson D, Verma S, Slemko J, Brindley P, Kustogiannis DJ, Jacka M, Shaw A, Wheatley M, Windram J, Opgenorth D, Baig N, Rewa OG, Bagshaw SM, Buchanan BM. Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study. Crit Care Med 2023; 51:1023-1032. [PMID: 36971440 PMCID: PMC10335602 DOI: 10.1097/ccm.0000000000005848] [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] [Indexed: 03/29/2023]
Abstract
OBJECTIVES Studies have suggested intrapulmonary shunts may contribute to hypoxemia in COVID-19 acute respiratory distress syndrome (ARDS) with worse associated outcomes. We evaluated the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia workup for shunt etiology and associations with mortality. DESIGN Prospective, observational cohort study. SETTING Four tertiary hospitals in Edmonton, Alberta, Canada. PATIENTS Adult critically ill, mechanically ventilated, ICU patients admitted with COVID-19 or non-COVID (November 16, 2020, to September 1, 2021). INTERVENTIONS Agitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler ± transesophageal echocardiography assessed for R-L shunts presence. MEASUREMENTS AND MAIN RESULTS Primary outcomes were shunt frequency and association with hospital mortality. Logistic regression analysis was used for adjustment. The study enrolled 226 patients (182 COVID-19 vs 42 non-COVID). Median age was 58 years (interquartile range [IQR], 47-67 yr) and Acute Physiology and Chronic Health Evaluation II scores of 30 (IQR, 21-36). In COVID-19 patients, the frequency of R-L shunt was 31 of 182 COVID patients (17.0%) versus 10 of 44 non-COVID patients (22.7%), with no difference detected in shunt rates (risk difference [RD], -5.7%; 95% CI, -18.4 to 7.0; p = 0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared with those without (54.8% vs 35.8%; RD, 19.0%; 95% CI, 0.1-37.9; p = 0.05). This did not persist at 90-day mortality nor after adjustment with regression. CONCLUSIONS There was no evidence of increased R-L shunt rates in COVID-19 compared with non-COVID controls. R-L shunt was associated with increased in-hospital mortality for COVID-19 patients, but this did not persist at 90-day mortality or after adjusting using logistic regression.
Collapse
Affiliation(s)
- Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Graham D Mah
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Xiaoming Wang
- Health Services Statistical and Analytic Methods, Alberta Health Services, Edmonton, AB, Canada
| | - Leon Byker
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Andrea Robinson
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Lazar Milovanovic
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Aws Alherbish
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Division of Cardiology, Department of Medicine, Faculty of Medicine, and Alberta Health Services, Edmonton, AB, Canada
| | - Jeffrey Odenbach
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cristian Vadeanu
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - David Lu
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Leo Smyth
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mitchell Rohatensky
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Brian Whiteside
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Phillip Gregoire
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Warren Luksun
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Department of Anesthesiology & Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Division of Cardiology, Department of Medicine, Faculty of Medicine, and Alberta Health Services, Edmonton, AB, Canada
| | - Dustin Anderson
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sanam Verma
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Division of Cardiology, Department of Medicine, Faculty of Medicine, and Alberta Health Services, Edmonton, AB, Canada
| | - Jocelyn Slemko
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Peter Brindley
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Demetrios J Kustogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Michael Jacka
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Andrew Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH
| | - Matt Wheatley
- Department of Neurosurgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jonathan Windram
- Division of Cardiology, Department of Medicine, Faculty of Medicine, and Alberta Health Services, Edmonton, AB, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Nadia Baig
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Brian M Buchanan
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| |
Collapse
|
6
|
Hockstein MA, Singam NS, Papolos AI, Kenigsberg BB. The Role of Echocardiography in Extracorporeal Membrane Oxygenation. Curr Cardiol Rep 2023; 25:9-16. [PMID: 36571660 DOI: 10.1007/s11886-022-01827-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) is increasingly used to temporarily support patients in severe circulatory and/or respiratory failure. Echocardiography is a core component of successful ECMO deployment. Herein, we review the role of echocardiography at different phases on extracorporeal support including candidate identification, cannulation, maintenance, complication vigilance, and decannulation. RECENT FINDINGS During cannulation, ultrasound is used to confirm intended vascular access and appropriate inflow cannula positioning. While on ECMO, echocardiographic evaluation of ventricular loading conditions and hemodynamics, cannula positioning, and surveillance for intracardiac or aortic thrombi is needed for complication mitigation. Echocardiography is crucial during all phases of ECMO use. Specific echocardiographic queries depend on the ECMO type, V-V, or V-A, and the specific cannula configuration strategy employed.
Collapse
Affiliation(s)
- Maxwell A Hockstein
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Narayana Sarma Singam
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA. .,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA.
| |
Collapse
|
7
|
Slobod D, Damia A, Leali M, Spinelli E, Mauri T. Pathophysiology and Clinical Meaning of Ventilation-Perfusion Mismatch in the Acute Respiratory Distress Syndrome. BIOLOGY 2022; 12:biology12010067. [PMID: 36671759 PMCID: PMC9855693 DOI: 10.3390/biology12010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023]
Abstract
Acute respiratory distress syndrome (ARDS) remains an important clinical challenge with a mortality rate of 35-45%. It is being increasingly demonstrated that the improvement of outcomes requires a tailored, individualized approach to therapy, guided by a detailed understanding of each patient's pathophysiology. In patients with ARDS, disturbances in the physiological matching of alveolar ventilation (V) and pulmonary perfusion (Q) (V/Q mismatch) are a hallmark derangement. The perfusion of collapsed or consolidated lung units gives rise to intrapulmonary shunting and arterial hypoxemia, whereas the ventilation of non-perfused lung zones increases physiological dead-space, which potentially necessitates increased ventilation to avoid hypercapnia. Beyond its impact on gas exchange, V/Q mismatch is a predictor of adverse outcomes in patients with ARDS; more recently, its role in ventilation-induced lung injury and worsening lung edema has been described. Innovations in bedside imaging technologies such as electrical impedance tomography readily allow clinicians to determine the regional distributions of V and Q, as well as the adequacy of their matching, providing new insights into the phenotyping, prognostication, and clinical management of patients with ARDS. The purpose of this review is to discuss the pathophysiology, identification, consequences, and treatment of V/Q mismatch in the setting of ARDS, employing experimental data from clinical and preclinical studies as support.
Collapse
Affiliation(s)
- Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Critical Care Medicine, McGill University, Montreal, QC H3A 3R1, Canada
| | - Anna Damia
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Marco Leali
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Correspondence:
| |
Collapse
|
8
|
Odenbach J, Dhanoa S, Sebastianski M, Milovanovic L, Robinson A, Mah G, Rewa OG, Bagshaw SM, Buchanan B, Lau VI. Acute Respiratory Distress Syndrome and Shunt Detection With Bubble Studies: A Systematic Review and Meta-Analysis. Crit Care Explor 2022; 4:e0789. [PMID: 36382336 PMCID: PMC9646622 DOI: 10.1097/cce.0000000000000789] [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] [Indexed: 12/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening respiratory injury with multiple physiological sequelae. Shunting of deoxygenated blood through intra- and extrapulmonary shunts may complicate ARDS management. Therefore, we conducted a systematic review to determine the prevalence of sonographically detected shunts, and their association with oxygenation and mortality in patients with ARDS. DATA SOURCES Medical literature analysis and retrieval system online, Excerpta Medica dataBASE, Cochrane Library, and database of abstracts of reviews of effects databases on March 26, 2021. STUDY SELECTION Articles relating to respiratory failure and sonographic shunt detection. DATA EXTRACTION Articles were independently screened and extracted in duplicate. Data pertaining to study demographics and shunt detection were compiled for mortality and oxygenation outcomes. Risk of bias was appraised using the Joanna-Briggs Institute and the Newcastle-Ottawa Scale tools with evidence rating certainty using Grading of Recommendations Assessment, Development and Evaluation methodology. DATA SYNTHESIS From 4,617 citations, 10 observational studies met eligibility criteria. Sonographic detection of right-to-left shunt was present in 21.8% of patients (range, 14.4-30.0%) among included studies using transthoracic, transesophageal, and transcranial bubble Doppler ultrasonographies. Shunt prevalence may be associated with increased mortality (risk ratio, 1.22; 95% CI, 1.01-1.49; p = 0.04, very low certainty evidence) with no difference in oxygenation as measured by Pao2:Fio2 ratio (mean difference, -0.7; 95% CI, -18.6 to 17.2; p = 0.94, very low certainty). CONCLUSIONS Intra- and extrapulmonary shunts are detected frequently in ARDS with ultrasound techniques. Shunts may increase mortality among patients with ARDS, but its association with oxygenation is uncertain.
Collapse
Affiliation(s)
- Jeffrey Odenbach
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Sumeet Dhanoa
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Meghan Sebastianski
- Alberta Strategy for Patient-Orientated Research Knowledge Translation Platform, University of Alberta, Edmonton, AB, Canada
| | - Lazar Milovanovic
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Andrea Robinson
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Graham Mah
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Brian Buchanan
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| |
Collapse
|
9
|
Abstract
Acute respiratory distress syndrome (ARDS) occurs in up to 10% of patients with respiratory failure admitted through the emergency department. Use of noninvasive respiratory support has proliferated in recent years; clinicians must understand the relative merits and risks of these technologies and know how to recognize signs of failure. The cornerstone of ARDS care of the mechanically ventilated patient is low-tidal volume ventilation based on ideal body weight. Adjunctive therapies, such as prone positioning and neuromuscular blockade, may have a role in the emergency department management of ARDS depending on patient and department characteristics.
Collapse
Affiliation(s)
- Alin Gragossian
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
10
|
Millington SJ, Cardinal P, Brochard L. Setting and Titrating Positive End-Expiratory Pressure. Chest 2022; 161:1566-1575. [DOI: 10.1016/j.chest.2022.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/12/2022] [Accepted: 01/28/2022] [Indexed: 12/16/2022] Open
|
11
|
|
12
|
Trifi A, Ouhibi A, Mahdi A, Masseoud L, Seghir E, Meftah A, Sellaouti S, Abdennebi C, Daly F, Touil Y, Abdellatif S, Ben Lakhal S. Shunt in critically ill Covid-19 ARDS patients: Prevalence and impact on outcome (cross-sectional study). J Crit Care 2022; 70:154048. [PMID: 35487113 PMCID: PMC9040705 DOI: 10.1016/j.jcrc.2022.154048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/14/2022] [Accepted: 04/16/2022] [Indexed: 12/04/2022]
Abstract
Purpose To examine critical Covid-19-acute respiratory distress syndrome (C-ARDS) patients requiring mechanical ventilation (MV), using transthoracic echocardiography (TTE) coupled with bubble test (BT), in order to search a right/left shunt. Methods A Cross-sectional and comparative study comparing several parameters according to the presence or not of shunt. Results 75 patients were included. Twenty-three shunts (31%) were detected: patent foramen oval (PFO) type [n=11 (15%)] and trans-pulmonary transit of bubbles (TPBT) [n = 12 (16%)]. The shunt did not affect P/F ratio (P/F=77 vs 81, p=0.97), nor mortality. Conclusion A right/left shunt was detected in a third of studied patients similarly between PFO and TPBT without significant impact on P/F ratio or outcome.
Collapse
Affiliation(s)
- Ahlem Trifi
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia.
| | - Asma Ouhibi
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Asma Mahdi
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Linda Masseoud
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Eya Seghir
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Amal Meftah
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Salim Sellaouti
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Cyrine Abdennebi
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Foued Daly
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Yosr Touil
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Sami Abdellatif
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| | - Salah Ben Lakhal
- Medical ICU, teaching hospital of la Rabta Faculty of medicine, Tunis El Manar University Tunis, Tunisia
| |
Collapse
|
13
|
Sanfilippo F, Palumbo GJ, Bignami E, Pavesi M, Ranucci M, Scolletta S, Pelosi P, Astuto M. Acute Respiratory Distress Syndrome in the Perioperative Period of Cardiac Surgery: Predictors, Diagnosis, Prognosis, Management Options, and Future Directions. J Cardiothorac Vasc Anesth 2022; 36:1169-1179. [PMID: 34030957 PMCID: PMC8141368 DOI: 10.1053/j.jvca.2021.04.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/08/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022]
Abstract
Acute respiratory distress syndrome (ARDS) after cardiac surgery is reported with a widely variable incidence (from 0.4%-8.1%). Cardiac surgery patients usually are affected by several comorbidities, and the development of ARDS significantly affects their prognosis. Herein, evidence regarding the current knowledge in the field of ARDS in cardiac surgery is summarized and is followed by a discussion on therapeutic strategies, with consideration of the peculiar aspects of ARDS after cardiac surgery. Prevention of lung injury during and after cardiac surgery remains pivotal. Blood product transfusions should be limited to minimize the risk, among others, of lung injury. Open lung ventilation strategy (ventilation during cardiopulmonary bypass, recruitment maneuvers, and the use of moderate positive end-expiratory pressure) has not shown clear benefits on clinical outcomes. Clinicians in the intraoperative and postoperative ventilatory settings carefully should consider the effect of mechanical ventilation on cardiac function (in particular the right ventricle). Driving pressure should be kept as low as possible, with low tidal volumes (on predicted body weight) and optimal positive end-expiratory pressure. Regarding the therapeutic options, management of ARDS after cardiac surgery challenges the common approach. For instance, prone positioning may not be easily applicable after cardiac surgery. In patients who develop ARDS after cardiac surgery, extracorporeal techniques may be a valid choice in experienced hands. The use of neuromuscular blockade and inhaled nitric oxide can be considered on a case-by-case basis, whereas the use of aggressive lung recruitment and oscillatory ventilation should be discouraged.
Collapse
Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Catania, Italy.
| | | | - Elena Bignami
- Unit of Anesthesiology, Division of Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marco Pavesi
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Sabino Scolletta
- Department of Urgency and Emergency, of Organ Transplantation, Anesthesia and Intensive Care, Siena University Hospital, Siena, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco”, Catania, Italy,Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| |
Collapse
|
14
|
Petit M, Jullien E, Vieillard-Baron A. Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation. Front Physiol 2022; 12:797252. [PMID: 35095561 PMCID: PMC8795709 DOI: 10.3389/fphys.2021.797252] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).
Collapse
Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Edouard Jullien
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
- *Correspondence: Antoine Vieillard-Baron,
| |
Collapse
|
15
|
Rollas K, Hanci P, Topeli A. Effects of end-expiratory lung volume versus PaO 2 guided PEEP determination on respiratory mechanics and oxygenation in moderate to severe ARDS. Exp Lung Res 2021; 48:12-22. [PMID: 34957895 DOI: 10.1080/01902148.2021.2021326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
There is no ideal method for determination of positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. We compared the effects of end-expiratory lung volume (EELV)-guided versus PaO2-guided PEEP determination on respiratory mechanics and oxygenation during the first 48 hours in moderate to severe ARDS. Twenty-two patients with moderate to severe ARDS admitted to an academic medical ICU were assigned to PaO2-guided (n = 11) or to EELV-guided PEEP determination (n = 11) group. First, an incremental PEEP trial was performed by increasing PEEP by 3 cmH2O steps from 8 to 20 cmH2O and in each step EELV and lung mechanics were measured in both groups. Then, oxygenation and respiratory mechanics were measured under the determined PEEP at 4, 12, 24, and 48th hours. After the incremental PEEP trial, over the 48 hours of the study period, in the EELV-guided group PaO2 and PaO2/FiO2 increased (p = 0.04 and p = 0.02; respectively), whereas they did not change in PaO2-guided group (p = 0.09 and p = 0.27; respectively). In all patients, the median value of EELV change (ΔEELV) during incremental PEEP trial was 25%. In patients with ΔEELV > 25% (n = 11) PaO2, PaO2/FiO2 and Cs increased over time in 48 hours (p = 0.03, p < 0.01, and p = 0.04; respectively), whereas they did not change in those with ΔEELV ≤ 25% (n = 11) (p = 0.73, p = 0.51, and p = 0.73; respectively). Compared to PaO2-guided PEEP determination, EELV-guided PEEP determination resulted in greater improvement in oxygenation over time. Patients who had > 25% improvement in EELV during a PEEP trial had greater improvement in oxygenation and compliance over 48 hours. Supplemental data for this article is available online at.
Collapse
Affiliation(s)
- Kazim Rollas
- Division of Intensive Care Medicine, Department of Anaesthesiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Pervin Hanci
- Division of Intensive Care Medicine, Department of Pulmonology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Arzu Topeli
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| |
Collapse
|
16
|
Dodson BK, Major CK, Grant M, Yoo BS, Goodman BM. Platypnea Orthodeoxia Due to a Patent Foramen Ovale and Intrapulmonary Shunting After Severe COVID-19 Pneumonia. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933975. [PMID: 34697281 PMCID: PMC8559663 DOI: 10.12659/ajcr.933975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patient: Male, 85-year-old
Final Diagnosis: Platypnea orthodeoxia
Symptoms: Dyspnea • orthostatic intolerance
Medication: —
Clinical Procedure: —
Specialty: Infectious Diseases
Collapse
Affiliation(s)
- Blair K Dodson
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - C Kendall Major
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Maxwell Grant
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Byung Soo Yoo
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - B Mitchell Goodman
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| |
Collapse
|
17
|
Rajendram R, Hussain A, Mahmood N, Via G. Dynamic right-to-left interatrial shunt may complicate severe COVID-19. BMJ Case Rep 2021; 14:14/10/e245301. [PMID: 34598966 PMCID: PMC8488708 DOI: 10.1136/bcr-2021-245301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Right-to-left (RTL) interatrial shunt (IAS) may complicate select cases of COVID-19 pneumonia. We describe the use of serial imaging to monitor shunt in critically ill patients. A 52-year-old man presented with COVID-19 pneumonia. Hypoxia worsened despite maximal medical therapy and non-invasive ventilation. On day 8, saline microbubble contrast-enhanced transthoracic echocardiography revealed a patent foramen ovale (PFO) with RTLIAS. Invasive ventilation was initiated the next day. The course was complicated by intermittent severe desaturation without worsening aeration or haemodynamic instability, so PFO closure was considered. However, on day 12, saline microbubble contrast-enhanced transoesophageal echocardiography excluded RTLIAS. The patient was extubated on day 27 and discharged home 12 days later. Thus, RTLIAS may be dynamic and changes can be detected and monitored by serial imaging. Bedside echocardiography with saline microbubble contrast, a simple, minimally invasive bedside test, may be useful in the management of patients with severe hypoxia.
Collapse
Affiliation(s)
- Rajkumar Rajendram
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Arif Hussain
- Department of Cardiovascular Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Naveed Mahmood
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Gabriele Via
- Department of Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
| |
Collapse
|
18
|
Abstract
Acute respiratory distress syndrome (ARDS) is one of the most common severe diseases seen in the clinical setting. With the continuous exploration of ARDS in recent decades, the understanding of ARDS has improved. ARDS is not a simple lung disease but a clinical syndrome with various etiologies and pathophysiological changes. However, in the intensive care unit, ARDS often occurs a few days after primary lung injury or after a few days of treatment for other severe extrapulmonary diseases. Under such conditions, ARDS often progresses rapidly to severe ARDS and is difficult to treat. The occurrence and development of ARDS in these circumstances are thus not related to primary lung injury; the real cause of ARDS may be the “second hit” caused by inappropriate treatment. In view of the limited effective treatments for ARDS, the strategic focus has shifted to identifying potential or high-risk ARDS patients during the early stages of the disease and implementing treatment strategies aimed at reducing ARDS and related organ failure. Future research should focus on the prevention of ARDS.
Collapse
|
19
|
Eskandari S, Jalali P. Relationship between patent foramen ovale and COVID-19 in patients admitted to an intensive care unit. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:725-726. [PMID: 34030947 PMCID: PMC8096169 DOI: 10.1016/j.rec.2021.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/23/2021] [Indexed: 01/11/2023]
Affiliation(s)
- Saber Eskandari
- Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pooya Jalali
- Department of Medicine, Islamic Azad University Tabriz Branch, Tabriz, Iran.
| |
Collapse
|
20
|
Eskandari S, Jalali P. [Relationship between patent foramen ovale and COVID-19 in patients admitted to an intensive care unit]. Rev Esp Cardiol 2021; 74:725-726. [PMID: 34092897 PMCID: PMC8166536 DOI: 10.1016/j.recesp.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Saber Eskandari
- Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Teherán, Irán
| | - Pooya Jalali
- Department of Medicine, Islamic Azad University Tabriz Branch, Teherán, Irán
| |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW Among noninvasive lung imaging techniques that can be employed at the bedside electrical impedance tomography (EIT) and lung ultrasound (LUS) can provide dynamic, repeatable data on the distribution regional lung ventilation and response to therapeutic manoeuvres.In this review, we will provide an overview on the rationale, basic functioning and most common applications of EIT and Point of Care Ultrasound (PoCUS, mainly but not limited to LUS) in the management of mechanically ventilated patients. RECENT FINDINGS The use of EIT in clinical practice is supported by several studies demonstrating good correlation between impedance tomography data and other validated methods of assessing lung aeration during mechanical ventilation. Similarly, LUS also correlates with chest computed tomography in assessing lung aeration, its changes and several pathological conditions, with superiority over other techniques. Other PoCUS applications have shown to effectively complement the LUS ultrasound assessment of the mechanically ventilated patient. SUMMARY Bedside techniques - such as EIT and PoCUS - are becoming standards of the care for mechanically ventilated patients to monitor the changes in lung aeration, ventilation and perfusion in response to treatment and to assess weaning from mechanical ventilation.
Collapse
|
22
|
Reynolds AS, Lee AG, Renz J, DeSantis K, Liang J, Powell CA, Ventetuolo CE, Poor HD. Reply to Chiang and Gupta and to Swenson et al.. Am J Respir Crit Care Med 2021; 203:390-391. [PMID: 33207124 PMCID: PMC7874328 DOI: 10.1164/rccm.202010-3974le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Alison G Lee
- Icahn School of Medicine at Mount Sinai New York, New York
| | - Joshua Renz
- NovaSignal Corp. Los Angeles, California and
| | | | - John Liang
- Icahn School of Medicine at Mount Sinai New York, New York
| | | | | | - Hooman D Poor
- Icahn School of Medicine at Mount Sinai New York, New York
| |
Collapse
|
23
|
Katsanos AH, Palaiodimou L, Zand R, Yaghi S, Kamel H, Navi BB, Turc G, Romoli M, Sharma VK, Mavridis D, Shahjouei S, Catanese L, Shoamanesh A, Vadikolias K, Tsioufis K, Lagiou P, Alexandrov AV, Tsiodras S, Tsivgoulis G. The Impact of SARS-CoV-2 on Stroke Epidemiology and Care: A Meta-Analysis. Ann Neurol 2021; 89:380-388. [PMID: 33219563 PMCID: PMC7753413 DOI: 10.1002/ana.25967] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/15/2020] [Accepted: 11/17/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Emerging data indicate an increased risk of cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and highlight the potential impact of coronavirus disease (COVID-19) on the management and outcomes of acute stroke. We conducted a systematic review and meta-analysis to evaluate the aforementioned considerations. METHODS We performed a meta-analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARS-CoV-2 infection status. We used a random-effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (CIs). RESULTS We identified 18 cohort studies including 67,845 patients. Among patients with SARS-CoV-2, 1.3% (95% CI = 0.9-1.6%, I2 = 87%) were hospitalized for cerebrovascular events, 1.1% (95% CI = 0.8-1.3%, I2 = 85%) for ischemic stroke, and 0.2% (95% CI = 0.1-0.3%, I2 = 64%) for hemorrhagic stroke. Compared to noninfected contemporary or historical controls, patients with SARS-CoV-2 infection had increased odds of ischemic stroke (OR = 3.58, 95% CI = 1.43-8.92, I2 = 43%) and cryptogenic stroke (OR = 3.98, 95% CI = 1.62-9.77, I2 = 0%). Diabetes mellitus was found to be more prevalent among SARS-CoV-2 stroke patients compared to noninfected historical controls (OR = 1.39, 95% CI = 1.00-1.94, I2 = 0%). SARS-CoV-2 infection status was not associated with the likelihood of receiving intravenous thrombolysis (OR = 1.42, 95% CI = 0.65-3.10, I2 = 0%) or endovascular thrombectomy (OR = 0.78, 95% CI = 0.35-1.74, I2 = 0%) among hospitalized ischemic stroke patients during the COVID-19 pandemic. Odds of in-hospital mortality were higher among SARS-CoV-2 stroke patients compared to noninfected contemporary or historical stroke patients (OR = 5.60, 95% CI = 3.19-9.80, I2 = 45%). INTERPRETATION SARS-CoV-2 appears to be associated with an increased risk of ischemic stroke, and potentially cryptogenic stroke in particular. It may also be related to an increased mortality risk. ANN NEUROL 2021;89:380-388.
Collapse
Affiliation(s)
- Aristeidis H. Katsanos
- Division of NeurologyMcMaster University/Population Health Research InstituteHamiltonOntarioCanada
- Second Department of Neurology, Attikon Hospital, School of MedicineNational and Kapodistrian University of AthensAthensGreece
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon Hospital, School of MedicineNational and Kapodistrian University of AthensAthensGreece
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health SystemDanvillePA
| | - Shadi Yaghi
- Department of NeurologyNYU Langone HealthNew YorkNY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of NeurologyWeill Cornell MedicineNew YorkNY
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of NeurologyWeill Cornell MedicineNew YorkNY
| | - Guillaume Turc
- Department of NeurologyParis Psychiatry and Neurosciences University Hospital Group, Sainte Anne HospitalParisFrance
- University of ParisParisFrance
- INSERM U1266ParisFrance
- FHU NeurovascParisFrance
| | - Michele Romoli
- Neurology UnitMaurizio Bufalini HospitalCesenaItaly
- Neurology Clinic, University of Perugia–S. Maria del la Misericordia HospitalPerugiaItaly
| | - Vijay K. Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore and School of MedicineNational University of SingaporeSingapore
| | - Dimitris Mavridis
- Department of Primary EducationUniversity of IoanninaIoanninaGreece
- Faculty of MedicineParis Descartes UniversityParisFrance
| | | | - Luciana Catanese
- Division of NeurologyMcMaster University/Population Health Research InstituteHamiltonOntarioCanada
| | - Ashkan Shoamanesh
- Division of NeurologyMcMaster University/Population Health Research InstituteHamiltonOntarioCanada
| | - Konstantinos Vadikolias
- Department of Neurology, School of MedicineDemocritus University of ThraceAlexandroupolisGreece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration HospitalAthensGreece
| | - Pagona Lagiou
- Department of Hygiene, Epidemiology, and Medical Statistics, School of MedicineNational and Kapodistrian University of AthensAthensGreece
- Department of EpidemiologyHarvard T. H. Chan School of Public HealthBostonMA
| | | | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, Attikon University HospitalNational and Kapodistrian University of AthensAthensGreece
- National Public Health Organization of GreeceAthensGreece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of MedicineNational and Kapodistrian University of AthensAthensGreece
- Department of NeurologyUniversity of Tennessee Health Science CenterMemphisTN
| |
Collapse
|
24
|
Albiero R, Seresini G. Letter by Albiero and Seresini Regarding Article, "Deep Vein Thrombosis in Hospitalized Patients With COVID-19 in Wuhan, China: Prevalence, Risk Factors, and Outcome". Circulation 2021; 143:e31-e32. [PMID: 33523727 DOI: 10.1161/circulationaha.120.050551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Remo Albiero
- Interventional Cardiology Unit, Cardiovascular Department, Sondrio Hospital, Italy
| | - Giuseppe Seresini
- Interventional Cardiology Unit, Cardiovascular Department, Sondrio Hospital, Italy
| |
Collapse
|
25
|
Rajendram R, Hussain A, Mahmood N, Kharal M. Feasibility of using a handheld ultrasound device to detect and characterize shunt and deep vein thrombosis in patients with COVID-19: an observational study. Ultrasound J 2020; 12:49. [PMID: 33252722 PMCID: PMC7702202 DOI: 10.1186/s13089-020-00197-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/17/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported. OBJECTIVES Determine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt. METHODS A handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer. RESULTS After screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17-22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected. CONCLUSION Use of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.
Collapse
Affiliation(s)
- Rajkumar Rajendram
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Arif Hussain
- Department of Cardiac Sciences, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Naveed Mahmood
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mubashar Kharal
- Department of Medicine, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
26
|
Bagate F, Tuffet S, Masi P, Perier F, Razazi K, de Prost N, Carteaux G, Payen D, Mekontso Dessap A. Rescue therapy with inhaled nitric oxide and almitrine in COVID-19 patients with severe acute respiratory distress syndrome. Ann Intensive Care 2020; 10:151. [PMID: 33150525 PMCID: PMC7641257 DOI: 10.1186/s13613-020-00769-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/24/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In COVID-19 patients with severe acute respiratory distress syndrome (ARDS), the relatively preserved respiratory system compliance despite severe hypoxemia, with specific pulmonary vascular dysfunction, suggests a possible hemodynamic mechanism for VA/Q mismatch, as hypoxic vasoconstriction alteration. This study aimed to evaluate the capacity of inhaled nitric oxide (iNO)-almitrine combination to restore oxygenation in severe COVID-19 ARDS (C-ARDS) patients. METHODS We conducted a monocentric preliminary pilot study in intubated patients with severe C-ARDS. Respiratory mechanics was assessed after a prone session. Then, patients received iNO (10 ppm) alone and in association with almitrine (10 μg/kg/min) during 30 min in each step. Echocardiographic and blood gases measurements were performed at baseline, during iNO alone, and iNO-almitrine combination. The primary endpoint was the variation of oxygenation (PaO2/FiO2 ratio). RESULTS Ten severe C-ARDS patients were assessed (7 males and 3 females), with a median age of 60 [52-72] years. Combination of iNO and almitrine outperformed iNO alone for oxygenation improvement. The median of PaO2/FiO2 ratio varied from 102 [89-134] mmHg at baseline, to 124 [108-146] mmHg after iNO (p = 0.13) and 180 [132-206] mmHg after iNO and almitrine (p < 0.01). We found no correlation between the increase in oxygenation caused by iNO-almitrine combination and that caused by proning. CONCLUSION In this pilot study of severe C-ARDS patients, iNO-almitrine combination was associated with rapid and significant improvement of oxygenation. These findings highlight the role of pulmonary vascular function in COVID-19 pathophysiology.
Collapse
Affiliation(s)
- François Bagate
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Samuel Tuffet
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Paul Masi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - François Perier
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Keyvan Razazi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Guillaume Carteaux
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France
| | - Didier Payen
- UFR de Médecine Villemin, Université Paris 7 Paris Cité Sorbonne, Paris, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France. .,Univ Paris Est Créteil, CARMAS, 94010, Créteil, France. .,Univ Paris Est Créteil, INSERM, IMRB, 94 010, Créteil, France.
| |
Collapse
|
27
|
Jensen MP, Le Quesne J, Officer-Jones L, Teodòsio A, Thaventhiran J, Ficken C, Goddard M, Smith C, Menon D, Allinson KSJ. Neuropathological findings in two patients with fatal COVID-19. Neuropathol Appl Neurobiol 2020; 47:17-25. [PMID: 32895961 DOI: 10.1111/nan.12662] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/31/2020] [Accepted: 08/22/2020] [Indexed: 01/23/2023]
Abstract
AIMS To describe the neuropathological findings in two cases of fatal Coronavirus Disease 2019 (COVID-19) with neurological decline. METHODS Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection was confirmed in both patients by reverse transcription polymerase chain reaction (RT-PCR) from nasopharyngeal swabs antemortem. Coronial autopsies were performed on both patients and histological sampling of the brain was undertaken with a variety of histochemical and immunohistochemical stains. RNAscope® in situ hybridization (ISH) using the V-nCoV2019-S probe and RT-PCR SARS-CoV-2 ribonucleic acid (RNA) was performed in paraffin-embedded brain tissue sampled from areas of pathology. RESULTS Case 1 demonstrated severe multifocal cortical infarction with extensive perivascular calcification and numerous megakaryocytes, consistent with a severe multi-territorial cerebral vascular injury. There was associated cerebral thrombotic microangiopathy. Case 2 demonstrated a brainstem encephalitis centred on the dorsal medulla and a subacute regional infarct involving the cerebellar cortex. In both cases, ISH and RT-PCR for SARS-CoV-2 RNA were negative in tissue sampled from the area of pathology. CONCLUSIONS Our case series adds calcifying cerebral cortical infarction with associated megakaryocytes and brainstem encephalitis to the spectrum of neuropathological findings that may contribute to the neurological decompensation seen in some COVID-19 patients. Viral RNA was not detected in post-mortem brain tissue, suggesting that these pathologies may not be a direct consequence of viral neuroinvasion and may represent para-infectious phenomena, relating to the systemic hyperinflammatory and hypercoagulable syndromes that both patients suffered.
Collapse
Affiliation(s)
| | - J Le Quesne
- MRC Toxicology Unit, University of Cambridge, Cambridge, UK.,Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | | | - A Teodòsio
- MRC Toxicology Unit, University of Cambridge, Cambridge, UK
| | - J Thaventhiran
- MRC Toxicology Unit, University of Cambridge, Cambridge, UK
| | - C Ficken
- MRC Toxicology Unit, University of Cambridge, Cambridge, UK
| | - M Goddard
- Department of Pathology, Royal Papworth Hospital, Cambridge, UK
| | - C Smith
- Department of Virology, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - D Menon
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - K S J Allinson
- Department of Pathology, Addenbrooke's Hospital, Cambridge, UK
| |
Collapse
|
28
|
Systemic thromboemboli in patients with Covid-19 may result from paradoxical embolization. Thromb Res 2020; 196:206-208. [PMID: 32906012 PMCID: PMC7462541 DOI: 10.1016/j.thromres.2020.08.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/07/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022]
Abstract
There is increasing evidence that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection causes an unusual pneumonia and a pro-coagulant state that significantly increases the risk of arterial and venous thromboembolism. We hypothesize that, in select patients, some complications of COVID-19 may be due to right-to-left (RTL) shunt. Shunt may be intra-pulmonary, or extra-pulmonary, and can cause paradoxical embolization, hypoxia and platypnoea orthodeoxia. Saline microbubble contrast echocardiography is a minimally invasive, inexpensive, bedside test that can detect, quantify, and define the anatomical substrate of intra-pulmonary and intra-cardiac shunts. The prevalence of patent foramen ovale (PFO) in the general population is high (20–30%) but is even higher in patients who have a stroke (50%). Thus, the striking absence of data on patients with PFO who develop COVID-19 suggests that this is being under-diagnosed. This may be because physicians and sonographers currently feel that screening for shunt is unnecessary. This could be an unintended consequence of guidance from several specialist societies to defer procedures to close PFO until after the pandemic. This may be counterproductive. Patients with shunt may be at particularly high risk of complications from COVID-19 and interventions to minimise RTL shunt could prevent paradoxical embolization and improve hypoxia in select high risk patients with COVID-19. There is significant variation in the neurological sequelae of Coronavirus 2019 (COVID-19). Patent foramen ovale (PFO) is present in 25-30% of the general population. Inter-atrial defects may account for some of the heterogeneity of COVID-19 Echocardiography with microbubble contrast should be used to screen for shunt in patients with COVID-19 Closure of PFO may prevent paradoxical embolism and improve hypoxia in select high risk patients with COVID-19
Collapse
|
29
|
Reversible platypnea-orthodeoxia in COVID-19 acute respiratory distress syndrome survivors. Respir Physiol Neurobiol 2020; 282:103515. [PMID: 32777268 PMCID: PMC7413098 DOI: 10.1016/j.resp.2020.103515] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 01/09/2023]
Abstract
Platypnea-orthodeoxia syndrome (POS) is a rare clinical syndrome characterized by orthostatic oxygen desaturation and positional dyspnea from supine to an upright position. We observed POS in 5 of 20 cases of severe 2019 novel coronavirus (COVID-19) pneumonia, which demonstrated persistently elevated shunt fraction even after liberation from mechanical ventilation. POS was first observed during physiotherapy sessions; median oxygen desaturation was 8 % (range: 8-12 %). Affected individuals were older (median 64 vs 53 years old, p = 0.05) and had lower body mass index (median 24.7 vs 27.6 kg/m2, p = 0.03) compared to those without POS. While POS caused alarm and reduced tolerance to therapy, this phenomenon resolved over a median of 17 days with improvement of parenchymal disease. The mechanisms of POS are likely due to gravitational redistribution of pulmonary blood flow resulting in increased basal physiological shunting and upper zone dead space ventilation due to the predominantly basal distribution of consolidative change and reported vasculoplegia and microthrombi in severe COVID-19 disease.
Collapse
|
30
|
Masi P, Bagate F, d'Humières T, Al-Assaad L, Abou Chakra L, Derumeaux G, Mekontso Dessap A. Is hypoxemia explained by intracardiac or intrapulmonary shunt in COVID-19-related acute respiratory distress syndrome? Ann Intensive Care 2020; 10:108. [PMID: 32761524 PMCID: PMC7407421 DOI: 10.1186/s13613-020-00726-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/30/2020] [Indexed: 01/27/2023] Open
Abstract
Hypoxemia is the main feature of COVID-19-related acute respiratory distress syndrome (C-ARDS), but its underlying mechanisms are debated, especially in patients with low respiratory system elastance (Ers). We assessed 60 critically ill patients hospitalized in our intensive care unit for C-ARDS. We used contrast transthoracic echocardiography to assess patent foramen ovale (PFO) shunt and transpulmonary bubble transit (TPBT). The median Ers was 32 cmH2O/L. PFO shunt was detected in six (10%) patients and TPBT in 12 (20%) patients. PFO shunt and TPBT were similar in patients with higher or lower Ers. In conclusion, PFO and TPBT do not seem to be the main drivers of hypoxemia in C-ARDS, especially in patients with lower Ers.
Collapse
Affiliation(s)
- Paul Masi
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France. .,Groupe de recherche clinique CARMAS, Faculté de Santé, Université Paris Est Créteil, 94010, Créteil, France.
| | - François Bagate
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de recherche clinique CARMAS, Faculté de Santé, Université Paris Est Créteil, 94010, Créteil, France
| | - Thomas d'Humières
- Service de Physiologie, AP-HP, Hôpitaux Universitaires Henri Mondor, 94010, Créteil, France.,INSERM U955, Université Paris-Est, Créteil, France
| | - Lara Al-Assaad
- Service de Physiologie, AP-HP, Hôpitaux Universitaires Henri Mondor, 94010, Créteil, France
| | - Laure Abou Chakra
- Service de Physiologie, AP-HP, Hôpitaux Universitaires Henri Mondor, 94010, Créteil, France
| | - Genevieve Derumeaux
- Service de Physiologie, AP-HP, Hôpitaux Universitaires Henri Mondor, 94010, Créteil, France.,INSERM U955, Université Paris-Est, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de recherche clinique CARMAS, Faculté de Santé, Université Paris Est Créteil, 94010, Créteil, France
| |
Collapse
|
31
|
Albiero R, Seresini G. Letter by Albiero and Seresini Regarding Article, "SARS-CoV-2 and Stroke in a New York Healthcare System". Stroke 2020; 51:e310-e311. [PMID: 32755455 PMCID: PMC7434005 DOI: 10.1161/strokeaha.120.031093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Remo Albiero
- Interventional Cardiology Unit, Cardiovascular Department, Sondrio Hospital, Italy
| | - Giuseppe Seresini
- Interventional Cardiology Unit, Cardiovascular Department, Sondrio Hospital, Italy
| |
Collapse
|
32
|
Abstract
OBJECTIVES To characterize contemporary use of inhaled nitric oxide in pediatric acute respiratory failure and to assess relationships between clinical variables and outcomes. We sought to study the relationship of inhaled nitric oxide response to patient characteristics including right ventricular dysfunction and clinician responsiveness to improved oxygenation. We hypothesize that prompt clinician responsiveness to minimize hyperoxia would be associated with improved outcomes. DESIGN An observational cohort study. SETTING Eight sites of the Collaborative Pediatric Critical Care Research Network. PATIENTS One hundred fifty-one patients who received inhaled nitric oxide for a primary respiratory indication. MEASUREMENTS AND MAIN RESULTS Clinical data were abstracted from the medical record beginning at inhaled nitric oxide initiation and continuing until the earliest of 28 days, ICU discharge, or death. Ventilator-free days, oxygenation index, and Functional Status Scale were calculated. Echocardiographic reports were abstracted assessing for pulmonary hypertension, right ventricular dysfunction, and other cardiovascular parameters. Clinician responsiveness to improved oxygenation was determined. One hundred thirty patients (86%) who received inhaled nitric oxide had improved oxygenation by 24 hours. PICU mortality was 29.8%, while a new morbidity was identified in 19.8% of survivors. Among patients who had echocardiograms, 27.9% had evidence of pulmonary hypertension, 23.1% had right ventricular systolic dysfunction, and 22.1% had an atrial communication. Moderate or severe right ventricular dysfunction was associated with higher mortality. Clinicians responded to an improvement in oxygenation by decreasing FIO2 to less than 0.6 within 24 hours in 71% of patients. Timely clinician responsiveness to improved oxygenation with inhaled nitric oxide was associated with more ventilator-free days but not less cardiac arrests, mortality, or additional morbidity. CONCLUSIONS Clinician responsiveness to improved oxygenation was associated with less ventilator days. Algorithms to standardize ventilator management may improve signal to noise ratios in future trials enabling better assessment of the effect of inhaled nitric oxide on patient outcomes. Additionally, confining studies to more selective patient populations such as those with right ventricular dysfunction may be required.
Collapse
|
33
|
Severity of acute respiratory distress syndrome and echocardiographic findings in clinical practice-an echocardiographic pilot study. Heart Lung 2020; 49:622-625. [PMID: 32220394 DOI: 10.1016/j.hrtlng.2020.02.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUNDS The still high poor outcome of ARDS may be more consequence of circulatory failure than hypoxemia per se. For patients with circulatory failure and ARDS, hemodynamic instability is directly related to ARDS following pulmonary circulation dysfunction and its consequence - right ventricular (RV) dysfunction. OBJECTIVES We hypothesize that in the era of protective ventilation, echocardiographic abnormalities did not parallel ARDS severity, defined by the degree of hypoxemia. METHODS We included 63 consecutively identified mechanically ventilated ARDS patients (1st January 2015 to 31th December 2016). All had echocardiography performed routinely within the first 12 h after ICU admission. RESULTS The analysis included 110 exams. Twenty-eight patients had severe ARDS (28/63, 44.4%), 27 had moderate ARDS (27/63, 42.1%) and 8 mild ARDS (8/63, 12.7%).There was no difference in echocardiographic findings between mild-moderate and severe ARDS. At Pearson's linear regression analysis, TAPSE was directly correlated with LVEF (r = 0.22, p = 0.021) and inversely with sPAP (r = -0.37, p < 0.001). Systolic pulmonary arterial pressure (sPAP) showed a direct correlation with pCO2 (r = 0.30, p = 0.002) and an inverse one with pH (r = -0.35, p < 0.001) and TAPSE (r =-0.35, p < 0.001). CONCLUSIONS Among patients with ARDS, the severity of disease (as indicated by pO2) does not translate into specific cardiac abnormalities, detected by echocardiography. However, RV function (as indicated by TAPSE) is inversely related to pCO2 and to sPAP (which therefore may be underestimated in presence ofRV dysfunction). Our data strongly suggest that in mechanically ventilated ARDS, the interpretation of echo findings should consider also pCO2 values.
Collapse
|
34
|
Villablanca PA, Lemor A, So CY, Kang G, Jain T, Gupta T, Ando T, Mohananey D, Ranka S, Hernandez-Suarez DF, Michel P, Frisoli T, Wang DD, Eng M, O'Neill W, Ramakrishna H. Increased Risk of Perioperative Ischemic Stroke in Patients Who Undergo Noncardiac Surgery with Preexisting Atrial Septal Defect or Patent Foramen Ovale. J Cardiothorac Vasc Anesth 2020; 34:2060-2068. [PMID: 32127264 DOI: 10.1053/j.jvca.2020.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate whether a preoperative diagnosis of atrial septal defect (ASD) or patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery and their outcomes. DESIGN Retrospective cohort analysis. SETTING United States hospitals. PARTICIPANTS Adults patients (≥18 years old) who underwent major noncardiac surgery from 2010 to 2015 were identified using the Healthcare Cost and Utilization Project's National Readmission Database. INTERVENTIONS Preoperative diagnosis of ASD or patent foramen ovale. MEASUREMENTS AND MAIN RESULTS Among the 19,659,161 hospitalizations for major noncardiac surgery analyzed, 12,248 (0.06%) had a preoperative diagnosis of ASD/PFO. Perioperative ischemic stroke occurred in 723 (5.9%) of patients with ASD/PFO and 373,291 (0.02%) of those without ASD/PFO (adjusted odds ratio [aOR], 16.7; 95% confidence interval [CI]: 13.9-20.0). Amongst the different types of noncardiac surgeries, obstetric, endocrine, and skin and burn surgery were associated with higher risk of stroke in patients with pre-existing ASD/PFO. Moreover, patients with ASD/PFO also had an increased in-hospital mortality (aOR, 4.6, 95% CI: 3.6-6.0), 30-day readmission (aOR, 1.2, 95% CI: 1.04-1.38), and 30-day stroke (aOR, 7.2, 95% CI: 3.1-16.6). After adjusting for atrial fibrillation, ischemic stroke remained significantly high in the ASD/PFO group (aOR: 23.7, 95%CI 19.4-28.9), as well as in-hospital mortality (aOR: 5.6, 95% CI 4.1-7.7), 30-day readmission (aOR: 1.19, 95%CI 1.0-1.4), and 30-day stroke (aOR: 9.3, 95% CI 3.7-23.6). CONCLUSIONS Among adult patients undergoing major noncardiac surgery, pre-existing ASD/PFO is associated with increased risk of perioperative ischemic stroke, in-hospital mortality, 30-day stroke, and 30-day readmission after surgery.
Collapse
Affiliation(s)
| | - Alejandro Lemor
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI; Universidad de San Martín de Porres, Facultad de Medicina, Centro de Investigación de Epidemiología Clínica y Medicina Basada en la Evidencia, Lima, Peru
| | - Chak-Yu So
- Universidad de San Martín de Porres, Facultad de Medicina, Centro de Investigación de Epidemiología Clínica y Medicina Basada en la Evidencia, Lima, Peru; Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - Guson Kang
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Tarun Jain
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Tanush Gupta
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Tomo Ando
- Department of Cardiology, Wayne State University/Detroit Medical Center, Detroit, MI
| | | | - Sagar Ranka
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Dagmar F Hernandez-Suarez
- Division of Cardiovascular Medicine, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR
| | - Pablo Michel
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Tiberio Frisoli
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Marvin Eng
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - William O'Neill
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
| |
Collapse
|
35
|
Himebauch AS, Yehya N, Wang Y, McGowan FX, Mercer-Rosa L. New or Persistent Right Ventricular Systolic Dysfunction Is Associated With Worse Outcomes in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2020; 21:e121-e128. [PMID: 31851127 PMCID: PMC11215761 DOI: 10.1097/pcc.0000000000002206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The trajectory and importance of right ventricular systolic function and pulmonary hypertension during the course of pediatric acute respiratory distress syndrome are unknown. We hypothesized that new or persistent right ventricular systolic dysfunction and pulmonary hypertension would be associated with worse patient outcomes. DESIGN Retrospective, single-center cohort study. SETTING Tertiary care, university-affiliated PICU. PATIENTS Children who had at least two echocardiograms less than 8 days following pediatric acute respiratory distress syndrome diagnosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between July 1, 2012, and April 30, 2018, 74 children met inclusion criteria. The first echocardiogram was performed a median of 0.61 days (interquartile range, 0.36-0.94 d) and the second echocardiogram was performed a median of 2.57 days (interquartile range, 1.67-3.63 d) after pediatric acute respiratory distress syndrome diagnosis. Univariate analyses showed that new or persistent right ventricular systolic dysfunction as defined by global longitudinal strain or free wall strain was associated with a greater number of ICU days in survivors (global longitudinal strain p = 0.04, free wall strain p = 0.04), lower ventilator-free days at 28 days (global longitudinal strain p = 0.03, free wall strain p = 0.01), and higher rate of PICU death (global longitudinal strain p = 0.046, free wall strain p = 0.01). Mixed-effects multivariate modeling showed that right ventricular global longitudinal strain and right ventricular fractional area change stayed relatively constant over the course of the first 8 days in nonsurvivors and that there was a linear improvement in global longitudinal strain (p = 0.037) and fractional area change (p = 0.05) in survivors. Worsening right ventricular dysfunction at the time of repeat echocardiogram as defined by global longitudinal strain and free wall strain were independently associated with decreased probability of extubation (subdistribution hazard ratio, 0.30 [0.14-0.67]; p = 0.003 and subdistribution hazard ratio, 0.47 [0.23-0.98]; p = 0.043, respectively). In univariate and multivariate analyses, pulmonary hypertension had no significant associations with outcomes in his cohort. CONCLUSIONS New or persistent right ventricular systolic dysfunction over the first week following pediatric acute respiratory distress syndrome onset is associated with worse patient outcomes, including decreased probability of extubation and higher PICU mortality.
Collapse
Affiliation(s)
- Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yan Wang
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Francis X McGowan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Laura Mercer-Rosa
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
36
|
Chen L, Del Sorbo L, Grieco DL, Junhasavasdikul D, Rittayamai N, Soliman I, Sklar MC, Rauseo M, Ferguson ND, Fan E, Richard JCM, Brochard L. Potential for Lung Recruitment Estimated by the Recruitment-to-Inflation Ratio in Acute Respiratory Distress Syndrome. A Clinical Trial. Am J Respir Crit Care Med 2020; 201:178-187. [DOI: 10.1164/rccm.201902-0334oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Lu Chen
- Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, and
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology and Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Domenico L. Grieco
- Istituto di Anestesia e Rianimazione, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Nuttapol Rittayamai
- Division of Respiratory Diseases and Tuberculosis, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ibrahim Soliman
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Michael C. Sklar
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Michela Rauseo
- Anestesia e Rianimazione, Ospedali Riuniti di Foggia, Foggia, Italy; and
| | - Niall D. Ferguson
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology and Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eddy Fan
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology and Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Laurent Brochard
- Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, and
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
37
|
Sugiyama MG, Mintsopoulos V, Raheel H, Goldenberg NM, Batt JE, Brochard L, Kuebler WM, Leong-Poi H, Karshafian R, Lee WL. Lung Ultrasound and Microbubbles Enhance Aminoglycoside Efficacy and Delivery to the Lung in Escherichia coli-induced Pneumonia and Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2019; 198:404-408. [PMID: 29638143 DOI: 10.1164/rccm.201711-2259le] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Michael G Sugiyama
- 1 University of Toronto Toronto, Ontario, Canada.,2 St. Michael's Hospital Toronto, Ontario, Canada
| | - Victoria Mintsopoulos
- 1 University of Toronto Toronto, Ontario, Canada.,2 St. Michael's Hospital Toronto, Ontario, Canada
| | - Hira Raheel
- 1 University of Toronto Toronto, Ontario, Canada.,2 St. Michael's Hospital Toronto, Ontario, Canada
| | | | - Jane E Batt
- 1 University of Toronto Toronto, Ontario, Canada.,2 St. Michael's Hospital Toronto, Ontario, Canada
| | - Laurent Brochard
- 1 University of Toronto Toronto, Ontario, Canada.,2 St. Michael's Hospital Toronto, Ontario, Canada
| | - Wolfgang M Kuebler
- 2 St. Michael's Hospital Toronto, Ontario, Canada.,3 Charité - Universitätsmedizin Berlin Berlin, Germany and
| | - Howard Leong-Poi
- 1 University of Toronto Toronto, Ontario, Canada.,2 St. Michael's Hospital Toronto, Ontario, Canada
| | | | - Warren L Lee
- 1 University of Toronto Toronto, Ontario, Canada.,2 St. Michael's Hospital Toronto, Ontario, Canada
| |
Collapse
|
38
|
Deana C, Conangla L, Vetrugno L, Saltarini M, Buttera S, Bove T, Bassi F, De Monte A. Persistent hypoxemia after an asthma attack. Ultrasound J 2019; 11:6. [PMID: 31359291 PMCID: PMC6638612 DOI: 10.1186/s13089-019-0121-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/27/2019] [Indexed: 02/07/2023] Open
Abstract
The presence of an unknown intracardiac shunt due to a patent foramen ovale may be an unusual cause of hypoxemia. We report the case of a patient who presented persistent hypoxemia after an adequate treatment for a severe asthma attack requiring intensive care unit admission. The patient underwent a transthoracic microbubbles contrast echocardiography that showed a massive patent foramen ovale. The favorable clinical course and the absence of major signs and symptoms related to patent foramen ovale allowed a conservative approach with a follow-up program. Patent foramen ovale should be suspected in case of persistent hypoxemia after a severe asthma attack had resolved.
Collapse
Affiliation(s)
- Cristian Deana
- Anesthesiology and Intensive Care 1, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata-Udine, P.le S.Maria Della Misericordia n. 15, 33100, Udine, Italy.
| | - Laura Conangla
- Primary Care Service Barcelonès Nord i Maresme, Catalan Health Institute, Barcelona, Spain
| | - Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, P.le S. Maria Della Misericordia n.15, 33100, Udine, Italy
| | - Massimiliano Saltarini
- Anesthesiology and Intensive Care 1, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata-Udine, P.le S.Maria Della Misericordia n. 15, 33100, Udine, Italy
| | - Stefania Buttera
- Anesthesiology and Intensive Care 2, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata-Udine, P.le S.Maria Della Misericordia n. 15, 33100, Udine, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, P.le S. Maria Della Misericordia n.15, 33100, Udine, Italy
| | - Flavio Bassi
- Anesthesiology and Intensive Care 2, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata-Udine, P.le S.Maria Della Misericordia n. 15, 33100, Udine, Italy
| | - Amato De Monte
- Anesthesiology and Intensive Care 1, Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata-Udine, P.le S.Maria Della Misericordia n. 15, 33100, Udine, Italy
| |
Collapse
|
39
|
Abstract
We present the case of a critically ill woman whose dialysis line was noted to be circulating bright red blood. Located in the right internal jugular vein, the line had previously been working normally with the change occurring shortly after the patient was liberated from positive pressure mechanical ventilation. An arterial malposition was ruled out and subsequent investigations revealed the presence of a left-sided partial anomalous pulmonary venous connection (PAPVC) that had been previously undiagnosed. The identification of a left-sided PAPVC from blood gas measurements taken from a right internal jugular vein dialysis catheter in this case provides an informative opportunity to consider the intricate physiological relationship between the respiratory and cardiovascular systems in critically ill patients requiring invasive procedures and treatments.
Collapse
Affiliation(s)
- Diana Elena Amariei
- Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Robert Michael Reed
- Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
40
|
Petitjeans F, Pichot C, Ghignone M, Quintin L. Building on the Shoulders of Giants: Is the use of Early Spontaneous Ventilation in the Setting of Severe Diffuse Acute Respiratory Distress Syndrome Actually Heretical? Turk J Anaesthesiol Reanim 2018; 46:339-347. [PMID: 30263856 DOI: 10.5152/tjar.2018.01947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/13/2018] [Indexed: 12/14/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is not a failure of the neurological command of the ventilatory muscles or of the ventilatory muscles; it is an oxygenation defect. As positive pressure ventilation impedes the cardiac function, paralysis under general anaesthesia and controlled mandatory ventilation should be restricted to the interval needed to control the acute cardio-ventilatory distress observed upon admission into the critical care unit (CCU; "salvage therapy" during "shock state"). Current management of early severe diffuse ARDS rests on a prolonged interval of controlled mechanical ventilation with low driving pressure, paralysis (48 h, too often overextended), early proning and positive end-expiratory pressure (PEEP). Therefore, the time interval between arrival to the CCU and switching to spontaneous ventilation (SV) is not focused on normalizing the different factors involved in the pathophysiology of ARDS: fever, low cardiac output, systemic acidosis, peripheral shutdown (local acidosis), supine position, hypocapnia (generated by hyperpnea and tachypnea), sympathetic activation, inflammation and agitation. Then, the extended period of controlled mechanical ventilation with paralysis under general anaesthesia leads to CCU-acquired pathology, including low cardiac output, myoneuropathy, emergence delirium and nosocomial infection. The stabilization of the acute cardio-ventilatory distress should primarily itemize the pathophysiological conditions: fever control, improved micro-circulation and normalized local acidosis, 'upright' position, minimized hypercapnia, sympathetic de-activation (normalized sympathetic activity toward baseline levels resulting in improved micro-circulation with alpha-2 agonists administered immediately following optimized circulation and endotracheal intubation), lowered inflammation and 'cooperative' sedation without respiratory depression evoked by alpha-2 agonists. Normalised metabolic, circulatory and ventilatory demands will allow one to single out the oxygenation defect managed with high PEEP (diffuse recruitable ARDS) under early spontaneous ventilation (airway pressure release ventilation+SV or low-pressure support). Assuming an improved overall status, PaO2/FiO2≥150-200 allows for extubation and continuous non-invasive ventilation. Such fast-tracking may avoid most of the CCU-acquired pathologies. Evidence-based demonstration is required.
Collapse
|
41
|
Acute life-threatening hypoxemia during mechanical ventilation. Curr Opin Crit Care 2018; 23:541-548. [PMID: 29016366 DOI: 10.1097/mcc.0000000000000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW To describe current evidence-based practice in the management of acute life-threatening hypoxemia in mechanically ventilated patients and some of the methods used to individualize the care of the patient. RECENT FINDINGS Patients with acute life-threatening hypoxemia will often meet criteria for severe ARDS, for which there are only a few treatment strategies that have been shown to improve survival outcomes. Recent findings have increased our knowledge of the physiological effects of spontaneous breathing and the application of PEEP. Additionally, the use of advanced bedside monitoring has a promising future in the management of hypoxemic patients to fine-tune the ventilator and to evaluate the individual patient response to therapy. SUMMARY Treating the patient with acute life-threatening hypoxemia during mechanical ventilation should begin with an evidence-based approach, with the goal of improving oxygenation and minimizing the harmful effects of mechanical ventilation. The use of advanced monitoring and the application of simple maneuvers at the bedside may assist clinicians to better individualize treatment and improve clinical outcomes.
Collapse
|
42
|
Huang SJ, Nalos M, Smith L, Rajamani A, McLean AS. The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research. Intensive Care Med 2018; 44:868-883. [PMID: 29789861 DOI: 10.1007/s00134-018-5211-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/05/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study. METHODS Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized. RESULTS Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices. CONCLUSIONS TAPSE seemed to be the most popular index in the last 2-3 years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.
Collapse
Affiliation(s)
- Stephen J Huang
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
| | - Marek Nalos
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Louise Smith
- Cardiovascular Ultrasound Laboratory, Intensive Care Unit, Nepean Hospital, Sydney, NSW, Australia
| | - Arvind Rajamani
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Anthony S McLean
- Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
43
|
Petitjeans F, Leroy S, Pichot C, Geloen A, Ghignone M, Quintin L. Hypothesis: Fever control, a niche for alpha-2 agonists in the setting of septic shock and severe acute respiratory distress syndrome? Temperature (Austin) 2018; 5:224-256. [PMID: 30393754 PMCID: PMC6209424 DOI: 10.1080/23328940.2018.1453771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 03/11/2018] [Indexed: 12/12/2022] Open
Abstract
During severe septic shock and/or severe acute respiratory distress syndrome (ARDS) patients present with a limited cardio-ventilatory reserve (low cardiac output and blood pressure, low mixed venous saturation, increased lactate, low PaO2/FiO2 ratio, etc.), especially when elderly patients or co-morbidities are considered. Rescue therapies (low dose steroids, adding vasopressin to noradrenaline, proning, almitrine, NO, extracorporeal membrane oxygenation, etc.) are complex. Fever, above 38.5-39.5°C, increases both the ventilatory (high respiratory drive: large tidal volume, high respiratory rate) and the metabolic (increased O2 consumption) demands, further limiting the cardio-ventilatory reserve. Some data (case reports, uncontrolled trial, small randomized prospective trials) suggest that control of elevated body temperature ("fever control") leading to normothermia (35.5-37°C) will lower both the ventilatory and metabolic demands: fever control should simplify critical care management when limited cardio-ventilatory reserve is at stake. Usually fever control is generated by a combination of general anesthesia ("analgo-sedation", light total intravenous anesthesia), antipyretics and cooling. However general anesthesia suppresses spontaneous ventilation, making the management more complex. At variance, alpha-2 agonists (clonidine, dexmedetomidine) administered immediately following tracheal intubation and controlled mandatory ventilation, with prior optimization of volemia and atrio-ventricular conduction, will reduce metabolic demand and facilitate normothermia. Furthermore, after a rigorous control of systemic acidosis, alpha-2 agonists will allow for accelerated emergence without delirium, early spontaneous ventilation, improved cardiac output and micro-circulation, lowered vasopressor requirements and inflammation. Rigorous prospective randomized trials are needed in subsets of patients with a high fever and spiraling toward refractory septic shock and/or presenting with severe ARDS.
Collapse
Affiliation(s)
- F. Petitjeans
- Critical Care, Hôpital d'Instruction des Armées Desgenettes, Lyon, France
| | - S. Leroy
- Pediatric Emergency Medicine, Hôpital Avicenne, Paris-Bobigny, France
| | - C. Pichot
- Critical Care, Hôpital d'Instruction des Armées Desgenettes, Lyon, France
| | - A. Geloen
- Physiology, INSA de Lyon (CARMeN, INSERM U 1060), Lyon-Villeurbanne, France
| | - M. Ghignone
- Critical Care, JF Kennedy Hospital North Campus, WPalm Beach, Fl, USA
| | - L. Quintin
- Critical Care, Hôpital d'Instruction des Armées Desgenettes, Lyon, France
| |
Collapse
|
44
|
Optimization of Positive End-Expiratory Pressure Targeting the Best Arterial Oxygen Transport in the Acute Respiratory Distress Syndrome: The OPTIPEP Study. ASAIO J 2018; 63:450-455. [PMID: 27984319 DOI: 10.1097/mat.0000000000000496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The optimal setting for positive end-expiratory pressure (PEEP) in mechanical ventilation remains controversial in the treatment of acute respiratory distress syndrome (ARDS). The aim of this study was to determine the optimum PEEP level in ARDS, which we defined as the level that allowed the best arterial oxygen delivery (DO2). We conducted a physiologic multicenter prospective study on patients who suffering from ARDS according to standard definition and persistent after 6 hours of ventilation. The PEEP was set to 6 cm H2O at the beginning of the test and then was increased by 2 cm H2O after at least 15 minutes of being stabilized until the plateau pressure achieved 30 cm H2O. At each step, the cardiac output was measured by transesophageal echocardiography and gas blood was sampled. We were able to determine the optimal PEEP for 12 patients. The ratio of PaO2/FiO2 at inclusion was 131 ± 40 with a mean FiO2 of 71 ± 3%. The optimal PEEP level was lower than the higher PEEP despite a constant increase in SaO2. The optimal PEEP levels varied between 8 and 18 cm H2O. Our results show that in patients with ARDS the optimal PEEP differs between each patient and require being determined with monitoring.
Collapse
|
45
|
Acute Right Ventricular Dysfunction in Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8217105. [PMID: 29201914 PMCID: PMC5671685 DOI: 10.1155/2017/8217105] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/13/2017] [Accepted: 09/18/2017] [Indexed: 02/07/2023]
Abstract
The role of the left ventricle in ICU patients with circulatory shock has long been considered. However, acute right ventricle (RV) dysfunction causes and aggravates many common critical diseases (acute respiratory distress syndrome, pulmonary embolism, acute myocardial infarction, and postoperative cardiac surgery). Several supportive therapies, including mechanical ventilation and fluid management, can make RV dysfunction worse, potentially exacerbating shock. We briefly review the epidemiology, pathophysiology, diagnosis, and recommendations to guide management of acute RV dysfunction in ICU patients. Our aim is to clarify the complex effects of mechanical ventilation, fluid therapy, vasoactive drug infusions, and other therapies to resuscitate the critical patient optimally.
Collapse
|
46
|
Radermacher P, Maggiore SM, Mercat A. FiftyYears ofResearch inARDS.Gas Exchange in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:964-984. [DOI: 10.1164/rccm.201610-2156so] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Peter Radermacher
- Institute of Anaesthesiological Pathophysiology and Process Engineering, University Medical School, Ulm, Germany
| | - Salvatore Maurizio Maggiore
- Section of Anesthesia, Analgesia, Perioperative, and Intensive Care, Department of Medical, Oral, and Biotechnological Sciences, School of Medicine and Health Sciences, “SS. Annunziata” Hospital, “Gabriele d’Annunzio” University of Chieti-Pescara, Chieti, Italy; and
| | - Alain Mercat
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France
| |
Collapse
|
47
|
Pham T, Brochard LJ, Slutsky AS. Mechanical Ventilation: State of the Art. Mayo Clin Proc 2017; 92:1382-1400. [PMID: 28870355 DOI: 10.1016/j.mayocp.2017.05.004] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/03/2017] [Accepted: 05/01/2017] [Indexed: 02/07/2023]
Abstract
Mechanical ventilation is the most used short-term life support technique worldwide and is applied daily for a diverse spectrum of indications, from scheduled surgical procedures to acute organ failure. This state-of-the-art review provides an update on the basic physiology of respiratory mechanics, the working principles, and the main ventilatory settings, as well as the potential complications of mechanical ventilation. Specific ventilatory approaches in particular situations such as acute respiratory distress syndrome and chronic obstructive pulmonary disease are detailed along with protective ventilation in patients with normal lungs. We also highlight recent data on patient-ventilator dyssynchrony, humidified high-flow oxygen through nasal cannula, extracorporeal life support, and the weaning phase. Finally, we discuss the future of mechanical ventilation, addressing avenues for improvement.
Collapse
Affiliation(s)
- Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.
| |
Collapse
|
48
|
Narendra DK, Hess DR, Sessler CN, Belete HM, Guntupalli KK, Khusid F, Carpati CM, Astiz ME, Raoof S. Update in Management of Severe Hypoxemic Respiratory Failure. Chest 2017; 152:867-879. [PMID: 28716645 DOI: 10.1016/j.chest.2017.06.039] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/17/2017] [Accepted: 06/25/2017] [Indexed: 02/07/2023] Open
Abstract
Mortality related to severe-moderate and severe ARDS remains high. We searched the literature to update this topic. We defined severe hypoxemic respiratory failure as Pao2/Fio2 < 150 mm Hg (ie, severe-moderate and severe ARDS). For these patients, we support setting the ventilator to a tidal volume of 4 to 8 mL/kg predicted body weight (PBW), with plateau pressure (Pplat) ≤ 30 cm H2O, and initial positive end-expiratory pressure (PEEP) of 10 to 12 cm H2O. To promote alveolar recruitment, we propose increasing PEEP in increments of 2 to 3 cm provided that Pplat remains ≤ 30 cm H2O and driving pressure does not increase. A fluid-restricted strategy is recommended, and nonrespiratory causes of hypoxemia should be considered. For patients who remain hypoxemic after PEEP optimization, neuromuscular blockade and prone positioning should be considered. Profound refractory hypoxemia (Pao2/Fio2 < 80 mm Hg) after PEEP titration is an indication to consider extracorporeal life support. This may necessitate early transfer to a center with expertise in these techniques. Inhaled vasodilators and nontraditional ventilator modes may improve oxygenation, but evidence for improved outcomes is weak.
Collapse
Affiliation(s)
- Dharani Kumari Narendra
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Dean R Hess
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Curtis N Sessler
- Division of Pulmonary Diseases and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Habtamu M Belete
- Department of Medicine, Lenox Hill and Northwell Hofstra School of Medicine, New York, NY
| | - Kalpalatha K Guntupalli
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Felix Khusid
- Respiratory Therapy and Pulmonary Physiology Center, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | | | - Mark Elton Astiz
- Departments of Internal Medicine and Critical Care Medicine, Lenox Hill Hospital, New York, NY
| | - Suhail Raoof
- Division of Pulmonary Medicine, Lenox Hill Hospital, and Hofstra Northwell School of Medicine, New York, NY.
| |
Collapse
|
49
|
Pragliola C, Di Michele S, Galzerano D. A Case of Shunting Postoperative Patent Foramen Ovale Under Mechanical Ventilation Controlled by Different Ventilator Settings. Clin Pract 2017; 7:969. [PMID: 28855978 PMCID: PMC5558089 DOI: 10.4081/cp.2017.969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/07/2017] [Accepted: 07/19/2017] [Indexed: 11/23/2022] Open
Abstract
A 56-year old male with ischemic heart disease and an unremarkable preoperative echocardiogram underwent surgical coronary revascularization. An intraoperative post pump trans-esophageal echocardiogram (TOE) performed while the patient was being ventilated at a positive end expiratory pressure (PEEP) of 8 cm H2O demonstrated a right to left interatrial shunt across a patent foramen ovale (PFO). Whereas oxygen saturation was normal, a reduction of the PEEP to 3 cm H2O led to the complete resolution of the shunt with no change in arterial blood gases. Attempts to increase the PEEP level above 3 mmHg resulted in recurrence of the interatrial shunt. The remaining of the TEE was unremarkable. Mechanical ventilation, particularly with PEEP, causes an increase in intrathoracic pressure. The resulting rise in right atrial pressure, mostly during inspiration, may unveil and pop open an unrecognized PFO, thus provoking a right to left shunt across a seemingly intact interatrial septum. This phenomenon increases the risk of paradoxical embolism and can lead to hypoxemia. The immediate management would be to adjust the ventilatory settings to a lower PEEP level. A routine search for a PFO should be performed in ventilated patients who undergo a TEE.
Collapse
Affiliation(s)
- Claudio Pragliola
- The Heart Centre, King Faisal Specialist Hospital and Research Centre, Ryadh, Saudi Arabia
| | - Sara Di Michele
- Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, La Sapienza University, Roma, Italy
| | - Domenico Galzerano
- The Heart Centre, King Faisal Specialist Hospital and Research Centre, Ryadh, Saudi Arabia
| |
Collapse
|
50
|
Intracardiac Right-to-Left Shunt Impeding Liberation From Veno-Venous Extracorporeal Membrane Oxygenation: Two Case Studies. Crit Care Med 2017; 44:e583-6. [PMID: 26807685 DOI: 10.1097/ccm.0000000000001619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Veno-venous extracorporeal membrane oxygenation is an increasingly used form of advanced respiratory support, but its effects on the physiology of the right heart are incompletely understood. We seek to illustrate the impact of veno-venous extracorporeal membrane oxygenation return blood flow upon the right atrium by considering the physiologic effects during interatrial shunting. PATIENTS Two veno-venous extracorporeal membrane oxygenation patients in whom an extracorporeal membrane oxygenation induced right-to-left interatrial shunt appears to have created a barrier to liberation from extracorporeal support. CONCLUSIONS Veno-venous extracorporeal membrane oxygenation return flow generates a high-pressure jet that has potential to exert focal pressure upon the intra-atrial septum. In patients with potential for interatrial flow, this may lead to a right-to-left shunt, which becomes physiologically apparent only when sweep gas flow is ceased.
Collapse
|