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Shao S, Wu Z, Wang Y, Wang Y, Wang Z, Ye H, Zhao H. Esophageal pressure monitoring and its clinical significance in severe blast lung injury. Front Bioeng Biotechnol 2024; 12:1280679. [PMID: 38784763 PMCID: PMC11112033 DOI: 10.3389/fbioe.2024.1280679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/22/2024] [Indexed: 05/25/2024] Open
Abstract
Background The incidence of blast lung injury (BLI) has been escalating annually due to military conflicts and industrial accidents. Currently, research into these injuries predominantly uses animal models. Despite the availability of various models, there remains a scarcity of studies focused on monitoring respiratory mechanics post-BLI. Consequently, our objective was to develop a model for monitoring esophageal pressure (Pes) following BLI using a biological shock tube (BST), aimed at providing immediate and precise monitoring of respiratory mechanics parameters post-injury. Methods Six pigs were subjected to BLI using a BST, during which Pes was monitored. We assessed vital signs; conducted blood gas analysis, hemodynamics evaluations, and lung ultrasound; and measured respiratory mechanics before and after the inflicted injury. Furthermore, the gross anatomy of the lungs 3 h post-injury was examined, and hematoxylin and eosin staining was conducted on the injured lung tissues for further analysis. Results The pressure in the experimental section of the BST reached 402.52 ± 17.95 KPa, with a peak pressure duration of 53.22 ± 1.69 ms. All six pigs exhibited an anatomical lung injury score ≥3, and pathology revealed classic signs of severe BLI. Post-injury vital signs showed an increase in HR and SI, along with a decrease in MAP (p < 0.05). Blood gas analyses indicated elevated levels of Lac, CO2-GAP, A-aDO2, HB, and HCT and reduced levels of DO2, OI, SaO2, and OER (p < 0.05). Hemodynamics and lung ultrasonography findings showed increased ELWI, PVPI, SVRI, and lung ultrasonography scores and decreased CI, SVI, GEDI, and ITBI (p < 0.05). Analysis of respiratory mechanics revealed increased Ppeak, Pplat, Driving P, MAP, PEF, Ri, lung elastance, MP, Ptp, Ppeak - Pplat, and ΔPes, while Cdyn, Cstat, and time constant were reduced (p < 0.05). Conclusion We have successfully developed a novel respiratory mechanics monitoring model for severe BLI. This model is reliable, repeatable, stable, effective, and user-friendly. Pes monitoring offers a non-invasive and straightforward alternative to blood gas analysis, facilitating early clinical decision-making. Our animal study lays the groundwork for the early diagnosis and management of severe BLI in clinical settings.
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Affiliation(s)
- Shifeng Shao
- Department of ICU, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhengbin Wu
- Department of ICU, Daping Hospital, Army Medical University, Chongqing, China
| | - Yi Wang
- The Fifth Outpatient Clinic, Western Theater General Hospital, Chengdu, China
| | - Yaoli Wang
- Department of ICU, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhen Wang
- Department of ICU, Daping Hospital, Army Medical University, Chongqing, China
| | - Huan Ye
- Department of Rehabilitation, The Third People’s Hospital of Chengdu, Chengdu, China
| | - Hui Zhao
- Institute for Traffic Medicine, Daping Hospital, Army Medical University, Chongqing, China
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2
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Guervilly C, Fournier T, Chommeloux J, Arnaud L, Pinglis C, Baumstarck K, Boucekine M, Valera S, Sanz C, Adda M, Bobot M, Daviet F, Gragueb-Chatti I, Forel JM, Roch A, Hraiech S, Dignat-George F, Schmidt M, Lacroix R, Papazian L. Ultra-lung-protective ventilation and biotrauma in severe ARDS patients on veno-venous extracorporeal membrane oxygenation: a randomized controlled study. Crit Care 2022; 26:383. [PMID: 36510324 PMCID: PMC9744058 DOI: 10.1186/s13054-022-04272-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Ultra-lung-protective ventilation may be useful during veno-venous extracorporeal membrane oxygenation (vv-ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator-induced lung injury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluated by numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilator strategies on vv-ECMO. METHODS This is a prospective randomized controlled study. Patients were randomized to receive during 48 h either ultra-lung-protective ventilation combining very low tidal volume (1-2 mL/kg of predicted body weight), low respiratory rate (5-10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung-protective-ventilation which followed the ECMO arm of the EOLIA trial (control group). RESULTS The primary outcome was the alveolar concentrations of interleukin-1-beta, interleukin-6, interleukin-8, surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin-2 48 h after randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratory rate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra-lung-protective group. None of the concentrations of the pre-specified biomarkers differed between the two groups 48 h after randomization. However, a trend to higher 60-day mortality was observed in the ultra-lung-protective group compared to the control group (45 vs 17%, p = 0.06). CONCLUSIONS Despite a significant reduction in the mechanical power, ultra-lung-protective ventilation during 48 h did not reduce biotrauma in patients with vv-ECMO-supported ARDS. The impact of this ventilation strategy on clinical outcomes warrants further investigation. Trial registration Clinical trial registered with www. CLINICALTRIALS gov ( NCT03918603 ). Registered 17 April 2019.
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Affiliation(s)
- Christophe Guervilly
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Théotime Fournier
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France
| | - Juliette Chommeloux
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Laurent Arnaud
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Camille Pinglis
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Karine Baumstarck
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mohamed Boucekine
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sabine Valera
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Celine Sanz
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mélanie Adda
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mickaël Bobot
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France ,grid.411535.70000 0004 0638 9491Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, 13005 Marseille, France
| | - Florence Daviet
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Ines Gragueb-Chatti
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Jean-Marie Forel
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Antoine Roch
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sami Hraiech
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Françoise Dignat-George
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Matthieu Schmidt
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Romaric Lacroix
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Laurent Papazian
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France ,Centre Hospitalier de Bastia, Service de Réanimation, 604 Chemin de Falconaja, 20600 Bastia, France
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3
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Ramin S, Arcelli M, Bouchdoug K, Laumon T, Duflos C, De Jong A, Jaber S, Capdevila X, Charbit J. Driving pressure is not predictive of ARDS outcome in chest trauma patients under mechanical ventilation. Anaesth Crit Care Pain Med 2022; 41:101095. [PMID: 35489710 DOI: 10.1016/j.accpm.2022.101095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/27/2022] [Accepted: 03/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between the driving pressure of the respiratory system (ΔPrs) under mechanical ventilation and worse outcome has never been studied specifically in chest trauma patients. The objective of the present study was to assess in cases of chest trauma the relationship between ΔPrs and severity of acute respiratory distress syndrome (ARDS) or death and length of stay. METHODS A retrospective analysis of severe trauma patients (ISS > 15) with chest injuries admitted to the Trauma Centre from January 2010 to December 2018 was performed. Patients who received mechanical ventilation were included in our analysis. Mechanical ventilation parameters and ΔPrs were recorded during the stay in the intensive care unit. Association of ΔPrs with mortality and outcomes was specifically studied at the onset of ARDS (ΔPrs-ARDS) by receiver operator characteristic curve analysis, Kaplan-Meier curves, and multivariate analysis. RESULTS Among the 266 chest trauma patients studied, 194 (73%) developed ARDS. ΔPrs was significantly higher in the ARDS group versus in the no ARDS group (11.6 ± 2.4 cm H2O vs. 10.9 ± 1.9 cm H2O, p = 0.04). Among the patients with ARDS, no difference according to the duration of mechanical ventilation was found between the high ΔPrs group (ΔPrs-ARDS > 14 cm H2O) and the low ΔPrs group (ΔPrs-ARDS ≤ 14 cm H2O), (p = 0.75). ΔPrs-ARDS was not independently associated with the duration of mechanical ventilation (hazard ratio [HR], 1.006; 95% CI, 0.95-1.07; p = 0.8) or mortality (HR, 1.07; 95% CI, 0.9-1.28; p = 0.45). High mechanical power (≥ 12 J/min) was associated with a lower time for weaning of mechanical ventilation in Kaplan-Meier curves but not in multivariate analysis (HR, 0.98; 95% CI, 0.94-1.02; p = 0.22). CONCLUSION A high ΔPrs-ARDS was not significantly associated with an increase in mechanical ventilation duration or mortality risk in ARDS patients with chest trauma in contrast with medical patients.
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Affiliation(s)
- Severin Ramin
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France.
| | - Matteo Arcelli
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Karim Bouchdoug
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France; Department of Statistical Analysis, Montpellier, France
| | - Thomas Laumon
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | | | - Audrey De Jong
- Department of Anaesthesiology and Critical Care Medicine, Saint Eloi University Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Samir Jaber
- Department of Anaesthesiology and Critical Care Medicine, Saint Eloi University Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Xavier Capdevila
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Jonathan Charbit
- Department of Anaesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
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4
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Sarge T, Baedorf-Kassis E, Banner-Goodspeed V, Novack V, Loring SH, Gong MN, Cook D, Talmor D, Beitler JR. Effect of Esophageal Pressure-Guided Positive End-Expiratory Pressure on Survival from Acute Respiratory Distress Syndrome: A Risk-Based and Mechanistic Reanalysis of the EPVent-2 Trial. Am J Respir Crit Care Med 2021; 204:1153-1163. [PMID: 34464237 DOI: 10.1164/rccm.202009-3539oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE In acute respiratory distress syndrome (ARDS), the effect of positive end-expiratory pressure (PEEP) may depend on the extent to which multiorgan dysfunction contributes to risk of death, and the precision with which PEEP is titrated to attenuate atelectrauma without exacerbating overdistension. OBJECTIVE To evaluate whether multiorgan dysfunction and lung mechanics modified treatment effect in EPVent-2, a multicenter trial of esophageal pressure (PES)-guided PEEP versus empirical high PEEP in moderate-to-severe ARDS. METHODS This post-hoc reanalysis of EPVent-2 evaluated for heterogeneity of treatment effect on mortality by baseline multiorgan dysfunction, determined via Acute Physiology and Chronic Health Evaluation-II (APACHE-II). It also evaluated whether PEEP titrated to end-expiratory transpulmonary pressure near 0 cmH2O was associated with survival. MEASUREMENTS AND MAIN RESULTS All 200 trial participants were included. Treatment effect on 60-day mortality differed by multiorgan dysfunction severity (p=0.03 for interaction). PES-guided PEEP was associated with lower mortality among patients with lower APACHE-II (HR 0.43, 95% CI 0.20-0.92 for APACHE-II less than median) and may have had the opposite effect in patients with higher APACHE-II (HR 1.69; 95% CI 0.93-3.05). Independent of treatment group or multiorgan dysfunction severity, mortality was lowest when PEEP titration achieved end-expiratory transpulmonary pressure near 0 cmH2O. CONCLUSIONS The effect on survival of PES-guided PEEP, compared to empirical high PEEP, differed by multiorgan dysfunction severity. Independent of multiorgan dysfunction, PEEP titrated to end-expiratory transpulmonary pressure closer to 0 cmH2O was associated with greater survival than more positive or negative values. These findings warrant prospective testing in a future trial.
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Affiliation(s)
- Todd Sarge
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Elias Baedorf-Kassis
- Beth Israel Deaconess Medical Center, 1859, Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Valerie Banner-Goodspeed
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Victor Novack
- Soroka Medical Center, 26746, Clinical Research Center, Beer-Sheva, Israel
| | - Stephen H Loring
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Michelle N Gong
- Montefiore Medical Center, 2013, Division of Critical Care Medicine, Bronx, New York, United States.,Albert Einstein College of Medicine, 2006, Bronx, New York, United States
| | - Deborah Cook
- McMaster University, 3710, Department of Medicine, Pathology & Molecular Medicine, Hamilton, Ontario, Canada
| | - Daniel Talmor
- Beth Israel Deaconess Medical Center, 1859, Anesthesia, Critical Care, and Pain Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - Jeremy R Beitler
- Columbia University College of Physicians and Surgeons, 12294, Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, New York, New York, United States.,NewYork-Presbyterian Hospital, 25065, New York, New York, United States;
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5
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Madahar P, Talmor D, Beitler JR. Transpulmonary Pressure-guided Ventilation to Attenuate Atelectrauma and Hyperinflation in Acute Lung Injury. Am J Respir Crit Care Med 2021; 203:934-937. [PMID: 33227213 PMCID: PMC8048752 DOI: 10.1164/rccm.202011-4116ed] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Purnema Madahar
- Center for Acute Respiratory Failure.,Division of Pulmonary, Allergy, and Critical Care Medicine Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital New York, New York and
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine Harvard Medical School and Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure.,Division of Pulmonary, Allergy, and Critical Care Medicine Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital New York, New York and
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6
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D'Angelo E, Koutsoukou A, Della Valle P, Gentile G, Pecchiari M. The development of various forms of lung injury with increasing tidal volume in normal rats. Respir Physiol Neurobiol 2020; 274:103369. [PMID: 31911202 DOI: 10.1016/j.resp.2020.103369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/11/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
Sixty-three, open-chest normal rats were subjected to mechanical ventilation (MV) with tidal volumes (VT) ranging from 7.5-39.5ml kg-1 and PEEP 2.3 cmH2O. Arterial blood gasses and pressure, and lung mechanics were measured during baseline ventilation (VT = 7.5ml kg-1) before and after test ventilation, when cytokine, von Willebrand factor (vWF), and albumin concentration in serum and broncho-alveolar lavage fluid (BALF), wet-to-dry weight ratio (W/D), and histologic injury scores were assessed. Elevation of W/D and serum vWF and cytokine concentration occurred with VT > 25ml kg-1. With VT > 30ml kg-1 cytokine and albumin concentration increased also in BALF, arterial oxygen tension decreased, lung mechanics and histology deteriorated, while W/D and vWF and cytokine concentration increased further. Hence, the initial manifestation of injurious MV consists of damage of extra-alveolar vessels leading to interstitial edema, as shown by elevated vWF and cytokine levels in serum but not in BALF. Failure of the endothelial-epithelial barrier occurs at higher stress-strain levels, with alveolar edema, small airway injury, and mechanical alterations.
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Affiliation(s)
- Edgardo D'Angelo
- Department of Physiopathology and Transplantations, Università di Milano, Milan, Italy.
| | | | - Patrizia Della Valle
- Coagulation Service and Thrombosis Research Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Guendalina Gentile
- Department of Biomedical Sciences for Health, Università di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Physiopathology and Transplantations, Università di Milano, Milan, Italy
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7
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Yoshida T, Amato MBP, Grieco DL, Chen L, Lima CAS, Roldan R, Morais CCA, Gomes S, Costa ELV, Cardoso PFG, Charbonney E, Richard JCM, Brochard L, Kavanagh BP. Esophageal Manometry and Regional Transpulmonary Pressure in Lung Injury. Am J Respir Crit Care Med 2019; 197:1018-1026. [PMID: 29323931 DOI: 10.1164/rccm.201709-1806oc] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Esophageal manometry is the clinically available method to estimate pleural pressure, thus enabling calculation of transpulmonary pressure (Pl). However, many concerns make it uncertain in which lung region esophageal manometry reflects local Pl. OBJECTIVES To determine the accuracy of esophageal pressure (Pes) and in which regions esophageal manometry reflects pleural pressure (Ppl) and Pl; to assess whether lung stress in nondependent regions can be estimated at end-inspiration from Pl. METHODS In lung-injured pigs (n = 6) and human cadavers (n = 3), Pes was measured across a range of positive end-expiratory pressure, together with directly measured Ppl in nondependent and dependent pleural regions. All measurements were obtained with minimal nonstressed volumes in the pleural sensors and esophageal balloons. Expiratory and inspiratory Pl was calculated by subtracting local Ppl or Pes from airway pressure; inspiratory Pl was also estimated by subtracting Ppl (calculated from chest wall and respiratory system elastance) from the airway plateau pressure. MEASUREMENTS AND MAIN RESULTS In pigs and human cadavers, expiratory and inspiratory Pl using Pes closely reflected values in dependent to middle lung (adjacent to the esophagus). Inspiratory Pl estimated from elastance ratio reflected the directly measured nondependent values. CONCLUSIONS These data support the use of esophageal manometry in acute respiratory distress syndrome. Assuming correct calibration, expiratory Pl derived from Pes reflects Pl in dependent to middle lung, where atelectasis usually predominates; inspiratory Pl estimated from elastance ratio may indicate the highest level of lung stress in nondependent "baby" lung, where it is vulnerable to ventilator-induced lung injury.
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Affiliation(s)
- Takeshi Yoshida
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Domenico Luca Grieco
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,5 Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione "Policlinico universitario A. Gemelli," Rome, Italy.,6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada
| | - Lu Chen
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and
| | | | - Rollin Roldan
- 4 Divisao de Pneumologia and.,7 Unidad de Cuidados Intensivos, Hospital Rebagliati, Lima, Perú
| | | | | | | | - Paulo F G Cardoso
- 8 Disciplina de Cirurgia Torácica, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Emmanuel Charbonney
- 6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada.,9 Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada; and
| | - Jean-Christophe M Richard
- 6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada.,10 Department of Pre-Hospital and Emergency Medicine, General Hospital of Annecy, Annecy, France
| | - Laurent Brochard
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada
| | - Brian P Kavanagh
- 2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Südy R, Fodor GH, Dos Santos Rocha A, Schranc Á, Tolnai J, Habre W, Peták F. Different contributions from lungs and chest wall to respiratory mechanics in mice, rats, and rabbits. J Appl Physiol (1985) 2019; 127:198-204. [PMID: 31161880 DOI: 10.1152/japplphysiol.00048.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Changes in lung mechanics are frequently inferred from intact-chest measures of total respiratory system mechanics without consideration of the chest wall contribution. The participation of lungs and chest wall in respiratory mechanics has not been evaluated systematically in small animals commonly used in respiratory research. Thus, we compared these contributions in intact-chest mice, rats, and rabbits and further characterized the influence of positive end-expiratory pressure (PEEP). Forced oscillation technique was applied to anesthetized mechanically ventilated healthy animals to obtain total respiratory system impedance (Zrs) at 0, 3, and 6 cmH2O PEEP levels. Esophageal pressure was measured by a catheter-tip micromanometer to separate Zrs into pulmonary (ZL) and chest wall (Zcw) components. A model containing a frequency-independent Newtonian resistance (RN), inertance, and a constant-phase tissue damping (G) and elastance (H) was fitted to Zrs, ZL, and Zcw spectra. The contribution of Zcw to RN was negligible in all species and PEEP levels studied. However, the participation of Zcw in G and H was significant in all species and increased significantly with increasing PEEP and animal size (rabbit > rat > mice). Even in mice, the chest wall contribution to G and H was still considerable, reaching 47.0 ± 4.0(SE)% and 32.9 ± 5.9% for G and H, respectively. These findings demonstrate that airway parameters can be assessed from respiratory system mechanical measurements. However, the contribution from the chest wall should be considered when intact-chest measurements are used to estimate lung parenchymal mechanics in small laboratory models (even in mice), particularly at elevated PEEP levels. NEW & NOTEWORTHY In species commonly used in respiratory research (rabbits, rats, mice), esophageal pressure-based estimates revealed negligible contribution from the chest wall to the Newtonian resistance. Conversely, chest wall participation in the viscoelastic tissue mechanical parameters increased with body size (rabbit > rat > mice) and positive end-expiratory pressure, with contribution varying between 30 and 50%, even in mice. These findings demonstrate the potential biasing effects of the chest wall when lung tissue mechanics are inferred from intact-chest measurements in small laboratory animals.
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Affiliation(s)
- Roberta Südy
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva , Geneva , Switzerland.,Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
| | - Gergely H Fodor
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva , Geneva , Switzerland
| | - André Dos Santos Rocha
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva , Geneva , Switzerland
| | - Álmos Schranc
- Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
| | - József Tolnai
- Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
| | - Walid Habre
- Unit for Anesthesiological Investigations, Department of Acute Medicine, University of Geneva , Geneva , Switzerland
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged , Szeged , Hungary
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9
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Baedorf Kassis E, Loring SH, Talmor D. Should we titrate peep based on end-expiratory transpulmonary pressure?-yes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:390. [PMID: 30460264 DOI: 10.21037/atm.2018.06.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ventilator management of patients with acute respiratory distress syndrome (ARDS) has been characterized by implementation of basic physiology principles by minimizing harmful distending pressures and preventing lung derecruitment. Such strategies have led to significant improvements in outcomes. Positive end expiratory pressure (PEEP) is an important part of a lung protective strategy but there is no standardized method to set PEEP level. With widely varying types of lung injury, body habitus and pulmonary mechanics, the use of esophageal manometry has become important for personalization and optimization of mechanical ventilation in patients with ARDS. Esophageal manometry estimates pleural pressures, and can be used to differentiate the chest wall and lung (transpulmonary) contributions to the total respiratory system mechanics. Elevated pleural pressures may result in negative transpulmonary pressures at end expiration, leading to lung collapse. Measuring the esophageal pressures and adjusting PEEP to make transpulmonary pressures positive can decrease atelectasis, derecruitment of lung, and cyclical opening and closing of airways and alveoli, thus optimizing lung mechanics and oxygenation. Although there is some spatial and positional artifact, esophageal pressures in numerous animal and human studies in healthy, obese and critically ill patients appear to be a good estimate for the "effective" pleural pressure. Multiple studies have illustrated the benefit of using esophageal pressures to titrate PEEP in patients with obesity and with ARDS. Esophageal pressure monitoring provides a window into the unique physiology of a patient and helps improve clinical decision making at the bedside.
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Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen H Loring
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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10
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Silva PL, Rocco PRM. The basics of respiratory mechanics: ventilator-derived parameters. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:376. [PMID: 30460250 DOI: 10.21037/atm.2018.06.06] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Mechanical ventilation is a life-support system used to maintain adequate lung function in patients who are critically ill or undergoing general anesthesia. The benefits and harms of mechanical ventilation depend not only on the operator's setting of the machine (input), but also on their interpretation of ventilator-derived parameters (outputs), which should guide ventilator strategies. Once the inputs-tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), and inspiratory airflow (V')-have been adjusted, the following outputs should be measured: intrinsic PEEP, peak (Ppeak) and plateau (Pplat) pressures, driving pressure (ΔP), transpulmonary pressure (PL), mechanical energy, mechanical power, and intensity. During assisted mechanical ventilation, in addition to these parameters, the pressure generated 100 ms after onset of inspiratory effort (P0.1) and the pressure-time product per minute (PTP/min) should also be evaluated. The aforementioned parameters should be seen as a set of outputs, all of which need to be strictly monitored at bedside in order to develop a personalized, case-by-case approach to mechanical ventilation. Additionally, more clinical research to evaluate the safe thresholds of each parameter in injured and uninjured lungs is required.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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11
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Obi ON, Mazer M, Bangley C, Kassabo Z, Saadah K, Trainor W, Stephens K, Rice PL, Shaw R. Obesity and Weaning from Mechanical Ventilation-An Exploratory Study. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2018; 12:1179548418801004. [PMID: 30245572 PMCID: PMC6144576 DOI: 10.1177/1179548418801004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 08/22/2018] [Indexed: 12/25/2022]
Abstract
Introduction Obesity is associated with increased risk of hypercapnic respiratory failure, prolonged duration on mechanical ventilation, and extended weaning periods. Objective Pilot study to determine whether morbidly obese adult tracheotomized subjects (body mass index [BMI] ⩾ 40) can be more efficiently weaned from the ventilator by optimizing their positive end-expiratory pressure (PEEP) using either an esophageal balloon or the best achieved static effective compliance. Methods We randomly assigned 25 morbidly obese adult tracheotomized subjects (median [interquartile range] BMI 53.4 [26.4]; range 40.4-113.8) to 1 of 2 methods of setting PEEP; using either titration guided by esophageal balloon to overcome negative transpulmonary pressure (Ptp) (goal Ptp 0-5 cmH2O) (ESO group) or titration to maximize static effective lung compliance (Cstat group). Our outcomes of interest were number of subjects weaned by day 30 and time to wean. Results At day 30, there was no significant difference in percentage of subjects weaned. 8/13 subjects (62%) in the ESO Group were weaned vs. 9/12(75%) in the Cstat Group (P = 0.67). Among the 17 subjects who weaned, median time to ventilator liberation was significantly shorter in the ESO group: 3.5 days vs Cstat group 14 days (P = .01). Optimal PEEP in the ESO and Cstat groups was similar (ESO mean ± SD = 26.5 ± 5.7 cmH2O and Cstat 24.2 ± 7 cmH2O (P = .38). Conclusions Optimization of PEEP using esophageal balloon to achieve positive transpulmonary pressure did not change the proportion of patients weaned. Among patients who weaned, use of the esophageal balloon resulted in faster liberation from mechanical ventilation. There were no adverse consequences of the high PEEP (mean 25.4; range 13-37 cmH2O) used in our study. The study was approved by the Institutional Review Board at our institution (UMCIRB#10-0343) and registered with clinicaltrials.gov (NCT02323009).
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Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Mark Mazer
- Division of Pulmonary, Critical Care, and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Charles Bangley
- Department of Respiratory Care, Vidant Medical Center, Greenville, NC, USA
| | - Zuheir Kassabo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Khalid Saadah
- Division of Pulmonary, Critical Care, and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Wayne Trainor
- Department of Respiratory Care, Vidant Medical Center, Greenville, NC, USA
| | - Kenneth Stephens
- Department of Respiratory Care, Vidant Medical Center, Greenville, NC, USA
| | - Patricia L Rice
- Division of Pulmonary, Critical Care, and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Robert Shaw
- Division of Pulmonary, Critical Care, and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
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Comuzzi L, de Abreu MB, Motta-Ribeiro GC, Okuro RT, Barboza T, Carvalho N, Lucangelo U, Carvalho AR, Zin WA. Regional Lung Recruitability During Pneumoperitoneum Depends on Chest Wall Elastance - A Mechanical and Computed Tomography Analysis in Rats. Front Physiol 2018; 9:920. [PMID: 30057557 PMCID: PMC6053523 DOI: 10.3389/fphys.2018.00920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Laparoscopic surgery with pneumoperitoneum increases respiratory system elastance due to the augmented intra-abdominal pressure. We aim to evaluate to which extent positive end-expiratory pressure (PEEP) is able to counteract abdominal hypertension preventing progressive lung collapse and how rib cage elastance influences PEEP effect. Methods: Forty-four Wistar rats were mechanically ventilated and randomly assigned into three groups: control (CTRL), pneumoperitoneum (PPT) and pneumoperitoneum with restricted rib cage (PPT-RC). A pressure-volume (PV) curve followed by a recruitment maneuver and a decremental PEEP trial were performed in all groups. Thereafter, animals were ventilated using PEEP of 3 and 8 cmH2O divided into two subgroups used to evaluate respiratory mechanics or computed tomography (CT) images. In 26 rats, we compared respiratory system elastance (Ers) at the two PEEP levels. In 18 animals, CT images were acquired to calculate total lung volume (TLV), total volume and air volume in six anatomically delimited regions of interest (three along the cephalo-caudal and three along the ventro-dorsal axes). Results: PEEP of minimal Ers was similar in CTRL and PPT groups (3.8 ± 0.45 and 3.5 ± 3.89 cmH2O, respectively) and differed from PPT-RC group (9.8 ± 0.63 cmH2O). Chest restriction determined a right- and downward shift of the PV curve, increased Ers and diminished TLV and lung aeration. Increasing PEEP augmented TLV in CTRL group (11.8 ± 1.3 to 13.6 ± 2 ml, p < 0.05), and relative air content in the apex of PPT group (3.5 ± 1.4 to 4.6 ± 1.4% TLV, p < 0.03) and in the middle zones in PPT-RC group (21.4 ± 1.9 to 25.3 ± 2.1% TLV cephalo-caudally and 18.1 ± 4.3 to 22.0 ± 3.3% TLV ventro-dorsally, p < 0.005). Conclusion: Regional lung recruitment potential during pneumoperitoneum depends on rib cage elastance, reinforcing the concept of PEEP individualization according to the patient's condition.
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Affiliation(s)
- Lucia Comuzzi
- Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Perioperative Medicine, Intensive Care and Emergency, Università degli Studi di Trieste, Trieste, Italy
| | - Mariana B de Abreu
- Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gabriel C Motta-Ribeiro
- Laboratory of Pulmonary Engineering, Alberto Luiz Coimbra Institute of Post-Graduation and Engineering Research, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Renata T Okuro
- Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Thiago Barboza
- National Center for Structural Biology and Bioimaging, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Niedja Carvalho
- Laboratory of Pulmonary Engineering, Alberto Luiz Coimbra Institute of Post-Graduation and Engineering Research, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Umberto Lucangelo
- Department of Perioperative Medicine, Intensive Care and Emergency, Università degli Studi di Trieste, Trieste, Italy
| | - Alysson R Carvalho
- Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratory of Pulmonary Engineering, Alberto Luiz Coimbra Institute of Post-Graduation and Engineering Research, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Walter A Zin
- Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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13
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Nieman GF, Satalin J, Andrews P, Aiash H, Habashi NM, Gatto LA. Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI). Intensive Care Med Exp 2017; 5:8. [PMID: 28150228 PMCID: PMC5289131 DOI: 10.1186/s40635-017-0121-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/26/2017] [Indexed: 12/15/2022] Open
Abstract
It has been shown that mechanical ventilation in patients with, or at high-risk for, the development of acute respiratory distress syndrome (ARDS) can be a double-edged sword. If the mechanical breath is improperly set, it can amplify the lung injury associated with ARDS, causing a secondary ventilator-induced lung injury (VILI). Conversely, the mechanical breath can be adjusted to minimize VILI, which can reduce ARDS mortality. The current standard of care ventilation strategy to minimize VILI attempts to reduce alveolar over-distension and recruitment-derecruitment (R/D) by lowering tidal volume (Vt) to 6 cc/kg combined with adjusting positive-end expiratory pressure (PEEP) based on a sliding scale directed by changes in oxygenation. Thus, Vt is often but not always set as a "one-size-fits-all" approach and although PEEP is often set arbitrarily at 5 cmH2O, it may be personalized according to changes in a physiologic parameter, most often to oxygenation. However, there is evidence that oxygenation as a method to optimize PEEP is not congruent with the PEEP levels necessary to maintain an open and stable lung. Thus, optimal PEEP might not be personalized to the lung pathology of an individual patient using oxygenation as the physiologic feedback system. Multiple methods of personalizing PEEP have been tested and include dead space, lung compliance, lung stress and strain, ventilation patterns using computed tomography (CT) or electrical impedance tomography (EIT), inflection points on the pressure/volume curve (P/V), and the slope of the expiratory flow curve using airway pressure release ventilation (APRV). Although many studies have shown that personalizing PEEP is possible, there is no consensus as to the optimal technique. This review will assess various methods used to personalize PEEP, directed by physiologic parameters, necessary to adaptively adjust ventilator settings with progressive changes in lung pathophysiology.
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Affiliation(s)
- Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY USA
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY USA
- Cardiopulmonary Critical Care Lab, Department of Surgery, Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210 USA
| | | | - Hani Aiash
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY USA
| | - Nader M. Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Louis A. Gatto
- Biological Sciences Department, Biological Sciences Department, SUNY Cortland, Cortland, NY USA
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14
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Esophageal pressure: research or clinical tool? Med Klin Intensivmed Notfmed 2017; 113:13-20. [PMID: 29134245 DOI: 10.1007/s00063-017-0372-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
Esophageal manometry has traditionally been utilized for respiratory physiology research, but clinicians have recently found numerous applications within the intensive care unit. Esophageal pressure (PEs) is a surrogate for pleural pressures (PPl), and the difference between airway pressure (PAO) and PEs provides a good estimate for the pressure across the lung also known as the transpulmonary pressure (PL). Differentiating the effects of mechanical ventilation and spontaneous breathing on the respiratory system, chest wall, and across the lung allows for improved personalization in clinical decision making. Measuring PL in acute respiratory distress syndrome (ARDS) may help set positive end expiratory pressure (PEEP) to prevent derecruitment and atelectrauma, while assuring peak pressures do not cause over distension during tidal breathing and recruitment maneuvers. Monitoring PEs allows improved insight into patient-ventilator interactions and may help in decisions to adjust sedation and paralytics to correct dyssynchrony. Intrinsic PEEP (auto-PEEP) may be monitored using esophageal manometry, which may also improve patient comfort and synchrony with the ventilator. Finally, during weaning, PEs may be used to better predict weaning success and allow for rapid intervention during failure. Improved consistency in definition and terminology and further outcomes research is needed to encourage more widespread adoption; however, with clear clinical benefit and increased ease of use, it appears time to reintroduce basic physiology into personalized ventilator management in the intensive care unit.
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15
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Babik B, Balogh AL, Sudy R, Ivankovitsne-Kiss O, Fodor GH, Petak F. Levosimendan prevents bronchoconstriction and adverse respiratory tissue mechanical changes in rabbits. Am J Physiol Lung Cell Mol Physiol 2017; 313:L950-L956. [DOI: 10.1152/ajplung.00213.2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/15/2017] [Accepted: 08/15/2017] [Indexed: 11/22/2022] Open
Abstract
Levosimendan has a calcium-sensitizing effect in the myocardium and opens ATP-sensitive potassium channels (KATP) in vascular smooth muscle. Because airway smooth muscle also expresses KATP, we characterized the protective potential of levosimendan against increased airway and respiratory tissue resistances. Animals were administered levosimendan alone ( group L), levosimendan after pretreatment with a KATP channel blocker (glibenclamide, group LG), glibenclamide only ( group G), or solvent alone (dextrose, group C). Airway resistance (Raw), tissue damping, and elastance were determined by forced oscillations under baseline conditions and following provocation tests with intravenous methacholine (MCh). Cardiac output (CO) was assessed by transpulmonary thermodilution. The same sequence of measurements was then repeated during intravenous infusion of levosimendan in groups L and LG or glucose in groups G and C. Sham treatments in groups C and G had no effect on lung responsiveness. However, levosimendan treatment in group L elevated CO and inhibited the MCh-induced airway responses [Raw changes of 87.8 ± 83% (SD) vs. 24.4 ± 16% at 4 μg·kg−1·min−1 MCh, P < 0.001], and in G (35.2 ± 12.7 vs. 25.2 ± 12.9%, P < 0.05). The preventive affect of levosimendan against lung constriction vanished in the LG group. Levosimendan exerts a KATP-mediated potential to prevent bronchoconstriction and may prohibit adverse lung peripheral changes both in the small bronchi and the pulmonary parenchyma. The identification of a further pleiotropic property of levosimendan that is related to the pulmonary system is of particular importance for patients with decreased cardiorespiratory reserves for which simultaneous circulatory support is complemented with prevention of adverse respiratory events.
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Affiliation(s)
- Barna Babik
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; and
| | - Adam L. Balogh
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; and
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Roberta Sudy
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; and
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | | | - Gergely H. Fodor
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ferenc Petak
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
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16
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Norisue Y, Ashworth L, Naito T, Kataoka J, Takeuchi M, Usami S, Takada J, Fujitani S. Impact of physician education and availability of parameters regarding esophageal pressure and transpulmonary pressure on clinical decisions involving ventilator management. J Crit Care 2017; 41:112-118. [PMID: 28514715 DOI: 10.1016/j.jcrc.2017.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 04/09/2017] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE This study investigated the effects of physician education and the availability of Peso and PL data on physicians' decisions regarding ventilator management during specific simulated clinical conditions. MATERIALS AND METHODS The study was a prospective, before-after study using a case scenario-based questionnaire and a case simulator device comprising an Avea ventilator and an artificial lung and esophagus, which was connected to a Series 1101 Electronic Breathing Simulator. The 99 physicians participating in the study were provided with five simulated cases with on-time ventilator graphics without Peso and PL and completed a questionnaire on decisions they would make regarding ventilator management of the cases. Then, after receiving instruction on Peso and PL, they were given the same cases along with ventilator graphics that included Peso and PL. RESULTS After receiving instruction and data on Peso and PL, statistically significant numbers of physicians changed their answers regarding ventilator management decisions in all five cases. CONCLUSIONS Providing education and data for Peso and PL had a significant effect on physician decisions regarding ventilator management in simulated cases. The use of case scenario-based education with simulator devices for physicians may hasten worldwide understanding and clinical application of Peso and PL.
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Affiliation(s)
- Yasuhiro Norisue
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
| | - Lonny Ashworth
- Department of Respiratory Care, Boise State University, Boise, ID, USA
| | - Takaki Naito
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Jun Kataoka
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Muneyuki Takeuchi
- Department of Anesthesia and Critical Care Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Sunao Usami
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Junko Takada
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University Hospital, Kanagawa, Japan
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17
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Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 2016; 42:1360-73. [PMID: 27334266 DOI: 10.1007/s00134-016-4400-x] [Citation(s) in RCA: 286] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 05/17/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Esophageal pressure (Pes) is a minimally invasive advanced respiratory monitoring method with the potential to guide management of ventilation support and enhance specific diagnoses in acute respiratory failure patients. To date, the use of Pes in the clinical setting is limited, and it is often seen as a research tool only. METHODS This is a review of the relevant technical, physiological and clinical details that support the clinical utility of Pes. RESULTS After appropriately positioning of the esophageal balloon, Pes monitoring allows titration of controlled and assisted mechanical ventilation to achieve personalized protective settings and the desired level of patient effort from the acute phase through to weaning. Moreover, Pes monitoring permits accurate measurement of transmural vascular pressure and intrinsic positive end-expiratory pressure and facilitates detection of patient-ventilator asynchrony, thereby supporting specific diagnoses and interventions. Finally, some Pes-derived measures may also be obtained by monitoring electrical activity of the diaphragm. CONCLUSIONS Pes monitoring provides unique bedside measures for a better understanding of the pathophysiology of acute respiratory failure patients. Including Pes monitoring in the intensivist's clinical armamentarium may enhance treatment to improve clinical outcomes.
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How much esophageal pressure-guided end-expiratory transpulmonary pressure is sufficient to maintain lung recruitment in lavage-induced lung injury? J Trauma Acute Care Surg 2016; 80:302-7. [PMID: 26517781 DOI: 10.1097/ta.0000000000000900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Because of limitations of the esophageal balloon technique, the value of using esophageal pressure (Pes)-guided end-expiratory transpulmonary pressure (PL-exp) to maintain lung recruitment in adult respiratory distress syndrome is controversial. This study aimed to investigate whether tailoring PL-exp to greater than 0 was enough to maintain lung recruitment. METHODS Ten pigs with severe lavage-induced lung injury were mechanically ventilated in a decremental positive end-expiratory pressure (PEEP) trial that was reduced from 20 to 6 cm H2O after full-lung recruitment. Respiratory mechanics, blood gases, hemodynamic data, and whole-lung computed tomography scans were recorded at each PEEP level. Open-lung PEEP (OL-PEEP) was determined by computed tomography, while Pes-guided PEEP (Pes-PEEP) was to maintain PL-exp greater than 0. RESULTS OL-PEEP was higher than Pes-PEEP, which induced a higher PL-exp at OL-PEEP than at Pes-PEEP (4.6 [1.6] cm H2O vs. 1.2 [0.6] cm H2O, p < 0.001). Compared with OL-PEEP, the nonaerated lung region was significantly increased at Pes-PEEP. Superimposed pressure (SP) of the lung tissue between the esophageal plane and the dorsal level was higher at Pes-PEEP than at OL-PEEP, whereas PL-exp at the dorsal level was lower at Pes-PEEP than at OL-PEEP (-1.5 [0.7] cm H2O vs. 2.5 [1.5] cm H2O, p < 0.001). The SP correlated with PL-exp at the dorsal level and the nonaerated lung region. CONCLUSION In this surfactant-depleted model, maintaining PL-exp just greater than 0 using Pes was unable to maintain lung recruitment; this was partly caused by a lack of compensation for the increased SP between the esophageal plane and the dorsal level.
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Herbert JA, Valentine MS, Saravanan N, Schneck MB, Pidaparti R, Fowler AA, Reynolds AM, Heise RL. Conservative fluid management prevents age-associated ventilator induced mortality. Exp Gerontol 2016; 81:101-9. [PMID: 27188767 DOI: 10.1016/j.exger.2016.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 05/09/2016] [Accepted: 05/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Approximately 800 thousand patients require mechanical ventilation in the United States annually with an in-hospital mortality rate of over 30%. The majority of patients requiring mechanical ventilation are over the age of 65 and advanced age is known to increase the severity of ventilator-induced lung injury (VILI) and in-hospital mortality rates. However, the mechanisms which predispose aging ventilator patients to increased mortality rates are not fully understood. Ventilation with conservative fluid management decreases mortality rates in acute respiratory distress patients, but to date there has been no investigation of the effect of conservative fluid management on VILI and ventilator associated mortality rates. We hypothesized that age-associated increases in susceptibility and incidence of pulmonary edema strongly promote age-related increases in ventilator associated mortality. METHODS 2month old and 20month old male C57BL6 mice were mechanically ventilated with either high tidal volume (HVT) or low tidal volume (LVT) for up to 4h with either liberal or conservative fluid support. During ventilation, lung compliance, total lung capacity, and hysteresis curves were quantified. Following ventilation, bronchoalveolar lavage fluid was analyzed for total protein content and inflammatory cell infiltration. Wet to dry ratios were used to directly measure edema in excised lungs. Lung histology was performed to quantify alveolar barrier damage/destruction. Age matched non-ventilated mice were used as controls. RESULTS At 4h, both advanced age and HVT ventilation significantly increased markers of inflammation and injury, degraded pulmonary mechanics, and decreased survival rates. Conservative fluid support significantly diminished pulmonary edema and improved pulmonary mechanics by 1h in advanced age HVT subjects. In 4h ventilations, conservative fluid support significantly diminished pulmonary edema, improved lung mechanics, and resulted in significantly lower mortality rates in older subjects. CONCLUSION Our study demonstrates that conservative fluid alone can attenuate the age associated increase in ventilator associated mortality.
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Affiliation(s)
- Joseph A Herbert
- Department of Biomedical Engineering, Virginia Commonwealth University, 401 W Main St, PO Box 843067, Richmond, VA 23284, United States
| | - Michael S Valentine
- Department of Biomedical Engineering, Virginia Commonwealth University, 401 W Main St, PO Box 843067, Richmond, VA 23284, United States
| | - Nivi Saravanan
- Department of Biomedical Engineering, Virginia Commonwealth University, 401 W Main St, PO Box 843067, Richmond, VA 23284, United States
| | - Matthew B Schneck
- Department of Biomedical Engineering, Virginia Commonwealth University, 401 W Main St, PO Box 843067, Richmond, VA 23284, United States
| | | | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, United States
| | - Angela M Reynolds
- Department of Mathematics and Applies Mathematics 1015 Floyd Avenue P.O. Box 842014 Richmond, VA 23284-2014, United States
| | - Rebecca L Heise
- Department of Biomedical Engineering, Virginia Commonwealth University, 401 W Main St, PO Box 843067, Richmond, VA 23284, United States; Department of Physiology and Biophysics VCU School of Medicine 1101 East Marshall Street P.O. Box 980551 Richmond, VA 23298-0551, United States.
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Andrews PL, Sadowitz B, Kollisch-Singule M, Satalin J, Roy S, Snyder K, Gatto LA, Nieman GF, Habashi NM. Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury. Intensive Care Med Exp 2015. [PMID: 26215818 PMCID: PMC4480795 DOI: 10.1186/s40635-015-0054-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Improperly set mechanical ventilation (MV) with normal lungs can advance lung injury and increase the incidence of acute respiratory distress syndrome (ARDS). A key mechanism of ventilator-induced lung injury (VILI) is an alteration in alveolar mechanics including alveolar instability or recruitment/derecruitment (R/D). We hypothesize that R/D cannot be identified by PaO2 (masking occult VILI), and if protective ventilation is not applied, ARDS incidence will increase. METHODS Sprague-Dawley rats (n = 8) were anesthetized, surgically instrumented, and placed on MV. A thoracotomy was performed and an in vivo microscope attached to the pleural surface of the lung with baseline dynamic changes in alveolar size during MV recorded. Alveolar instability was induced by intra-tracheal instillation of Tween and alveolar R/D identified as a marked change in alveolar size from inspiration to expiration with increases in positive end-expiratory pressure (PEEP) levels. RESULTS Despite maintaining a clinically acceptable PaO2 (55-80 mmHg), the alveoli remained unstable with significant R/D at low PEEP levels. Although PaO2 consistently increased with an increase in PEEP, R/D did not plateau until PEEP was >9 cmH2O. CONCLUSIONS PaO2 remained clinically acceptable while alveolar instability persisted at all levels of PEEP (especially PEEP <9 cmH2O). Therefore, PaO2 levels cannot be used reliably to guide protective MV strategies or infer that VILI is not occurring. Using PaO2 to set a PEEP level necessary to stabilize the alveoli could underestimate the potential for VILI. These findings highlight the need for more accurate marker(s) of alveolar stability to guide protective MV necessary to prevent VILI.
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Affiliation(s)
- Penny L Andrews
- Department of Critical Care, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA,
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21
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Peng W, Zhu H, Shi H, Liu E. Volume-targeted ventilation is more suitable than pressure-limited ventilation for preterm infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2014; 99:F158-65. [PMID: 24277660 DOI: 10.1136/archdischild-2013-304613] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the effect of volume-targeted ventilation (VTV) compared with pressure-limited ventilation (PLV) in preterm infants. METHOD We searched the Cochrane Library (Issue 3, 2013), PubMed (1966 to 5 March 2013), China National Knowledge Infrastructure (CNKI) and periodical databases (1979 to 5 March 2013). We selected randomised controlled trials (RCTs) and quasi-RCTs of VTV versus PLV as active interventions in preterm infants. We performed meta-analyses using the Cochrane statistical package RevMan 5.0. RESULTS Eighteen trials met our inclusion criteria. There was no evidence that VTV modes reduced the incidence of death (relative risk (RR) 0.73, 95% CI 0.51 to 1.05). The use of VTV modes resulted in a reduction in the incidence of bronchopulmonary dysplasia (BPD) (RR 0.61, 95% CI 0.46 to 0.82) and duration of mechanical ventilation (mean difference (MD) -2.0 days, 95% CI -3.14 to -0.86). VTV modes also resulted in reductions in intraventricular haemorrhage (IVH) (RR 0.65, 95% CI 0.42 to 0.99), grade 3/4 IVH (RR 0.55, 95% CI 0.39 to 0.79), periventricular leukomalacia (PVL) (RR 0.33, 95% CI 0.15 to 0.72), pneumothorax (RR 0.52, 95% CI 0.29 to 0.93), failure of primary mode of ventilation (RR 0.64, 95% CI 0.43 to 0.94), hypocarbia (RR 0.56, 95% CI 0.33 to 0.96), mean airway pressure (MD -0.54 cmH2O, 95% CI -1.05 to -0.02) and days of supplemental oxygen administration (MD -1.68 days, 95% CI -2.47 to -0.88). CONCLUSIONS Preterm infants ventilated using VTV modes had reduced duration of mechanical ventilation, incidence of BPD, failure of primary mode of ventilation, hypocarbia, grade 3/4 IVH, pneumothorax and PVL compared with preterm infants ventilated using PLV modes. There was no evidence that infants ventilated with VTV modes had reduced death compared to infants ventilated using PLV modes.
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Affiliation(s)
- Wansheng Peng
- Department of Pediatrics, the First Affiliated Hospital of Bengbu Medical College, , Bengbu, P.R. China
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Khan M, Frankel H. Adjuncts to ventilatory support part 1: nitric oxide, surfactants, prostacyclin, steroids, sedation, and neuromuscular blockade. Curr Probl Surg 2013; 50:424-33. [PMID: 24156839 DOI: 10.1067/j.cpsurg.2013.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Fan E, Villar J, Slutsky AS. Novel approaches to minimize ventilator-induced lung injury. BMC Med 2013; 11:85. [PMID: 23536968 PMCID: PMC3621434 DOI: 10.1186/1741-7015-11-85] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 02/07/2013] [Indexed: 02/06/2023] Open
Abstract
Despite over 40 years of research, there is no specific lung-directed therapy for the acute respiratory distress syndrome (ARDS). Although much has evolved in our understanding of its pathogenesis and factors affecting patient outcome, supportive care with mechanical ventilation remains the cornerstone of treatment. Perhaps the most important advance in ARDS research has been the recognition that mechanical ventilation, although necessary to preserve life, can itself aggravate or cause lung damage through a variety of mechanisms collectively referred to as ventilator-induced lung injury (VILI). This improved understanding of ARDS and VILI has been important in designing lung-protective ventilatory strategies aimed at attenuating VILI and improving outcomes. Considerable effort has been made to enhance our mechanistic understanding of VILI and to develop new ventilatory strategies and therapeutic interventions to prevent and ameliorate VILI with the goal of improving outcomes in patients with ARDS. In this review, we will review the pathophysiology of VILI, discuss a number of novel physiological approaches for minimizing VILI, therapies to counteract biotrauma, and highlight a number of experimental studies to support these concepts.
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Affiliation(s)
- Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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25
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Physiological effects of an open lung ventilatory strategy titrated on elastance-derived end-inspiratory transpulmonary pressure. Crit Care Med 2012; 40:2124-31. [DOI: 10.1097/ccm.0b013e31824e1b65] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Wallingford B, Rubarth L, Abbott A, Miers LJ. Implementation and Evaluation of “Golden Hour” Practices in Infants Younger Than 33 Weeks' Gestation. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.nainr.2012.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Ye H, Zhan Q, Ren Y, Liu X, Yang C, Wang C. Cyclic deformation-induced injury and differentiation of rat alveolar epithelial type II cells. Respir Physiol Neurobiol 2011; 180:237-46. [PMID: 22154752 DOI: 10.1016/j.resp.2011.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 01/20/2023]
Abstract
The injury and differentiation of alveolar epithelial type II cells induced by alveolar epithelial deformation play important roles in the pathophysiology of ventilator-induced lung injury and repair of the lung injury, respectively. We developed an in vitro rat model to investigate the effects of deformation amplitude, peak deformation, and minimum deformation on the viability and differentiation of type II cells. Rat primary alveolar epithelial type II cells were exposed to a variety of equibiaxial cyclic stretch protocols, and deformation-induced cell survival and differentiation were analyzed. Cell death increased when deformation consisted of change in cell surface area (ΔSA) of 0-37%, 0-50%, 12-50%, 37-50% (P=0.001, P<0.001, P<0.001, and P=0.003, respectively). When ΔSA was at 12-37% and 12-50%, mRNA transcription (P=0.034 and P=0.036) and protein expressions (P=0.008 and P=0.001) of caveolin-1 (a marker for the type I phenotype) increased, in contrast to the decrease of their mRNA transcription of surfactant protein C (a marker for the type II phenotype) (P=0.011, 0.002). These results suggest that amplitude or minimum deformation ≥ 37% ΔSA is an important cause of cell death, and amplitude ≥ 25% ΔSA promotes cell differentiation. Appropriate amplitude (25% ΔSA) can not only avoid cell death but also promote cell differentiation.
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Affiliation(s)
- Huan Ye
- Department of Respiratory and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
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Richard JCM, Lefebvre JC, Tassaux D, Brochard L. Update in Mechanical Ventilation 2010. Am J Respir Crit Care Med 2011; 184:32-6. [DOI: 10.1164/rccm.201103-0424up] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
PURPOSE OF REVIEW Despite the well recognized role of mechanical ventilation in lung injury, appropriate surrogate markers to guide titration of ventilator settings remain elusive. One would like to strike a balance between protecting aerated units from overdistension while recruiting unstable units, thereby reducing tissue damage associated with their cyclic recruitment and derecruitment. To do so requires some estimate of the topographical distribution of parenchymal stress and strain. RECENT FINDINGS Recent studies have highlighted the importance of chest wall recoil and its effect on pleural pressure (Ppl) in determining lung stress. Although esophageal pressure (Pes) has traditionally been used to measure the average Ppl in normal upright patients, in recumbent acute lung injury/acute respiratory distress syndrome patients Pes-based estimates of Ppl are subject to untestable assumptions. Nevertheless, Pes measurements in recumbent patients with injured lungs strongly suggest that Ppl over dependent parts of the lung can exceed airway pressure by substantial amounts. Moreover, results of a pilot study in which Pes was used to titrate positive end-expiratory pressure (PEEP) suggest clinical benefit. SUMMARY Notwithstanding its theoretical limitations, esophageal manometry has shown promise in PEEP titration and deserves further evaluation in a larger trial on patients with injured lungs.
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Affiliation(s)
- Maria Plataki
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Karcz M, Vitkus A, Papadakos PJ, Schwaiberger D, Lachmann B. State-of-the-art mechanical ventilation. J Cardiothorac Vasc Anesth 2011; 26:486-506. [PMID: 21601477 DOI: 10.1053/j.jvca.2011.03.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Indexed: 02/01/2023]
Affiliation(s)
- Marcin Karcz
- Department of Anesthesiology, University of Rochester, Rochester, NY 14642, USA.
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Understanding and avoiding ventilator-induced lung injury: lessons from an insightful experimental study. Crit Care Med 2010; 38:2418-9. [PMID: 21088512 DOI: 10.1097/ccm.0b013e3181fd6747] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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