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Advanced Oxygen Therapy for the Small Animal Patient – High-Flow Oxygen Therapy and Mechanical Ventilation. Vet Clin North Am Small Anim Pract 2022; 52:689-705. [DOI: 10.1016/j.cvsm.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nyberg A, Gremo E, Blixt J, Sperber J, Larsson A, Lipcsey M, Pikwer A, Castegren M. Lung-protective ventilation increases cerebral metabolism and non-inflammatory brain injury in porcine experimental sepsis. BMC Neurosci 2021; 22:31. [PMID: 33926378 PMCID: PMC8082058 DOI: 10.1186/s12868-021-00629-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/23/2021] [Indexed: 12/03/2022] Open
Abstract
Background Protective ventilation with lower tidal volumes reduces systemic and organ-specific inflammation. In sepsis-induced encephalopathy or acute brain injury the use of protective ventilation has not been widely investigated (experimentally or clinically). We hypothesized that protective ventilation would attenuate cerebral inflammation in a porcine endotoxemic sepsis model. The aim of the study was to study the effect of tidal volume on cerebral inflammatory response, cerebral metabolism and brain injury. Nine animals received protective mechanical ventilation with a tidal volume of 6 mL × kg−1 and nine animals were ventilated with a tidal volume of 10 mL × kg−1. During a 6-h experiment, the pigs received an endotoxin intravenous infusion of 0.25 µg × kg−1 × h−1. Systemic, superior sagittal sinus and jugular vein blood samples were analysed for inflammatory cytokines and S100B. Intracranial pressure, brain tissue oxygenation and brain microdialysis were sampled every hour. Results No differences in systemic or sagittal sinus levels of TNF-α or IL-6 were seen between the groups. The low tidal volume group had increased cerebral blood flow (p < 0.001) and cerebral oxygen delivery (p < 0.001), lower cerebral vascular resistance (p < 0.05), higher cerebral metabolic rate (p < 0.05) along with higher cerebral glucose consumption (p < 0.05) and lactate production (p < 0.05). Moreover, low tidal volume ventilation increased the levels of glutamate (p < 0.01), glycerol (p < 0.05) and showed a trend towards higher lactate to pyruvate ratio (p = 0.08) in cerebral microdialysate as well as higher levels of S-100B (p < 0.05) in jugular venous plasma compared with medium–high tidal volume ventilation. Conclusions Contrary to the hypothesis, protective ventilation did not affect inflammatory cytokines. The low tidal volume group had increased cerebral blood flow, cerebral oxygen delivery and cerebral metabolism together with increased levels of markers of brain injury compared with medium–high tidal volume ventilation. Supplementary Information The online version contains supplementary material available at 10.1186/s12868-021-00629-0.
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Affiliation(s)
- Axel Nyberg
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Erik Gremo
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Jonas Blixt
- Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden.,The Department of Physiology and Pharmacology (FyFa), Karolinska Institute, Stockholm, Sweden
| | - Jesper Sperber
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Miklós Lipcsey
- Hedenstierna Laboratory, CIRRUS, Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andreas Pikwer
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Markus Castegren
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden. .,Department of Medical Sciences, Uppsala University, Uppsala, Sweden. .,Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden. .,The Department of Physiology and Pharmacology (FyFa), Karolinska Institute, Stockholm, Sweden. .,Department of Anaesthesiology & Intensive Care, Centre for Clinical Research, Sörmland, Mälarsjukhuset, 631 88, Eskilstuna, Sweden.
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3
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Hol L, Nijbroek SGLH, Schultz MJ. Perioperative Lung Protection: Clinical Implications. Anesth Analg 2020; 131:1721-1729. [PMID: 33186160 DOI: 10.1213/ane.0000000000005187] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In the past, it was common practice to use a high tidal volume (VT) during intraoperative ventilation, because this reduced the need for high oxygen fractions to compensate for the ventilation-perfusion mismatches due to atelectasis in a time when it was uncommon to use positive end-expiratory pressure (PEEP) in the operating room. Convincing and increasing evidence for harm induced by ventilation with a high VT has emerged over recent decades, also in the operating room, and by now intraoperative ventilation with a low VT is a well-adopted approach. There is less certainty about the level of PEEP during intraoperative ventilation. Evidence for benefit and harm of higher PEEP during intraoperative ventilation is at least contradicting. While some PEEP may prevent lung injury through reduction of atelectasis, higher PEEP is undeniably associated with an increased risk of intraoperative hypotension that frequently requires administration of vasoactive drugs. The optimal level of inspired oxygen fraction (FIO2) during surgery is even more uncertain. The suggestion that hyperoxemia prevents against surgical site infections has not been confirmed in recent research. In addition, gas absorption-induced atelectasis and its association with adverse outcomes like postoperative pulmonary complications actually makes use of a high FIO2 less attractive. Based on the available evidence, we recommend the use of a low VT of 6-8 mL/kg predicted body weight in all surgery patients, and to restrict use of a high PEEP and high FIO2 during intraoperative ventilation to cases in which hypoxemia develops. Here, we prefer to first increase FIO2 before using high PEEP.
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Affiliation(s)
| | | | - Marcus J Schultz
- Department of Intensive Care.,Department of Intensive Care and Anesthesiology, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location 'Amsterdam Medical Center', Amsterdam, the Netherlands.,Department of Intensive Care, Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Fordyce CB, Katz JN, Alviar CL, Arslanian-Engoren C, Bohula EA, Geller BJ, Hollenberg SM, Jentzer JC, Sims DB, Washam JB, van Diepen S. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e379-e406. [DOI: 10.1161/cir.0000000000000909] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non–CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.
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Shock Wave Therapy Enhances Mitochondrial Delivery into Target Cells and Protects against Acute Respiratory Distress Syndrome. Mediators Inflamm 2018; 2018:5425346. [PMID: 30420790 PMCID: PMC6215567 DOI: 10.1155/2018/5425346] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/05/2018] [Indexed: 01/11/2023] Open
Abstract
This study tested the hypothesis that shock wave therapy (SW) enhances mitochondrial uptake into the lung epithelial and parenchymal cells to attenuate lung injury from acute respiratory distress syndrome (ARDS). ARDS was induced in rats through continuous inhalation of 100% oxygen for 48 h, while SW entailed application 0.15 mJ/mm2 for 200 impulses at 6 Hz per left/right lung field. In vitro and ex vivo studies showed that SW enhances mitochondrial uptake into lung epithelial and parenchyma cells (all p < 0.001). Flow cytometry demonstrated that albumin levels and numbers of inflammatory cells (Ly6G+/CD14+/CD68+/CD11b/c+) in bronchoalveolar lavage fluid were the highest in untreated ARDS, were progressively reduced across SW, Mito, and SW + Mito (all p < 0.0001), and were the lowest in sham controls. The same profile was also seen for fibrosis/collagen deposition, levels of biomarkers of oxidative stress (NOX-1/NOX-2/oxidized protein), inflammation (MMP-9/TNF-α/NF-κB/IL-1β/ICAM-1), apoptosis (cleaved caspase 3/PARP), fibrosis (Smad3/TGF-β), mitochondrial damage (cytosolic cytochrome c) (all p < 0.0001), and DNA damage (γ-H2AX+), and numbers of parenchymal inflammatory cells (CD11+/CD14+/CD40L+/F4/80+) (p < 0.0001). These results suggest that SW-assisted Mito therapy effectively protects the lung parenchyma from ARDS-induced injury.
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van der Staay M, Chatburn RL. Advanced modes of mechanical ventilation and optimal targeting schemes. Intensive Care Med Exp 2018; 6:30. [PMID: 30136011 PMCID: PMC6104409 DOI: 10.1186/s40635-018-0195-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/30/2018] [Indexed: 11/26/2022] Open
Abstract
Recent research results provide new incentives to recognize and prevent ventilator-induced lung injury (VILI) and create targeting schemes for new modes of mechanical ventilation. For example, minimization of breathing power, inspiratory power, and inspiratory pressure are the underlying goals of optimum targeting schemes used in the modes called adaptive support ventilation (ASV), adaptive ventilation mode 2 (AVM2), and MID-frequency ventilation (MFV). We describe the mathematical models underlying these targeting schemes and present theoretical analyses for minimizing tidal volume, tidal pressure (also known as driving pressure), or tidal power as functions of ventilatory frequency. To go beyond theoretical equations, these targeting schemes were compared in terms of expected tidal volumes using different patient models. Results indicate that at the same ventilation efficiency (same PaCO2 level), we expect tidal volume dosage in the range of 7.4 mL/kg (for ASV), 6.2 mL/kg (for AVM2), and 6.7 mL/kg (for MFV) for adult ARDS simulation. For a neonatal RDS model, we expect 5.5 mL/kg (for ASV), 4.6 mL/kg (for AVM2), and 4.5 (for MFV).
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Liu W, Huang Q, Lin D, Zhao L, Ma J. Effect of lung protective ventilation on coronary heart disease patients undergoing lung cancer resection. J Thorac Dis 2018; 10:2760-2770. [PMID: 29997938 DOI: 10.21037/jtd.2018.04.90] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Mechanical ventilation, especially large tidal volume (Vt) one-lung ventilation (OLV), can cause ventilator-induced lung injury (VILI) that can stimulate cytokines. Meanwhile, cytokines are considered very important factor influencing coronary heart disease (CHD) patient prognosis. So minimization of pulmonary inflammatory responses by reduction of cytokine levels for CHD undergoing lung resection during OLV should be a priority. Because previous studies have demonstrated that lung-protective ventilation (LPV) reduced lung inflammation, this ventilation approach was studied for CHD patients undergoing lung resection here to evaluate the effects of LPV on pulmonary inflammatory responses. Methods This is a single center, randomized controlled trial. Primary endpoint of the study are plasma concentrations of tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-10 and C-reactive protein (CRP). Secondary endpoints include respiratory variables and hemodynamic variables. 60 CHD patients undergoing video-assisted thoracoscopic lung resection were randomly divided into conventional ventilation group [10 mL/kg Vt and 0 cmH2O positive end-expiratory pressure (PEEP), C group] and protective ventilation group (6 mL/kg Vt and 6 cmH2O PEEP, P group; 30 patients/group). Hemodynamic variables, peak inspiratory pressure (Ppeak), dynamic compliance (Cdyn), arterial oxygen tension (PaO2) and arterial carbon dioxide tension (PaCO2) were recorded as test data at three time points: T1-endotracheal intubation for two-lung ventilation (TLV) when breathing and hemodynamics were stable; T2-after TLV was substituted with OLV when breathing and hemodynamics were stable; T3-OLV was substituted with TLV at the end of surgery when breathing and hemodynamics were stable. The concentrations of TNF-α, IL-6, IL-10 and CRP in patients' blood in both groups at the very beginning of OLV (beginning of OLV) and the end moment of the surgery (end of surgery) were measured. Results The P group exhibited greater PaO2, higher Cdyn and lower Ppeak than the C group at T2, T3 (P<0.05). At the end moment of the surgery, although the P group tended to exhibit higher TNF-α and IL-10 values than the C group, the differences did not reach statistical significance(P=0.0817, P=0.0635). Compared with C group at the end moment of the surgery, IL-6 and CRP were lower in P group, the differences were statistically significant (P=0.0093, P=0.0005). There were no significant differences in hemodynamic variables between the two groups (P>0.05). Conclusions LPV can effectively reduce the airway pressure, improve Cdyn and PaO2, reduce concentrations of IL-6 and CRP during lung resection of CHD patients.Trial registration: The trial was registered in the Chinese Clinical Trial Registry.
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Affiliation(s)
- Wenjun Liu
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Qian Huang
- Department of Respiratory Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Duomao Lin
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Liyun Zhao
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jun Ma
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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8
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Abstract
Edema is typically presented as a secondary effect from injury, illness, disease, or medication, and its impact on patient wellness is nested within the underlying etiology. Therefore, it is often thought of more as an amplifier to current preexisting conditions. Edema, however, can be an independent risk factor for patient deterioration. Improper management of edema is costly not only to the patient, but also to treatment and care facilities, as mismanagement of edema results in increased lengths of hospital stay. Direct tissue trauma, disease, or inappropriate resuscitation and/or ventilation strategies result in edema formation through physical disruption and chemical messenger-based structural modifications of the microvascular barrier. Derangements in microvascular barrier function limit tissue oxygenation, nutrient flow, and cellular waste removal. Recent studies have sought to elucidate cellular signaling and structural alterations that result in vascular hyperpermeability in a variety of critical care conditions to include hemorrhage, burn trauma, and sepsis. These studies and many others have highlighted how multiple mechanisms alter paracellular and/or transcellular pathways promoting hyperpermeability. Roles for endothelial glycocalyx, extracellular matrix and basement membrane, vesiculo-vacuolar organelles, cellular junction and cytoskeletal proteins, and vascular pericytes have been described, demonstrating the complexity of microvascular barrier regulation. Understanding these basic mechanisms inside and out of microvessels aid in developing better treatment strategies to mitigate the harmful effects of excessive edema formation.
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9
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Algera AG, Pisani L, Chaves RCDF, Amorim TC, Cherpanath T, Determann R, Dongelmans DA, Paulus F, Tuinman PR, Pelosi P, Gama de Abreu M, Schultz MJ, Serpa Neto A. Effects of peep on lung injury, pulmonary function, systemic circulation and mortality in animals with uninjured lungs-a systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:25. [PMID: 29430442 DOI: 10.21037/atm.2017.12.05] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
It is well-known that positive end-expiratory pressure (PEEP) can prevent ventilator-induced lung injury (VILI) and improve pulmonary physiology in animals with injured lungs. It's uncertain whether PEEP has similar effects in animals with uninjured lungs. A systematic review of randomized controlled trials (RCTs) comparing different PEEP levels in animals with uninjured lungs was performed. Trials in animals with injured lungs were excluded, as were trials that compared ventilation strategies that also differed with respect to other ventilation settings, e.g., tidal volume size. The search identified ten eligible trials in 284 animals, including rodents and small as well as large mammals. Duration of ventilation was highly variable, from 1 to 6 hours and tidal volume size varied from 7 to 60 mL/kg. PEEP ranged from 3 to 20 cmH2O, and from 0 to 5 cmH2O, in the 'high PEEP' or 'PEEP' arms, and in the 'low PEEP' or 'no PEEP' arms, respectively. Definitions used for lung injury were quite diverse, as were other outcome measures. The effects of PEEP, at any level, on lung injury was not straightforward, with some trials showing less injury with 'high PEEP' or 'PEEP' and other trials showing no benefit. In most trials, 'high PEEP' or 'PEEP' was associated with improved respiratory system compliance, and better oxygen parameters. However, 'high PEEP' or 'PEEP' was also associated with occurrence of hypotension, a reduction in cardiac output, or development of hyperlactatemia. There were no differences in mortality. The number of trials comparing 'high PEEP' or 'PEEP' with 'low PEEP' or 'no PEEP' in animals with uninjured lungs is limited, and results are difficult to compare. Based on findings of this systematic review it's uncertain whether PEEP, at any level, truly prevents lung injury, while most trials suggest potential harmful effects on the systemic circulation.
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Affiliation(s)
- Anna Geke Algera
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Thiago Chaves Amorim
- Department of Anesthesiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thomas Cherpanath
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier Determann
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Groups, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Sperber J, Nyberg A, Lipcsey M, Melhus Å, Larsson A, Sjölin J, Castegren M. Protective ventilation reduces Pseudomonas aeruginosa growth in lung tissue in a porcine pneumonia model. Intensive Care Med Exp 2017; 5:40. [PMID: 28861863 PMCID: PMC5578946 DOI: 10.1186/s40635-017-0152-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 08/21/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Mechanical ventilation with positive end expiratory pressure and low tidal volume, i.e. protective ventilation, is recommended in patients with acute respiratory distress syndrome. However, the effect of protective ventilation on bacterial growth during early pneumonia in non-injured lungs is not extensively studied. The main objectives were to compare two different ventilator settings on Pseudomonas aeruginosa growth in lung tissue and the development of lung injury. METHODS A porcine model of severe pneumonia was used. The protective group (n = 10) had an end expiratory pressure of 10 cm H2O and a tidal volume of 6 ml x kg-1. The control group (n = 10) had an end expiratory pressure of 5 cm H2O and a tidal volume of 10 ml x kg-1. 1011 colony forming units of Pseudomonas aeruginosa were inoculated intra-tracheally at baseline, after which the experiment continued for 6 h. Two animals from each group received only saline, and served as sham animals. Lung tissue samples from each animal were used for bacterial cultures and wet-to-dry weight ratio measurements. RESULTS The protective group displayed lower numbers of Pseudomonas aeruginosa (p < 0.05) in the lung tissue, and a lower wet-to-dry ratio (p < 0.01) than the control group. The control group deteriorated in arterial oxygen tension/inspired oxygen fraction, whereas the protective group was unchanged (p < 0.01). CONCLUSIONS In early phase pneumonia, protective ventilation with lower tidal volume and higher end expiratory pressure has the potential to reduce the pulmonary bacterial burden and the development of lung injury.
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Affiliation(s)
- Jesper Sperber
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden. .,Centre for Clinical Research Sörmland, Department of Anesthesiology & Intensive Care Mälarsjukhuset, SE-631 88, Eskilstuna, Sweden.
| | - Axel Nyberg
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.,Centre for Clinical Research Sörmland, Department of Anesthesiology & Intensive Care Mälarsjukhuset, SE-631 88, Eskilstuna, Sweden
| | - Miklos Lipcsey
- Hedenstierna laboratory, Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Åsa Melhus
- Department of Medical Sciences, Section of Clinical Microbiology, Uppsala University, Uppsala, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Biochemical structure and function, Uppsala University, Uppsala, Sweden
| | - Jan Sjölin
- Department of Medical Sciences, Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Markus Castegren
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.,Hedenstierna laboratory, Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden.,Perioperative Medicine and Intensive Care, Karolinska University Hospital and CLINTEC, Karolinska Institute, Stockholm, Sweden
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11
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Martin DC, Richards GN. Predicted body weight relationships for protective ventilation - unisex proposals from pre-term through to adult. BMC Pulm Med 2017; 17:85. [PMID: 28535820 PMCID: PMC5442651 DOI: 10.1186/s12890-017-0427-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The lung-protective ventilation bundle has been shown to reduce mortality in adult acute respiratory distress syndrome (ARDS). This concept has expanded to other areas of acute adult ventilation and is recommended for pediatric ventilation. A component of lung-protective ventilation relies on a prediction of lean body weight from height. The predicted body weight (PBW) relationship employed in the ARDS Network trial is considered valid only for adults, with a dedicated formula required for each sex. No agreed PBW formula applies to smaller body sizes. This analysis investigated whether it might be practical to derive a unisex PBW formula spanning all body sizes, while retaining relevance to established adult protective ventilation practice. METHODS Historic population-based growth charts were adopted as a reference for lean body weight, from pre-term infant through to adult median weight. The traditional ARDSNet PBW formulae acted as the reference for prevailing protective ventilation practice. Error limits for derived PBW models were relative to these references. RESULTS The ARDSNet PBW formulae typically predict weights heavier than the population median, therefore no single relationship could satisfy both references. Four alternate piecewise-linear lean body-weight predictive formulae were presented for consideration, each with different balance between the objectives. CONCLUSIONS The 'PBWuf + MBW' model is proposed as an appropriate compromise between prevailing practice and simplification, while also better representing lean adult body-weight. This model applies the ARDSNet 'female' formula to both adult sexes, while providing a tight fit to median body weight at smaller statures down to pre-term. The 'PBWmf + MBW' model retains consistency with current practice over the adult range, while adding prediction for small statures.
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Affiliation(s)
- Dion C Martin
- ResMed Science Center, ResMed Ltd, 1 Elizabeth Macarthur Drive, Bella Vista, 2153, Sydney, Australia.
| | - Glenn N Richards
- ResMed Science Center, ResMed Ltd, 1 Elizabeth Macarthur Drive, Bella Vista, 2153, Sydney, Australia
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12
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Stueber T, Karsten J, Voigt N, Wilhelmi M. Influence of intraoperative positive end-expiratory pressure level on pulmonary complications in emergency major trauma surgery. Arch Med Sci 2017; 13:396-403. [PMID: 28261294 PMCID: PMC5332443 DOI: 10.5114/aoms.2016.59868] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/28/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Pulmonary complications have a major impact on the morbidity and mortality of critically ill patients with multiple trauma. Intraoperative protective ventilation with low tidal volume may prevent lung injury and infection, whereas the role of positive end-expiratory pressure (PEEP) levels is unclear. The aim of this study was to evaluate the influence of different intraoperative PEEP levels on incidence of pulmonary complications after emergency trauma surgery. MATERIAL AND METHODS We retrospectively analysed data of multiple trauma patients who underwent emergency surgery within 24 h after injury in our level I trauma centre (n = 86). On the basis of their intraoperative PEEP level, patients were divided into a low PEEP group with a PEEP of < 8 mbar and a high PEEP group with a PEEP of 8 mbar or higher. RESULTS Besides differences in body mass index and preoperative oxygenation, there were no differences in patients' baseline data. There was a significant difference between incidence of pneumonia within 7 days after trauma surgery, with an incidence 26.7% in the low PEEP group and 7.3% in the high PEEP group (p = 0.02). The low PEEP group had higher pulmonary infection scores at days 3 and 5 after surgery. Oxygenation was better in the higher PEEP group postoperatively. There was no difference with respect to the incidence of acute respiratory distress syndrome, the mortality up until hospital discharge or haemodynamic parameters between groups. CONCLUSIONS Higher PEEP levels were associated with perioperative improvement of oxygenation and a lower incidence of pneumonia, without impairment of haemodynamics. Additional studies should be initiated to confirm these observations.
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Affiliation(s)
- Thomas Stueber
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Jan Karsten
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Nikolas Voigt
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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13
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Schultz MJ, Serpa-Neto A. Optimizing perioperative mechanical ventilation as a key quality improvement target. Rev Bras Ter Intensiva 2016; 27:102-4. [PMID: 26340148 PMCID: PMC4489776 DOI: 10.5935/0103-507x.20150019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/01/2015] [Indexed: 11/20/2022] Open
Affiliation(s)
- Marcus J Schultz
- Laboratório de Terapia Intensiva e Anestesiologia Experimental (L.E.I.C.A), Centro Médico Acadêmico, University of Amsterdam, Amsterdam, Holanda
| | - Ary Serpa-Neto
- Departamento de Medicina Intensiva, Centro Médico Acadêmico, University of Amsterdam, Amsterdam, Holanda
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14
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Taniguchi C, Carnieli-Cazati D, Timenetsky KT, Saghabi C, Azevedo CSA, Correa NG, Schettino GPP, Eid RAC, Serpa Neto A. Implementation of an educational program to decrease the tidal volume size in a general intensive care unit: a pilot study. Intensive Care Med 2016; 42:1185-6. [PMID: 27189476 DOI: 10.1007/s00134-016-4359-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Corinne Taniguchi
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Denise Carnieli-Cazati
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Karina T Timenetsky
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Cilene Saghabi
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Carolina Sant'Anna A Azevedo
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Nathalia G Correa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Guilherme P P Schettino
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Raquel A C Eid
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 627, São Paulo, Brazil. .,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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15
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dos Reis FF, Reboredo MDM, Lucinda LMF, Bianchi AMA, Rabelo MAE, da Fonseca LMC, de Oliveira JCA, Pinheiro BV. Pre-treatment with dexamethasone attenuates experimental ventilator-induced lung injury. J Bras Pneumol 2016; 42:166-73. [PMID: 27383928 PMCID: PMC5569612 DOI: 10.1590/s1806-37562015000000350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 05/09/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the effects that administering dexamethasone before the induction of ventilator-induced lung injury (VILI) has on the temporal evolution of that injury. METHODS Wistar rats were allocated to one of three groups: pre-VILI administration of dexamethasone (dexamethasone group); pre-VILI administration of saline (control group); or ventilation only (sham group). The VILI was induced by ventilation at a high tidal volume. Animals in the dexamethasone and control groups were euthanized at 0, 4, 24, and 168 h after VILI induction. We analyzed arterial blood gases, lung edema, cell counts (total and differential) in the BAL fluid, and lung histology. RESULTS At 0, 4, and 24 h after VILI induction, acute lung injury (ALI) scores were higher in the control group than in the sham group (p < 0.05). Administration of dexamethasone prior to VILI induction decreased the severity of the lung injury. At 4 h and 24 h after induction, the ALI score in the dexamethasone group was not significantly different from that observed for the sham group and was lower than that observed for the control group (p < 0.05). Neutrophil counts in BAL fluid were increased in the control and dexamethasone groups, peaking at 4 h after VILI induction (p < 0.05). However, the neutrophil counts were lower in the dexamethasone group than in the control group at 4 h and 24 h after induction (p < 0.05). Pre-treatment with dexamethasone also prevented the post-induction oxygenation impairment seen in the control group. CONCLUSIONS Administration of dexamethasone prior to VILI induction attenuates the effects of the injury in Wistar rats. The molecular mechanisms of such injury and the possible clinical role of corticosteroids in VILI have yet to be elucidated. OBJETIVO Avaliar os efeitos da administração de dexametasona antes da indução de lesão pulmonar induzida por ventilação mecânica (LPIVM) na evolução temporal dessa lesão. MÉTODOS Ratos Wistar foram alocados em um dos três grupos: administração de dexametasona pré-LPIVM (grupo dexametasona); administração de salina pré-LPIVM (grupo controle); e somente ventilação (grupo sham). A LPIVM foi realizada por ventilação com volume corrente alto. Os animais dos grupos dexametasona e controle foram sacrificados em 0, 4, 24 e 168 h após LPIVM. Analisamos gasometria arterial, edema pulmonar, contagens de células (totais e diferenciais) no lavado broncoalveolar e histologia de tecido pulmonar. RESULTADOS Em 0, 4 e 24 h após LPIVM, os escores de lesão pulmonar aguda (LPA) foram maiores no grupo controle que no grupo sham (p < 0,05). A administração de dexametasona antes da LPIVM reduziu a gravidade da lesão pulmonar. Em 4 e 24 h após a indução, o escore de LPA no grupo dexametasona não foi significativamente diferente daquele observado no grupo sham e foi menor que o observado no grupo controle (p < 0,05). As contagens de neutrófilos no lavado broncoalveolar estavam aumentadas nos grupos controle e dexametasona, com pico em 4 h após LPIVM (p < 0,05). Entretanto, as contagens de neutrófilos foram menores no grupo dexametasona que no grupo controle em 4 e 24 h após LPIVM (p < 0,05). O pré-tratamento com dexametasona também impediu o comprometimento da oxigenação após a indução visto no grupo controle. CONCLUSÕES A administração de dexametasona antes de LPIVM atenua os efeitos da lesão em ratos Wistar. Os mecanismos moleculares dessa lesão e o possível papel clínico dos corticosteroides na LPIVM ainda precisam ser elucidados.
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Affiliation(s)
- Fernando Fonseca dos Reis
- . Laboratório de Pesquisa em Pneumologia, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
- . Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
| | - Maycon de Moura Reboredo
- . Laboratório de Pesquisa em Pneumologia, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
- . Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
| | - Leda Marília Fonseca Lucinda
- . Laboratório de Pesquisa em Pneumologia, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
- . Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
| | - Aydra Mendes Almeida Bianchi
- . Laboratório de Pesquisa em Pneumologia, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
- . Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
| | | | - Lídia Maria Carneiro da Fonseca
- . Laboratório de Pesquisa em Pneumologia, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
- . Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
| | | | - Bruno Valle Pinheiro
- . Laboratório de Pesquisa em Pneumologia, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
- . Centro de Biologia da Reprodução, Universidade Federal de Juiz de Fora, Juiz de Fora (MG) Brasil
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16
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Nieman GF, Gatto LA, Bates JHT, Habashi NM. Mechanical Ventilation as a Therapeutic Tool to Reduce ARDS Incidence. Chest 2016; 148:1396-1404. [PMID: 26135199 DOI: 10.1378/chest.15-0990] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Trauma, hemorrhagic shock, or sepsis can incite systemic inflammatory response syndrome, which can result in early acute lung injury (EALI). As EALI advances, improperly set mechanical ventilation (MV) can amplify early injury into a secondary ventilator-induced lung injury that invariably develops into overt ARDS. Once established, ARDS is refractory to most therapeutic strategies, which have not been able to lower ARDS mortality below the current unacceptably high 40%. Low tidal volume ventilation is one of the few treatments shown to have a moderate positive impact on ARDS survival, presumably by reducing ventilator-induced lung injury. Thus, there is a compelling case to be made that the focus of ARDS management should switch from treatment once this syndrome has become established to the application of preventative measures while patients are still in the EALI stage. Indeed, studies have shown that ARDS incidence is markedly reduced when conventional MV is applied preemptively using a combination of low tidal volume and positive end-expiratory pressure in both patients in the ICU and in surgical patients at high risk for developing ARDS. Furthermore, there is evidence from animal models and high-risk trauma patients that superior prevention of ARDS can be achieved using preemptive airway pressure release ventilation with a very brief duration of pressure release. Preventing rather than treating ARDS may be the way forward in dealing with this recalcitrant condition and would represent a paradigm shift in the way that MV is currently practiced.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY.
| | | | | | - Nader M Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
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17
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Serpa Neto A, Schultz MJ, Gama de Abreu M. Intraoperative ventilation strategies to prevent postoperative pulmonary complications: Systematic review, meta-analysis, and trial sequential analysis. Best Pract Res Clin Anaesthesiol 2015; 29:331-40. [PMID: 26643098 DOI: 10.1016/j.bpa.2015.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/10/2015] [Indexed: 01/16/2023]
Abstract
For many years, mechanical ventilation with high tidal volumes (V(T)) was common practice in operating theaters because this strategy recruits collapsed lung tissue, improves ventilation-perfusion mismatch, and thus decreases the need for high oxygen fractions. Positive end-expiratory pressure (PEEP) was seldom used because it could cause cardiac compromise. Increasing advances in the understanding of the mechanisms of ventilator-induced lung injury from animal studies and randomized controlled trials in patients with uninjured lungs in intensive care unit and operation room have pushed anesthesiologists to consider lung-protective strategies during intraoperative ventilation. These strategies at least include the use of low V(T), and perhaps also the use of PEEP, which when compared to high V(T) with low PEEP may prevent the occurrence of postoperative pulmonary complications (PPCs). Such protective effects, however, are likely ascribed to low V(T) rather than to PEEP. In fact, at least in nonobese patients undergoing open abdominal surgery, high PEEP does not protect against PPCs, and it can impair the hemodynamics. Further studies shall determine whether a strategy consisting of low V(T) combined with PEEP and recruitment maneuvers reduces PPCs in obese patients and other types of surgery (e.g., laparoscopic and thoracic), compared to low V(T) with low PEEP. Furthermore, the role of driving pressure for titrating ventilation settings in patients with uninjured lungs shall be investigated.
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Affiliation(s)
- Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, Santo André, Brazil; Department of Intensive Care, Academic Medical Center at The University of Amsterdam, Amsterdam, The Netherlands.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center at The University of Amsterdam, Amsterdam, The Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center at The University of Amsterdam, Amsterdam, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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18
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Modes of mechanical ventilation for the operating room. Best Pract Res Clin Anaesthesiol 2015; 29:285-99. [DOI: 10.1016/j.bpa.2015.08.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/20/2015] [Indexed: 12/22/2022]
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