1
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de Haro C, Santos-Pulpón V, Telías I, Xifra-Porxas A, Subirà C, Batlle M, Fernández R, Murias G, Albaiceta GM, Fernández-Gonzalo S, Godoy-González M, Gomà G, Nogales S, Roca O, Pham T, López-Aguilar J, Magrans R, Brochard L, Blanch L, Sarlabous L. Flow starvation during square-flow assisted ventilation detected by supervised deep learning techniques. Crit Care 2024; 28:75. [PMID: 38486268 PMCID: PMC10938655 DOI: 10.1186/s13054-024-04845-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/19/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Flow starvation is a type of patient-ventilator asynchrony that occurs when gas delivery does not fully meet the patients' ventilatory demand due to an insufficient airflow and/or a high inspiratory effort, and it is usually identified by visual inspection of airway pressure waveform. Clinical diagnosis is cumbersome and prone to underdiagnosis, being an opportunity for artificial intelligence. Our objective is to develop a supervised artificial intelligence algorithm for identifying airway pressure deformation during square-flow assisted ventilation and patient-triggered breaths. METHODS Multicenter, observational study. Adult critically ill patients under mechanical ventilation > 24 h on square-flow assisted ventilation were included. As the reference, 5 intensive care experts classified airway pressure deformation severity. Convolutional neural network and recurrent neural network models were trained and evaluated using accuracy, precision, recall and F1 score. In a subgroup of patients with esophageal pressure measurement (ΔPes), we analyzed the association between the intensity of the inspiratory effort and the airway pressure deformation. RESULTS 6428 breaths from 28 patients were analyzed, 42% were classified as having normal-mild, 23% moderate, and 34% severe airway pressure deformation. The accuracy of recurrent neural network algorithm and convolutional neural network were 87.9% [87.6-88.3], and 86.8% [86.6-87.4], respectively. Double triggering appeared in 8.8% of breaths, always in the presence of severe airway pressure deformation. The subgroup analysis demonstrated that 74.4% of breaths classified as severe airway pressure deformation had a ΔPes > 10 cmH2O and 37.2% a ΔPes > 15 cmH2O. CONCLUSIONS Recurrent neural network model appears excellent to identify airway pressure deformation due to flow starvation. It could be used as a real-time, 24-h bedside monitoring tool to minimize unrecognized periods of inappropriate patient-ventilator interaction.
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Affiliation(s)
- Candelaria de Haro
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació I Innovació Parc Taulí (I3PT-CERCA),, Carrer Parc Taulí, 1, 08208, Sabadell, Spain.
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Verónica Santos-Pulpón
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
| | - Irene Telías
- Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Alba Xifra-Porxas
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
| | - Carles Subirà
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Manresa, Spain
- IRIS - Catalunya Central I Grup de Recerca de Malalt Crític, Manresa, Spain
| | - Montserrat Batlle
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Manresa, Spain
- IRIS - Catalunya Central I Grup de Recerca de Malalt Crític, Manresa, Spain
| | - Rafael Fernández
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Critial Care Department, Althaia Xarxa Assistencial Universtaria de Manresa, Manresa, Spain
- IRIS - Catalunya Central I Grup de Recerca de Malalt Crític, Manresa, Spain
| | - Gastón Murias
- Critical Care Department, Hospital Británico, Buenos Aires, Argentina
| | - Guillermo M Albaiceta
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias. Universidad de Oviedo, Oviedo, Spain
| | - Sol Fernández-Gonzalo
- Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Gemma Gomà
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació I Innovació Parc Taulí (I3PT-CERCA),, Carrer Parc Taulí, 1, 08208, Sabadell, Spain
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sara Nogales
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació I Innovació Parc Taulí (I3PT-CERCA),, Carrer Parc Taulí, 1, 08208, Sabadell, Spain
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Roca
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació I Innovació Parc Taulí (I3PT-CERCA),, Carrer Parc Taulí, 1, 08208, Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Tai Pham
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, Center de Recherche en Epidémiologie et Santé Des Populations, Villejuif, France
| | - Josefina López-Aguilar
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
| | | | - Laurent Brochard
- Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Lluís Blanch
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació I Innovació Parc Taulí (I3PT-CERCA),, Carrer Parc Taulí, 1, 08208, Sabadell, Spain
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Leonardo Sarlabous
- Centro Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Sabadell, Spain
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2
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Widing H, Pellegrini M, Chiodaroli E, Persson P, Hallén K, Perchiazzi G. Positive end-expiratory pressure limits inspiratory effort through modulation of the effort-to-drive ratio: an experimental crossover study. Intensive Care Med Exp 2024; 12:10. [PMID: 38311676 PMCID: PMC10838888 DOI: 10.1186/s40635-024-00597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/11/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND How assisted spontaneous breathing should be used during acute respiratory distress syndrome is questioned. Recent evidence suggests that high positive end-expiratory pressure (PEEP) may limit the risk of patient self-inflicted lung injury (P-SILI). The aim of this study was to assess the effects of PEEP on esophageal pressure swings, inspiratory drive, and the neuromuscular efficiency of ventilation. We hypothesized that high PEEP would reduce esophageal pressure swings, regardless of inspiratory drive changes, by modulating the effort-to-drive ratio (EDR). This was tested retrospectively in an experimental animal crossover study. Anesthetized pigs (n = 15) were subjected to mild to moderate lung injury and different PEEP levels were applied, changing PEEP from 0 to 15 cmH2O and back to 0 cmH2O in steps of 3 cmH2O. Airway pressure, esophageal pressure (Pes), and electric activity of the diaphragm (Edi) were collected. The EDR was calculated as the tidal change in Pes divided by the tidal change in Edi. Statistical differences were tested using the Wilcoxon signed-rank test. RESULTS Inspiratory esophageal pressure swings decreased from - 4.2 ± 3.1 cmH2O to - 1.9 ± 1.5 cmH2O (p < 0.01), and the mean EDR fell from - 1.12 ± 1.05 cmH2O/µV to - 0.24 ± 0.20 (p < 0.01) as PEEP was increased from 0 to 15 cmH2O. The EDR was significantly correlated to the PEEP level (rs = 0.35, p < 0.01). CONCLUSIONS Higher PEEP limits inspiratory effort by modulating the EDR of the respiratory system. These findings indicate that PEEP may be used in titration of the spontaneous impact on ventilation and in P-SILI risk reduction, potentially facilitating safe assisted spontaneous breathing. Similarly, ventilation may be shifted from highly spontaneous to predominantly controlled ventilation using PEEP. These findings need to be confirmed in clinical settings.
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Affiliation(s)
- Hannes Widing
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden.
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.
| | - Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Department of Anesthesia, Operation, and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Elena Chiodaroli
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Anesthesia and Intensive Care Medicine, Polo Universitario San Paolo, University of Milan, Milan, Italy
| | - Per Persson
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Hallén
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Department of Anesthesia, Operation, and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
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3
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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4
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Sistanian F, Sedaghat A, Badpeyma M, Rezaiyan MK, Moghaddam AB, Ranjbar G, Arabi M, Bagherniya M, Norouzy A. Low plasma vitamin D is associated with increased 28-day mortality and worse clinical outcomes in critically ill patients. BMC Nutr 2024; 10:6. [PMID: 38195535 PMCID: PMC10775546 DOI: 10.1186/s40795-023-00801-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 11/24/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND & OBJECTIVE Patients in the intensive care unit have a high prevalence of vitamin D deficiency (VDD). In the present study, clinical outcomes in the ICU were analyzed with vitamin D status. MATERIALS AND METHODS In this prospective, multicenter study, sampling was conducted on seven ICUs in three hospitals. Within the first 24 h of ICU admission, patient's serum vitamin D levels were measured, and their disease severity was monitored using the scores of acute physiologic assessment and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), and the modified Nutrition Risk in Critically ill (mNUTRIC) score. RESULTS A total of 236 patients were enrolled in this study, of which 163 (69.1%) had lower vitamin D levels than 20 ng/ml upon ICU admission. The patients with VDD had higher APACHE II scores)P = 0.02), SOFA scores (P < 0.001), and mNUTRIC scores (P = 0.01). Patients with sufficient levels of vitamin D (> 30 ng/ml) had a shorter stay at ICU (P < 0.001). VDD was independently associated with 28-day mortality (OR: 4.83; 95% CI: 1.63-14.27; P = 0.004). CONCLUSION The data showed that VDD was common among the critically ill and was related to a more severe course of illness and a higher mortality rate.
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Affiliation(s)
- Fatemeh Sistanian
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 985138002421, Iran
| | - Alireza Sedaghat
- Department of Anesthesiology, Faculty of Medicine, Lung Diseases Research Center, Mashhad University of Medical Science, Mashhad, Iran
| | - Mohaddeseh Badpeyma
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Clinical Nutrition, Nutrition Research Center, School of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Majid Khadem Rezaiyan
- Department of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ahmad Bagheri Moghaddam
- Department of Anesthesiology, Faculty of Medicine, Lung Diseases Research Center, Mashhad University of Medical Science, Mashhad, Iran
| | - Golnaz Ranjbar
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 985138002421, Iran
| | - Mostafa Arabi
- Department of Basic Sciences, School of Medicine, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Mohammad Bagherniya
- Nutrition and Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
- Anesthesia and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abdolreza Norouzy
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, 985138002421, Iran.
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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5
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Zhang J, Feng J, Jia J, Wang X, Zhou J, Liu L. Research progress on the pathogenesis and treatment of ventilator-induced diaphragm dysfunction. Heliyon 2023; 9:e22317. [PMID: 38053869 PMCID: PMC10694316 DOI: 10.1016/j.heliyon.2023.e22317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/07/2023] Open
Abstract
Prolonged controlled mechanical ventilation (CMV) can cause diaphragm fiber atrophy and inspiratory muscle weakness, resulting in diaphragmatic contractile dysfunction, called ventilator-induced diaphragm dysfunction (VIDD). VIDD is associated with higher rates of in-hospital deaths, nosocomial pneumonia, difficulty weaning from ventilators, and increased costs. Currently, appropriate clinical strategies to prevent and treat VIDD are unavailable, necessitating the importance of exploring the mechanisms of VIDD and suitable treatment options to reduce the healthcare burden. Numerous animal studies have demonstrated that ventilator-induced diaphragm dysfunction is associated with oxidative stress, increased protein hydrolysis, disuse atrophy, and calcium ion disorders. Therefore, this article summarizes the molecular pathogenesis and treatment of ventilator-induced diaphragm dysfunction in recent years so that it can be better served clinically and is essential to reduce the duration of mechanical ventilation use, intensive care unit (ICU) length of stay, and the medical burden.
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Affiliation(s)
- Jumei Zhang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Jianguo Feng
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Jing Jia
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Xiaobin Wang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Jun Zhou
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
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6
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Alay GH, Tatlisuluoglu D, Turan G. Evaluation of IntelliVent-ASV® and PS-SIMV Mode Using Ultrasound (US) Measurements in Terms of Diaphragm Atrophy. Cureus 2023; 15:e40244. [PMID: 37309540 PMCID: PMC10257811 DOI: 10.7759/cureus.40244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Mechanical ventilation is a life-saving intervention for critically ill patients, but it can also lead to diaphragm atrophy, which may prolong the duration of mechanical ventilation and the length of stay in the intensive care unit. IntelliVent-ASV® (Hamilton Medical, Rhäzüns, Switzerland) is a new mode of ventilation that has been developed to reduce diaphragm atrophy by promoting spontaneous breathing efforts. In this study, we aimed to evaluate the effectiveness of IntelliVent-ASV® and pressure support-synchronized intermittent mandatory ventilation (PS-SIMV) mode in reducing diaphragm atrophy by measuring diaphragm thickness using ultrasound (US) imaging. METHODS We enrolled 60 patients who required mechanical ventilation due to respiratory failure and were randomized into two groups: IntelliVent-ASV® and PS-SIMV. We measured the diaphragm thickness using US imaging at admission and on the seventh day of mechanical ventilation. RESULTS Our results showed that diaphragm thickness decreased significantly in the PS-SIMV group but remained unchanged in the IntelliVent-ASV® group. The difference in diaphragm thickness between the two groups was statistically significant on the seventh day of mechanical ventilation. CONCLUSIONS IntelliVent-ASV® may reduce diaphragm atrophy by promoting spontaneous breathing efforts. Our study suggests that this new mode of ventilation may be a promising approach to preventing diaphragm atrophy in mechanically ventilated patients. Further studies using invasive measures of diaphragm function are warranted to confirm these findings.
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Affiliation(s)
- Gulcin Hilal Alay
- Intensive Care Unit, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, TUR
| | - Derya Tatlisuluoglu
- Intensive Care Unit, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, TUR
| | - Guldem Turan
- Intensive Care Unit, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, TUR
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7
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Duyndam A, Smit J, Heunks L, Molinger J, IJland M, van Rosmalen J, van Dijk M, Tibboel D, Ista E. Reference values of diaphragmatic dimensions in healthy children aged 0-8 years. Eur J Pediatr 2023:10.1007/s00431-023-04920-6. [PMID: 36939879 DOI: 10.1007/s00431-023-04920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/21/2023]
Abstract
Diaphragmatic thickness (Tdi) and diaphragm thickening fraction (dTF) are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children are scarce. We determined reference values of Tdi and dTF using ultrasound in healthy children aged 0-8 years old and assessed their reproducibility. In a prospective, observational cohort, Tdi and dTF were measured on ultrasound images across four age groups comprising at least 30 children per group: group 1 (0-6 months), group 2 (7 months-1 year), group 3 (2-4 years) and group 4 (5-8 years). Ultrasound images of 137 healthy children were included. Mean Tdi at inspiration was 2.07 (SD 0.40), 2.09 (SD 0.40), 1.69 (SD 0.30) and 1.72 (SD 0.30) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at expiration was 1.64 (SD 0.30), 1.67 (SD 0.30), 1.38 (SD 0.20) and 1.42 (SD 0.20) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at inspiration and mean Tdi at expiration for groups 1 and 2 were significantly greater than those for groups 3 and 4 (both p < 0.001). Mean dTF was 25.4% (SD 10.4), 25.2% (SD 8.3), 22.8% (SD 10.9) and 21.3% (SD 7.1) for group 1, 2, 3 and 4, respectively. The intraclass correlation coefficients (ICC) representing the level of inter-rater reliability between two examiners performing the ultrasounds was 0.996 (95% CI 0.982-0.999). ICC of the inter-rater reliability between the raters in 11 paired assessments was 0.989 (95% CI 0.973-0.995). Conclusion: Ultrasound measurements of Tdi and dTF were highly reproducible in healthy children aged 0-8 years. Trial registration: ClinicalTrials.gov identifier (NCT number): NCT04589910. What is Known: • Diaphragmatic thickness and diaphragm thickening fraction are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children to compare these with are scarce. What is New: • We determined normal values of diaphragmatic thickness and diaphragm thickening fraction using ultrasound in 137 healthy children aged 0-8 years old. The diaphragmatic thickness of infants up to 1 year old was significantly greater than that of children from 2 to 8 years old. Diaphragmatic thickness decreased with an increase in body surface area. These normal values in healthy children can be used to assess changes in respiratory muscle thickness in mechanically ventilated children.
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Affiliation(s)
- Anita Duyndam
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands.
| | - Joke Smit
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
| | - Leo Heunks
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jeroen Molinger
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Division of Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Marloes IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Monique van Dijk
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
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8
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Santana PV, Cardenas LZ, de Albuquerque ALP. Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts. Diagnostics (Basel) 2023; 13:diagnostics13061116. [PMID: 36980423 PMCID: PMC10046995 DOI: 10.3390/diagnostics13061116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
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Affiliation(s)
- Pauliane Vieira Santana
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| | - Letícia Zumpano Cardenas
- Intensive Care Unit, Physical Therapy Department, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
| | - Andre Luis Pereira de Albuquerque
- Pulmonary Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo 01308-060, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
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Soundoulounaki S, Sylligardos E, Akoumianaki E, Sigalas M, Kondili E, Georgopoulos D, Trahanias P, Vaporidi K. Neural Network-Enabled Identification of Weak Inspiratory Efforts during Pressure Support Ventilation Using Ventilator Waveforms. J Pers Med 2023; 13:jpm13020347. [PMID: 36836581 PMCID: PMC9966968 DOI: 10.3390/jpm13020347] [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: 01/16/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023] Open
Abstract
During pressure support ventilation (PSV), excessive assist results in weak inspiratory efforts and promotes diaphragm atrophy and delayed weaning. The aim of this study was to develop a classifier using a neural network to identify weak inspiratory efforts during PSV, based on the ventilator waveforms. Recordings of flow, airway, esophageal and gastric pressures from critically ill patients were used to create an annotated dataset, using data from 37 patients at 2-5 different levels of support, computing the inspiratory time and effort for every breath. The complete dataset was randomly split, and data from 22 patients (45,650 breaths) were used to develop the model. Using a One-Dimensional Convolutional Neural Network, a predictive model was developed to characterize the inspiratory effort of each breath as weak or not, using a threshold of 50 cmH2O*s/min. The following results were produced by implementing the model on data from 15 different patients (31,343 breaths). The model predicted weak inspiratory efforts with a sensitivity of 88%, specificity of 72%, positive predictive value of 40%, and negative predictive value of 96%. These results provide a 'proof-of-concept' for the ability of such a neural-network based predictive model to facilitate the implementation of personalized assisted ventilation.
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Affiliation(s)
- Stella Soundoulounaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Emmanouil Sylligardos
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Markos Sigalas
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Panos Trahanias
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Correspondence:
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10
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Itagaki T, Akimoto Y, Nakano Y, Ueno Y, Ishihara M, Tane N, Tsunano Y, Oto J. Relationships between double cycling and inspiratory effort with diaphragm thickness during the early phase of mechanical ventilation: A prospective observational study. PLoS One 2022; 17:e0273173. [PMID: 35976965 PMCID: PMC9385032 DOI: 10.1371/journal.pone.0273173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Increased and decreased diaphragm thickness during mechanical ventilation is associated with poor outcomes. Some types of patient-ventilator asynchrony theoretically cause myotrauma of the diaphragm. However, the effects of double cycling on structural changes in the diaphragm have not been previously evaluated. Hence, this study aimed to investigate the relationship between double cycling during the early phase of mechanical ventilation and changes in diaphragm thickness, and the involvement of inspiratory effort in the occurrence of double cycling. Methods We evaluated adult patients receiving invasive mechanical ventilation for more than 48 h. The end-expiratory diaphragm thickness (Tdiee) was assessed via ultrasonography on days 1, 2, 3, 5 and 7 after the initiation of mechanical ventilation. Then, the maximum rate of change from day 1 (ΔTdiee%) was evaluated. Concurrently, we recorded esophageal pressure and airway pressure on days 1, 2 and 3 for 1 h during spontaneous breathing. Then, the waveforms were retrospectively analyzed to calculate the incidence of double cycling (double cycling index) and inspiratory esophageal pressure swing (ΔPes). Finally, the correlation between double cycling index as well as ΔPes and ΔTdiee% was investigated using linear regression models. Results In total, 19 patients with a median age of 69 (interquartile range: 65–78) years were enrolled in this study, and all received pressure assist-control ventilation. The Tdiee increased by more than 10% from baseline in nine patients, decreased by more than 10% in nine and remained unchanged in one. The double cycling indexes on days 1, 2 and 3 were 2.2%, 1.3% and 4.5%, respectively. There was a linear correlation between the double cycling index on day 3 and ΔTdiee% (R2 = 0.446, p = 0.002). The double cycling index was correlated with the ΔPes on days 2 (R2 = 0.319, p = 0.004) and 3 (R2 = 0.635, p < 0.001). Conclusions Double cycling on the third day of mechanical ventilation was associated with strong inspiratory efforts and, possibly, changes in diaphragm thickness.
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Affiliation(s)
- Taiga Itagaki
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, Tokushima, Japan
- * E-mail:
| | - Yusuke Akimoto
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yuki Nakano
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yoshitoyo Ueno
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Manabu Ishihara
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Natsuki Tane
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Yumiko Tsunano
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Jun Oto
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
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11
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Tagliabue G, Ji M, Suneby Jagers JV, Zuege DJ, Kieser TM, Easton PA. Expiratory and Inspiratory Action of Transversus Abdominis During Eupnea and Hypercapnic Ventilation. Respir Physiol Neurobiol 2022; 306:103951. [PMID: 35914691 DOI: 10.1016/j.resp.2022.103951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recently, there is interest in the clinical importance of monitoring abdominal muscles during respiratory failure. The clinical interpretation relies on the assumption that expiration is a passive physiologic process and, since diaphragm and abdomen are arranged in series, any inward motion of the abdominal wall represents a sign of diaphragm dysfunction. However, previous studies suggest Transversus Abdominis might be active even during eupnea and is preferentially recruited over the other abdominal muscles. OBJECTIVE 1) Is Transversus Abdominis normally recruited during eupnea? 2) What is the degree of activation of Transversus Abdominis during hypercapnia? 3) Does the end-inspiratory length of Transversus Abdominis change during hypercapnia, while diaphragm function is normal? METHODS In 30 spontaneously breathing canines, awake without confounding anesthetic, we measured directly both electrical activity and corresponding mechanical length and shortening of Transversus Abdominis during eupnea and hypercapnia. RESULTS Transversus Abdominis is consistently recruited during eupnea. During hypercapnia, Transversus Abdominis recruitment is progressive and significant. Throughout hypercapnia, Transversus Abdominis baseline end-inspiratory length is not constant: baseline length decreases progressively throughout hypercapnia. After expiration, into early inspiration, Transversus Abdominis shows a consistent neural mechanical post -expiratory expiratory activity (PEEA) at rest, which progressively increases during hypercapnia. CONCLUSION Transversus Abdominis is an obligatory expiratory muscle, reinforcing the fundamental principle expiration is not a passive process. Beyond expiration, during hypercapnic ventilation, Transversus Abdominis contributes as an "accessory inspiratory muscle" into the early phase of inspiration. Clinical monitoring of abdominal wall motion during respiratory failure may be confounded by action of Transversus Abdominis.
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Affiliation(s)
- Giovanni Tagliabue
- University of Calgary, Department of Critical Care Medicine, Calgary, Alberta, Canada
| | - Michael Ji
- University of Calgary, Department of Critical Care Medicine, Calgary, Alberta, Canada
| | - Jenny V Suneby Jagers
- University of Calgary, Department of Critical Care Medicine, Calgary, Alberta, Canada
| | - Dan J Zuege
- University of Calgary, Department of Critical Care Medicine, Calgary, Alberta, Canada
| | - Teresa M Kieser
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Paul A Easton
- University of Calgary, Department of Critical Care Medicine, Calgary, Alberta, Canada.
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12
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Imamović A, Wagner D, Lindenmann J, Fink-Neuböck N, Sauseng S, Bajric T, Werkgartner G, Mischinger HJ. Life threatening rupture of the diaphragm after Covid 19 pneumonia: a case report. J Cardiothorac Surg 2022; 17:145. [PMID: 35672705 PMCID: PMC9171738 DOI: 10.1186/s13019-022-01886-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/19/2022] [Indexed: 11/22/2022] Open
Abstract
Background The incidence of diaphragmatic rupture is low; however, it may be life threatening. Normally caused by blunt trauma, some cases are reported after pulmonary infections with extensive coughing. Covid 19 causes pulmonary infections and pneumonia and has been associated with weakening of the diaphragm after prolonged ventilation. We present a patient who suffered from diaphragmatic rupture 2 months after recovering from a severe Covid 19 pneumonia.
Case A 71 years old male patient presented with massive thoraco-abdominal pain and severe dyspnea. At the time of admission, the patient was diagnosed with rupture of the diaphragm and developed cardiogenic shock. Intraoperatively there was a 4 cm diameter large rupture of the diaphragm with enterothorax (transverse colon, stomach, spleen, parts of the jejunum). Avulsion of the mesenteric arteries made a segmental resection of the jejunum together with the spleen necessary. A jejuno-jejunostomy was performed and organs were replaced into the abdomen. The rupture of the diaphragm underwent primary closure with non-resorbable suture material. The patient has shown an uneventful post-operative course, fully recovered and was discharged on day 11 after surgery. Conclusion Covid 19 is a disease that is known to have various effects on different organs. The diaphragm is only paid heed in case of dysfunction. Also in the setting of Covid 19 it is not known as prominent effector organ. Nevertheless its affection by coughing caused by Covid 19 can lead to life threatening complications.
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13
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Tronstad O, Martí JD, Ntoumenopoulos G, Gosselink R. An Update on Cardiorespiratory Physiotherapy during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:390-404. [PMID: 35453171 DOI: 10.1055/s-0042-1744307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Physiotherapists are integral members of the multidisciplinary team managing critically ill adult patients. However, the scope and role of physiotherapists vary widely internationally, with physiotherapists in some countries moving away from providing early and proactive respiratory care in the intensive care unit (ICU) and focusing more on early mobilization and rehabilitation. This article provides an update of cardiorespiratory physiotherapy for patients receiving mechanical ventilation in ICU. Common and some more novel assessment tools and treatment options are described, along with the mechanisms of action of the treatment options and the evidence and physiology underpinning them. The aim is not only to summarize the current state of cardiorespiratory physiotherapy but also to provide information that will also hopefully help support clinicians to deliver personalized and optimal patient care, based on the patient's unique needs and guided by accurate interpretation of assessment findings and the current evidence. Cardiorespiratory physiotherapy plays an essential role in optimizing secretion clearance, gas exchange, lung recruitment, and aiding with weaning from mechanical ventilation in ICU. The physiotherapists' skill set and scope is likely to be further optimized and utilized in the future as the evidence base continues to grow and they get more and more integrated into the ICU multidisciplinary team, leading to improved short- and long-term patient outcomes.
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Affiliation(s)
- Oystein Tronstad
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.,Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Joan-Daniel Martí
- Cardiac Surgery Critical Care Unit, Institut Clinic Cardiovascular, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Rik Gosselink
- Department Rehabilitation Sciences, University of Leuven, University Hospitals Leuven, Belgium
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14
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Yuan J, Cen S, Li J, Wang K, Chen Q, Li H, Zhang Y. Effect of Lung Protective Ventilation Combined With Flurbiprofen Axetil on Immune Function During Thoracoscopic Radical Resection of Lung Cancer. Front Surg 2022; 9:840420. [PMID: 35252340 PMCID: PMC8891475 DOI: 10.3389/fsurg.2022.840420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/04/2022] [Indexed: 11/16/2022] Open
Abstract
The decreased immune function of patients with lung cancer has always been the focus of clinical attention. However, the stress response caused by surgery, anesthesia and pain will further reduce the body's immune function and affect the prognosis of patients to a certain extent. It was found that both protective ventilation and flurbiprofen ester pretreatment could reduce the immunosuppression caused by stress response. In this study, 120 lung cancer patients treated with video-assisted thoracoscopic radical resection were divided into group A, group B, group C and group D, which were treated with conventional mechanical ventilation, lung protective ventilation, conventional mechanical ventilation + flurbiprofen axetil and lung protective ventilation + flurbiprofen axetil, respectively. The results showed that the levels of CD3+, CD4+, CD4/CD8+, and NK in groups A, B, and C were lower than T0 on T1, T2, and T3, while those indicators in group D were lower than T0 on T1 and T2 (P < 0.05). The above indicators in group D were higher than those in the other three groups on T1, T2, and T3 (P < 0.05). The above indicators were statistically significant compared with those in group A and group C, group B and group D, and group A and group B at T1, T2, and T3 (P < 0.05). The comparisons of CD3+, CD4+, CD4/CD8+, and NK among the four groups within different time groups, and the repeated - measures analysis of variance (repeated - measures ANOVA) showed that there were interactions among time, group, and between groups × within groups (P < 0.05). It was confirmed that lung protective ventilation combined with flurbiprofen axetil could alleviate the immunosuppression of patients undergoing thoracoscopic radical lung cancer, providing a new idea for clinical treatment.
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15
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Giustivi D, Bottazzini F, Belliato M. Respiratory Monitoring at Bedside in COVID-19 Patients. J Clin Med 2021; 10:jcm10214943. [PMID: 34768462 PMCID: PMC8585054 DOI: 10.3390/jcm10214943] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/20/2021] [Accepted: 10/25/2021] [Indexed: 12/19/2022] Open
Abstract
The SARS-CoV-2 (COVID-19) pandemic has forced some reflections to be had surrounding the ventilatory support to be applied to certain types of patients. The model of two phenotypes, set out by Professor Gattinoni and colleagues, suggests that adequate monitoring of respiratory effort may play a key role in the treatment of respiratory failure due to COVID-19. An insufficient control of the patient’s respiratory efforts could lead to an aggravation of lung damage, mainly due to the possibility of generating Patient Self-Inflicted Lung Injury (PSILI) with a consequent aggravation of the pathological picture. Nevertheless, effectively monitoring the patient’s respiratory work, especially in nonintensive settings, is not easy. This article briefly describes some methods that allow the assessment of respiratory effort, such as the use of ultrasound and respiratory tests, which can be performed in nonintensive settings.
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Affiliation(s)
- Davide Giustivi
- A&E Department ASST Provincia di Lodi, 26900 Lodi, Italy
- Correspondence:
| | - Francesco Bottazzini
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 2 Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
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Arai Y, Nakanishi N, Ono Y, Inoue S, Kotani J, Harada M, Oto J. Ultrasound assessment of muscle mass has potential to identify patients with low muscularity at intensive care unit admission: A retrospective study. Clin Nutr ESPEN 2021; 45:177-183. [PMID: 34620314 DOI: 10.1016/j.clnesp.2021.08.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Muscle mass is an important biomarker of survival from a critical illness; however, there is no widely accepted method for routine assessment of low muscularity at intensive care unit (ICU) admission. We hypothesize that ultrasound-based partial muscle mass assessments can reflect the trunk muscle mass. Therefore, we aimed to investigate whether ultrasound muscle mass measurements could reflect trunk muscle mass and identify patients with low muscularity. METHODS We performed a retrospective analysis of prospectively obtained ultrasound data at ICU admission. We included patients who underwent computed tomography (CT) imaging at the third lumbar vertebra (L3) within 2 days before and 2 days after ICU admission. Primary outcomes included the correlation between the femoral muscle mass measurements using ultrasound and the cross-sectional area (CSA) at L3 obtained by CT. Low muscularity was defined as a skeletal muscle index of 36.0 cm2/m2 for males and 29.0 cm2/m2 for females. Secondary outcomes included the correlation with the ultrasound measurements of the biceps brachii muscle mass and diaphragm thickness. RESULTS Among 133 patients, 89 underwent CT imaging, which included the L3. The patient mean age was 72 ± 13 years, and 60 patients (67%) were male. The correlation between the femoral muscle ultrasound and CT was ρ = 0.57 (p < 0.01, n = 89) and ρ = 0.48 (p < 0.01, n = 89) for quadriceps muscle layer thickness and rectus femoris muscle CSA, and these had the discriminative power to assess low muscularity, with the areas under the curve of 0.84 and 0.76, respectively. The ultrasound measurements of the biceps brachii muscle mass and diaphragm thickness were correlated with CT imaging [ρ = 0.57-0.60 (p < 0.01, n = 52) and ρ = 0.35 (p < 0.01, n = 79)]. CONCLUSIONS Ultrasound measurements of muscle mass were correlated with CT measurements, and the measurements of femoral muscle mass were useful to assess low muscularity at ICU admission. TRIAL REGISTRATION UMIN000044032 (retrospectively registered on April 25, 2021).
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Affiliation(s)
- Yuta Arai
- Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan; Department of Radiology, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan
| | - Nobuto Nakanishi
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan; Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan.
| | - Yuko Ono
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan
| | - Masafumi Harada
- Department of Radiology, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan
| | - Jun Oto
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan
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17
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Crulli B, Kawaguchi A, Praud JP, Petrof BJ, Harrington K, Emeriaud G. Evolution of inspiratory muscle function in children during mechanical ventilation. Crit Care 2021; 25:229. [PMID: 34193216 PMCID: PMC8243304 DOI: 10.1186/s13054-021-03647-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no universally accepted method to assess the pressure-generating capacity of inspiratory muscles in children on mechanical ventilation (MV), and no study describing its evolution over time in this population. METHODS In this prospective observational study, we have assessed the function of the inspiratory muscles in children on various modes of MV. During brief airway occlusion maneuvers, we simultaneously recorded airway pressure depression at the endotracheal tube (ΔPaw, force generation) and electrical activity of the diaphragm (EAdi, central respiratory drive) over five consecutive inspiratory efforts. The neuro-mechanical efficiency ratio (NME, ΔPaw/EAdimax) was also computed. The evolution over time of these indices in a group of children in the pediatric intensive care unit (PICU) was primarily described. As a secondary objective, we compared these values to those measured in a group of children in the operating room (OR). RESULTS In the PICU group, although median NMEoccl decreased over time during MV (regression coefficient - 0.016, p = 0.03), maximum ΔPawmax remained unchanged (regression coefficient 0.109, p = 0.50). Median NMEoccl at the first measurement in the PICU group (after 21 h of MV) was significantly lower than at the only measurement in the OR group (1.8 cmH2O/µV, Q1-Q3 1.3-2.4 vs. 3.7 cmH2O/µV, Q1-Q3 3.5-4.2; p = 0.015). Maximum ΔPawmax in the PICU group was, however, not significantly different from the OR group (35.1 cmH2O, Q1-Q3 21-58 vs. 31.3 cmH2O, Q1-Q3 28.5-35.5; p = 0.982). CONCLUSIONS The function of inspiratory muscles can be monitored at the bedside of children on MV using brief airway occlusions. Inspiratory muscle efficiency was significantly lower in critically ill children than in children undergoing elective surgery, and it decreased over time during MV in critically ill children. This suggests that both critical illness and MV may have an impact on inspiratory muscle efficiency.
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Affiliation(s)
- Benjamin Crulli
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Atsushi Kawaguchi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
- Pediatric Intensive Care Unit, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Basil J Petrof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Karen Harrington
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
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18
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Pellegrini M, Hedenstierna G, Larsson AS, Perchiazzi G. Inspiratory Efforts, Positive End-Expiratory Pressure, and External Resistances Influence Intraparenchymal Gas Redistribution in Mechanically Ventilated Injured Lungs. Front Physiol 2021; 11:618640. [PMID: 33633578 PMCID: PMC7900494 DOI: 10.3389/fphys.2020.618640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background Potentially harmful lung overstretch can follow intraparenchymal gas redistribution during mechanical ventilation. We hypothesized that inspiratory efforts characterizing spontaneous breathing, positive end-expiratory pressure (PEEP), and high inspiratory resistances influence inspiratory intraparenchymal gas redistribution. Methods This was an experimental study conducted on a swine model of mild acute respiratory distress syndrome. Dynamic computed tomography and respiratory mechanics were simultaneously acquired at different PEEP levels and external resistances, during both spontaneous breathing and controlled mechanical ventilation. Images were collected at two cranial-caudal levels. Delta-volume images (ΔVOLs) were obtained subtracting pairs of consecutive inspiratory images. The first three ΔVOLs, acquired for each analyzed breath, were used for the analysis of inspiratory pendelluft defined as intraparenchymal gas redistribution before the start of inspiratory flow at the airway opening. The following ΔVOLs were used for the analysis of gas redistribution during ongoing inspiratory flow at the airway opening. Results During the first flow-independent phase of inspiration, the pendelluft of gas was observed only during spontaneous breathing and along the cranial-to-caudal and nondependent-to-dependent directions. The pendelluft was reduced by high PEEP (p < 0.04 comparing PEEP 15 and PEEP 0 cm H2O) and low external resistances (p < 0.04 comparing high and low external resistance). During the flow-dependent phase of inspiration, two patterns were identified: (1) gas displacing characterized by large gas redistribution areas; (2) gas scattering characterized by small, numerous areas of gas redistribution. Gas displacing was observed at low PEEP, high external resistances, and it characterized controlled mechanical ventilation (p < 0.01, comparing high and low PEEP during controlled mechanical ventilation). Conclusions Low PEEP and high external resistances favored inspiratory pendelluft. During the flow-dependent phase of the inspiration, controlled mechanical ventilation and low PEEP and high external resistances favored larger phenomena of intraparenchymal gas redistribution (gas displacing) endangering lung stability.
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Affiliation(s)
- Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Intensive Care Unit, Department of Anesthesia, Operation and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Göran Hedenstierna
- Hedenstierna Laboratory, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Sune Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Intensive Care Unit, Department of Anesthesia, Operation and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
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19
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Abstract
PURPOSE OF REVIEW Complications of mechanical ventilation, such as ventilator-induced lung injury (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD), adversely affect the outcome of critically ill patients. Although mostly studied during control ventilation, it is increasingly appreciated that VILI and VIDD also occur during assisted ventilation. Hence, current research focuses on identifying ways to monitor and deliver protective ventilation in assisted modes. This review describes the operating principles of proportional modes of assist, their implications for lung and diaphragm protective ventilation, and the supporting clinical data. RECENT FINDINGS Proportional modes of assist, proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA, deliver a pressure assist that is proportional to the patient's effort, enabling ventilation to be better controlled by the patient's brain. This control underlies the potential of proportional modes to avoid over-assist and under-assist, improve patient--ventilator interaction, and provide protective ventilation. Indeed, in clinical studies, proportional modes have been associated with reduced asynchronies, enhanced diaphragmatic recovery, and limitation of excessive tidal volume. Additionally, proportional modes facilitate better monitoring of the delivery of protective assisted ventilation. SUMMARY Physiological rationale and clinical data suggest a potential role for proportional modes of assist in providing and monitoring lung and diaphragm protective ventilation.
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20
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van Steveninck AL, Imming LM. Diaphragm dysfunction prior to intubation in a patient with Covid-19 pneumonia; assessment by point of care ultrasound and potential implications for patient monitoring. Respir Med Case Rep 2020; 31:101284. [PMID: 33200066 PMCID: PMC7654235 DOI: 10.1016/j.rmcr.2020.101284] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/09/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022] Open
Abstract
The clinical research described in this case report was initiated because of the recognized need for early identification of Covid-19 patients at risk of respiratory failure. We used point of care ultrasound to identify diaphragm dysfunction in a spontaneously breathing Covid-19 patient. Measurements of diaphragm thickness and thickening fraction indicated diaphragm dysfunction prior to intubation while respiratory failure was not yet evident from arterial blood gas analysis. Recovery of diaphragm contractility was demonstrated within two days of controlled mechanical ventilation when the patient was switched to a pressure support mode. With recovery of the diaphragm very large fractional shortening was seen after discontinuation of rocuronium, which was associated with a reduced dynamic compliance. In conclusion, this case report illustrates the need to be aware of potential diaphragm dysfunction in spontaneously breathing Covid-19 patients. With recovery, point of care ultrasound allows repeated evaluation of diaphragm function which appears to be responsive to changes in pulmonary compliance.
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Affiliation(s)
| | - Leonie M Imming
- Department of Pulmonary Medicine, Deventer Hospital, Deventer, the Netherlands
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21
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Medrinal C, Combret Y, Hilfiker R, Prieur G, Aroichane N, Gravier FE, Bonnevie T, Contal O, Lamia B. ICU outcomes can be predicted by noninvasive muscle evaluation: a meta-analysis. Eur Respir J 2020; 56:13993003.02482-2019. [PMID: 32366493 DOI: 10.1183/13993003.02482-2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/22/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND The relationship between muscle function in critically ill patients assessed using bedside techniques and clinical outcomes has not been systematically described. We aimed to evaluate the association between muscle weakness assessed by bedside evaluation and mortality or weaning from mechanical ventilation, and the capacity of each evaluation tool to predict outcomes. METHODS Five databases (PubMed, Embase, CINAHL, Cochrane Library, Science Direct) were searched from January 2000 to December 2018. Data were extracted and random effects meta-analyses were performed. RESULTS 60 studies were analysed, including 4382 patients. Intensive care unit (ICU)-related muscle weakness was associated with an increase in overall mortality with odds ratios ranging from 1.2 (95% CI 0.60-2.40) to 4.48 (95% CI 1.49-13.42). Transdiaphragmatic twitch pressure had the highest predictive capacity for overall mortality, with a sensitivity of 0.87 (95% CI 0.76-0.93) and a specificity of 0.36 (95% CI 0.27-0.43). The area under the curve (AUC) was 0.74 (95% CI 0.70-0.78). Muscle weakness was associated with an increase in mechanical ventilation weaning failure rate with an odds ratio ranging from 2.64 (95% CI 0.72-9.64) to 19.07 (95% CI 9.35-38.9). Diaphragm thickening fraction had the highest predictive capacity for weaning failure with a sensitivity of 0.76 (95% CI 0.67-0.83) and a specificity of 0.86 (95% CI 0.78-0.92). The AUC was 0.86 (95% CI 0.83-0.89). CONCLUSION ICU-related muscle weakness detected by bedside techniques is a serious issue associated with a high risk of death or prolonged mechanical ventilation. Evaluating diaphragm function should be a clinical priority in the ICU.
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Affiliation(s)
- Clément Medrinal
- Normandie Univ, UNIROUEN, EA3830-GRHV, Rouen, France .,Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,Groupe Hospitalier du Havre, Intensive Care Unit Dept, Montivilliers, France
| | - Yann Combret
- Groupe Hospitalier du Havre, Intensive Care Unit Dept, Montivilliers, France.,Research and Clinical Experimentation Institute (IREC), Pulmonology, ORL and Dermatology, Louvain Catholic University, Brussels, Belgium
| | - Roger Hilfiker
- University of Applied Sciences and Arts Western Switzerland Valais (HES-SO Valais-Wallis), School of Health Sciences, Leukerbad, Switzerland
| | - Guillaume Prieur
- Normandie Univ, UNIROUEN, EA3830-GRHV, Rouen, France.,Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,Groupe Hospitalier du Havre, Intensive Care Unit Dept, Montivilliers, France.,Research and Clinical Experimentation Institute (IREC), Pulmonology, ORL and Dermatology, Louvain Catholic University, Brussels, Belgium
| | - Nadine Aroichane
- School of Physiotherapy, Rouen University Hospital, Rouen, France
| | - Francis-Edouard Gravier
- Normandie Univ, UNIROUEN, EA3830-GRHV, Rouen, France.,Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,ADIR Association, Bois-Guillaume, France
| | - Tristan Bonnevie
- Normandie Univ, UNIROUEN, EA3830-GRHV, Rouen, France.,Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,ADIR Association, Bois-Guillaume, France
| | - Olivier Contal
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland.,Both authors contributed equally
| | - Bouchra Lamia
- Normandie Univ, UNIROUEN, EA3830-GRHV, Rouen, France.,Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France.,Groupe Hospitalier du Havre, Pulmonology Dept, Montivilliers, France.,Pulmonology, Respiratory Dept, Rouen University Hospital, Rouen, France.,Both authors contributed equally
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22
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Abstract
The aim of the study was to establish the prevalence of diaphragmatic dysfunction (DD), depending on the strategy of mechanical ventilation (MV).
Materials and methods. We completed the prospective single-center cohort study. Data analysis included 82 patients (1 month – 18 years old), divided into I group (lung-protective MV) and II group (diaphragm-protective in addition to lung-protective MV).
Patients were divided into age subgroups. Stages of the study: 1st day (d1), 3rd (d3), 5th (d5), 7th (d7), 9th (d9), 14th (d14), 28th (d28). We studied amplitude of diaphragm movement; thickening fraction, parameters of acid-base balance and MV. Results are described as median [IQR - interquartile range] with level of significance p.
Results. In patients of the 1st age subgroup in I group there were episodes with under-assist during MV, while in II group diaphragm overload was registered only on d5.
In patients of 2nd subgroup in I group we found over-assist of MV with excessive work of the right hemidiaphragm and low contractions of left dome at all stages of study, while in II group – the only episode of diaphragmatic weakness on d3 due to under-assist of MV. In the 3rd subgroup the proper diaphragmatic activity in I group was restored significantly later than in II group. In 4th subgroup of I group there was episode of high work of diaphragm on d5, whereas in II group – all data were within the recommended parameters for diaphragm-protective strategy of MV. In 5th subgroup of I group excessive work of both right and left domes of diaphragm was significantly more often registered than in II group, however, in II group there were found episodes of both type changes – diaphragmatic weakness and excessive work.
Conclusion: The prevalence and variety of manifestations of DD depend on the strategy of MV. Low incidence of DD was associated with lower duration of MV: in 1st age subgroup in 1.5 times; in 2nd age subgroup – in 2.4 times; in 4th age subgroup – in 1.75 times; in 5th age subgroup – in 4.25 times.
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23
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Formenti P, Umbrello M, Dres M, Chiumello D. Ultrasonographic assessment of parasternal intercostal muscles during mechanical ventilation. Ann Intensive Care 2020; 10:120. [PMID: 32894372 PMCID: PMC7475948 DOI: 10.1186/s13613-020-00735-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/30/2020] [Indexed: 02/08/2023] Open
Abstract
Although mechanical ventilation is a lifesaving treatment, abundant evidence indicates that its prolonged use (1 week or more) promotes respiratory muscle weakness due to both contractile dysfunction and atrophy. Along with the diaphragm, the intercostal muscles are one of the most important groups of respiratory muscles. In recent years, muscular ultrasound has become a useful bedside tool for the clinician to identify patients with respiratory muscle dysfunction related to critical illness and/or invasive mechanical ventilation. Images obtained over the course of illness can document changes in muscle dimension and can be used to estimate changes in function. Recent evidence suggests the clinical usefulness of ultrasound imaging in the assessment of intercostal muscle function. In this narrative review, we summarize the current literature on ultrasound imaging of the parasternal intercostal muscles as used to assess the extent of muscle activation and muscle weakness and its potential impact during discontinuation of mechanical ventilation. In addition, we proposed a practical flowchart based on recent evidence and experience of our group that can be applied during the weaning phase. This approach integrates multiple predictive parameters of weaning success with respiratory muscle ultrasound.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.
| | - Michele Umbrello
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP Sorbonne Université. Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive-Réanimation, 75013, Paris, France
| | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy.,Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
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24
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Mechanical Ventilation - A Friend in Need? J Crit Care Med (Targu Mures) 2020; 6:143-145. [PMID: 32864458 PMCID: PMC7430355 DOI: 10.2478/jccm-2020-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 11/30/2022] Open
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25
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Neurally Adjusted Ventilatory Assist versus Pressure Support Ventilation in Difficult Weaning: A Randomized Trial. Anesthesiology 2020; 132:1482-1493. [PMID: 32217876 DOI: 10.1097/aln.0000000000003207] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Difficult weaning frequently develops in ventilated patients and is associated with poor outcome. In neurally adjusted ventilatory assist, the ventilator is controlled by diaphragm electrical activity, which has been shown to improve patient-ventilator interaction. The objective of this study was to compare neurally adjusted ventilatory assist and pressure support ventilation in patients difficult to wean from mechanical ventilation. METHODS In this nonblinded randomized clinical trial, difficult-to-wean patients (n = 99) were randomly assigned to neurally adjusted ventilatory assist or pressure support ventilation mode. The primary outcome was the duration of weaning. Secondary outcomes included the proportion of successful weaning, patient-ventilator asynchrony, ventilator-free days, and mortality. Weaning duration was calculated as 28 days for patients under mechanical ventilation at day 28 or deceased before day 28 without successful weaning. RESULTS Weaning duration in all patients was statistically significant shorter in the neurally adjusted ventilatory assist group (n = 47) compared with the pressure support ventilation group (n = 52; 3.0 [1.2 to 8.0] days vs. 7.4 [2.0 to 28.0], mean difference: -5.5 [95% CI, -9.2 to -1.4], P = 0.039). Post hoc sensitivity analysis also showed that the neurally adjusted ventilatory assist group had shorter weaning duration (hazard ratio, 0.58; 95% CI, 0.34 to 0.98). The proportion of patients with successful weaning from invasive mechanical ventilation was higher in neurally adjusted ventilatory assist (33 of 47 patients, 70%) compared with pressure support ventilation (25 of 52 patients, 48%; respiratory rate for neurally adjusted ventilatory assist: 1.46 [95% CI, 1.04 to 2.05], P = 0.026). The number of ventilator-free days at days 14 and 28 was statistically significantly higher in neurally adjusted ventilatory assist compared with pressure support ventilation. Neurally adjusted ventilatory assist improved patient ventilator interaction. Mortality and length of stay in the intensive care unit and in the hospital were similar among groups. CONCLUSIONS In patients difficult to wean, neurally adjusted ventilatory assist decreased the duration of weaning and increased ventilator-free days.
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26
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Pellegrini M, Gudmundsson M, Bencze R, Segelsjö M, Freden F, Rylander C, Hedenstierna G, Larsson AS, Perchiazzi G. Expiratory Resistances Prevent Expiratory Diaphragm Contraction, Flow Limitation, and Lung Collapse. Am J Respir Crit Care Med 2020; 201:1218-1229. [PMID: 32150440 DOI: 10.1164/rccm.201909-1690oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Tidal expiratory flow limitation (tidal-EFL) is not completely avoidable by applying positive end-expiratory pressure and may cause respiratory and hemodynamic complications in ventilated patients with lungs prone to collapse. During spontaneous breathing, expiratory diaphragmatic contraction counteracts tidal-EFL. We hypothesized that during both spontaneous breathing and controlled mechanical ventilation, external expiratory resistances reduce tidal-EFL.Objectives: To assess whether external expiratory resistances 1) affect expiratory diaphragmatic contraction during spontaneous breathing, 2) reduce expiratory flow and make lung compartments more homogeneous with more similar expiratory time constants, and 3) reduce tidal atelectasis, preventing hyperinflation.Methods: Three positive end-expiratory pressure levels and four external expiratory resistances were tested in 10 pigs after lung lavage. We analyzed expiratory diaphragmatic electric activity and respiratory mechanics. On the basis of computed tomography scans, four lung compartments-not inflated (atelectasis), poorly inflated, normally inflated, and hyperinflated-were defined.Measurements and Main Results: Consequently to additional external expiratory resistances, and mainly in lungs prone to collapse (at low positive end-expiratory pressure), 1) the expiratory transdiaphragmatic pressure decreased during spontaneous breathing by >10%, 2) expiratory flow was reduced and the expiratory time constants became more homogeneous, and 3) the amount of atelectasis at end-expiration decreased from 24% to 16% during spontaneous breathing and from 32% to 18% during controlled mechanical ventilation, without increasing hyperinflation.Conclusions: The expiratory modulation induced by external expiratory resistances preserves the positive effects of the expiratory brake while minimizing expiratory diaphragmatic contraction. External expiratory resistances optimize lung mechanics and limit tidal-EFL and tidal atelectasis, without increasing hyperinflation.
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Affiliation(s)
- Mariangela Pellegrini
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Magni Gudmundsson
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Reka Bencze
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Monica Segelsjö
- Department of Radiology, Uppsala University Hospital, Uppsala, Sweden; and
| | - Filip Freden
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Hedenstierna
- Department of Medical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - Anders S Larsson
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Gaetano Perchiazzi
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
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27
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Lilitsis E, Stamatopoulou V, Andrianakis E, Petraki A, Antonogiannaki EM, Georgopoulos D, Vaporidi K, Kondili E. Inspiratory effort and breathing pattern change in response to varying the assist level: A physiological study. Respir Physiol Neurobiol 2020; 280:103474. [PMID: 32531441 PMCID: PMC7283104 DOI: 10.1016/j.resp.2020.103474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 10/25/2022]
Abstract
AIM To describe the response of breathing pattern and inspiratory effort upon changes in assist level and to assesss if changes in respiratory rate may indicate changes in respiratory muscle effort. METHODS Prospective study of 82 patients ventilated on proportional assist ventilation (PAV+). At three levels of assist (20 %-50 %-80 %), patients' inspiratory effort and breathing pattern were evaluated using a validated prototype monitor. RESULTS Independent of the assist level, a wide range of respiratory rates (16-35br/min) was observed when patients' effort was within the accepted range. Changing the assist level resulted in paired changes in inspiratory effort and rate of the same tendency (increase or decrease) in all but four patients. Increasing the level in assist resulted in a 31 % (8-44 %) decrease in inspiratory effort and a 10 % (0-18 %) decrease in respiratory rate. The change in respiratory rate upon the change in assist correlated modestly with the change in the effort (R = 0.5). CONCLUSION Changing assist level results in changes in both respiratory rate and effort in the same direction, with change in effort being greater than that of respiratory rate. Yet, neither the magnitude of respiratory rate change nor the resulting absolute value may reliably predict the level of effort after a change in assist.
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Affiliation(s)
- Emmanouil Lilitsis
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Vaia Stamatopoulou
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Eleftherios Andrianakis
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Adamantia Petraki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Elvira-Markela Antonogiannaki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece.
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28
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Grassi A, Ferlicca D, Lupieri E, Calcinati S, Francesconi S, Sala V, Ormas V, Chiodaroli E, Abbruzzese C, Curto F, Sanna A, Zambon M, Fumagalli R, Foti G, Bellani G. Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:85. [PMID: 32164784 PMCID: PMC7068963 DOI: 10.1186/s13054-020-2761-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Diaphragm atrophy and dysfunction are consequences of mechanical ventilation and are determinants of clinical outcomes. We hypothesize that partial preservation of diaphragm function, such as during assisted modes of ventilation, will restore diaphragm thickness. We also aim to correlate the changes in diaphragm thickness and function to outcomes and clinical factors. METHODS This is a prospective, multicentre, observational study. Patients mechanically ventilated for more than 48 h in controlled mode and eventually switched to assisted ventilation were enrolled. Diaphragm ultrasound and clinical data collection were performed every 48 h until discharge or death. A threshold of 10% was used to define thinning during controlled and recovery of thickness during assisted ventilation. Patients were also classified based on the level of diaphragm activity during assisted ventilation. We evaluated the association between changes in diaphragm thickness and activity and clinical outcomes and data, such as ventilation parameters. RESULTS Sixty-two patients ventilated in controlled mode and then switched to the assisted mode of ventilation were enrolled. Diaphragm thickness significantly decreased during controlled ventilation (1.84 ± 0.44 to 1.49 ± 0.37 mm, p < 0.001) and was partially restored during assisted ventilation (1.49 ± 0.37 to 1.75 ± 0.43 mm, p < 0.001). A diaphragm thinning of more than 10% was associated with longer duration of controlled ventilation (10 [5, 15] versus 5 [4, 8.5] days, p = 0.004) and higher PEEP levels (12.6 ± 4 versus 10.4 ± 4 cmH2O, p = 0.034). An increase in diaphragm thickness of more than 10% during assisted ventilation was not associated with any clinical outcome but with lower respiratory rate (16.7 ± 3.2 versus 19.2 ± 4 bpm, p = 0.019) and Rapid Shallow Breathing Index (37 ± 11 versus 44 ± 13, p = 0.029) and with higher Pressure Muscle Index (2 [0.5, 3] versus 0.4 [0, 1.9], p = 0.024). Change in diaphragm thickness was not related to diaphragm function expressed as diaphragm thickening fraction. CONCLUSION Mode of ventilation affects diaphragm thickness, and preservation of diaphragmatic contraction, as during assisted modes, can partially reverse the muscle atrophy process. Avoiding a strenuous inspiratory work, as measured by Rapid Shallow Breathing Index and Pressure Muscle Index, may help diaphragm thickness restoration.
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Affiliation(s)
- Alice Grassi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Daniela Ferlicca
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Ermes Lupieri
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Serena Calcinati
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Silvia Francesconi
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Vittoria Sala
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Valentina Ormas
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Elena Chiodaroli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Chiara Abbruzzese
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Curto
- Neurocritical Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Sanna
- Neurocritical Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Massimo Zambon
- Department of Anesthesia and Intensive Care Medicine, Cernusco sul Naviglio Hospital, ASST Melegnano e Martesana, Milan, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy. .,Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy.
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29
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Tuinman PR, Jonkman AH, Dres M, Shi ZH, Goligher EC, Goffi A, de Korte C, Demoule A, Heunks L. Respiratory muscle ultrasonography: methodology, basic and advanced principles and clinical applications in ICU and ED patients-a narrative review. Intensive Care Med 2020; 46:594-605. [PMID: 31938825 PMCID: PMC7103016 DOI: 10.1007/s00134-019-05892-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
Respiratory muscle ultrasound is used to evaluate the anatomy and function of the respiratory muscle pump. It is a safe, repeatable, accurate, and non-invasive bedside technique that can be successfully applied in different settings, including general intensive care and the emergency department. Mastery of this technique allows the intensivist to rapidly diagnose and assess respiratory muscle dysfunction in critically ill patients and in patients with unexplained dyspnea. Furthermore, it can be used to assess patient-ventilator interaction and weaning failure in critically ill patients. This paper provides an overview of the basic and advanced principles underlying respiratory muscle ultrasound with an emphasis on the diaphragm. We review different ultrasound techniques useful for monitoring of the respiratory muscle pump and possible therapeutic consequences. Ideally, respiratory muscle ultrasound is used in conjunction with other components of critical care ultrasound to obtain a comprehensive evaluation of the critically ill patient. We propose the ABCDE-ultrasound approach, a systematic ultrasound evaluation of the heart, lungs and respiratory muscle pump, in patients with weaning failure.
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Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Martin Dres
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Capital Medical University, Beijing Tiantan Hospital, Beijing, 100050, China
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Critical Care Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Critical Care Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Chris de Korte
- Department of Radiology, Radboud UMC, Nijmegen, The Netherlands
| | - Alexandre Demoule
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.
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30
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Zhou XL, Wei XJ, Li SP, Ma HL, Zhao Y. Lung-protective ventilation worsens ventilator-induced diaphragm atrophy and weakness. Respir Res 2020; 21:16. [PMID: 31924204 PMCID: PMC6954632 DOI: 10.1186/s12931-020-1276-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background Lung–protective ventilation (LPV) has been found to minimize the risk of ventilator–induced lung injury (VILI). However, whether LPV is able to diminish ventilator–induced diaphragm dysfunction (VIDD) remains unknown. This study was designed to test the hypothesis that LPV protects the diaphragm against VIDD. Methods Adult male Wistar rats received either conventional mechanical (tidal volume [VT]: 10 ml/kg, positive end–expiratory pressure [PEEP]: 2 cm H2O; CV group) or lung-protective (VT: 5 ml/kg, PEEP: 10 cm H2O; LPV group) ventilation for 12 h. Then, diaphragms and lungs were collected for biochemical and histological analyses. Transcriptome sequencing (RNA–seq) was performed to determine the differentially expressed genes in the diaphragms between groups. Results Our results suggested that LPV was associated with diminished pulmonary injuries and reduced oxidative stress compared with the effects of the CV strategy in rats. However, animals that received LPV showed increased protein degradation, decreased cross–sectional areas (CSAs) of myofibers, and reduced forces of the diaphragm compared with the same parameters in animals receiving CV (p < 0.05). In addition, the LPV group showed a higher level of oxidative stress in the diaphragm than the CV group (p < 0.05). Moreover, RNA–seq and western blots revealed that the peroxisome proliferator–activated receptor γ coactivator–1alpha (PGC–1α), a powerful reactive oxygen species (ROS) inhibitor, was significantly downregulated in the LPV group compared with its expression in the CV group (p < 0.05). Conclusions Compared with the CV strategy, the LPV strategy did not protect the diaphragm against VIDD in rats. In contrast, the LPV strategy worsened VIDD by inducing oxidative stress together with the downregulation of PGC–1α in the diaphragm. However, further studies are required to determine the roles of PGC–1α in ventilator-induced diaphragmatic oxidative stress.
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Affiliation(s)
- Xian-Long Zhou
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Xiao-Jun Wei
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Shao-Ping Li
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Hao-Li Ma
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Yan Zhao
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China.
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31
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Itagaki T, Nakanishi N, Takashima T, Ueno Y, Tane N, Tsunano Y, Nunomura T, Oto J. Effect of controlled ventilation during assist-control ventilation on diaphragm thickness : a post hoc analysis of an observational study. THE JOURNAL OF MEDICAL INVESTIGATION 2020; 67:332-337. [PMID: 33148911 DOI: 10.2152/jmi.67.332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background : Since diaphragm passivity induces oxidative stress that leads to rapid atrophy of diaphragm, we investigated the effect of controlled ventilation on diaphragm thickness during assist-control ventilation (ACV). Methods : Previously, we measured end-expiratory diaphragm thickness (Tdiee) of patients mechanically ventilated for more than 48 hours on days 1, 3, 5 and 7 after the start of ventilation. We retrospectively investigated the proportion of controlled ventilation during the initial 48-hour ACV (CV48%). Patients were classified according to CV48% : Low group, less than 25% ; High group, higher than 25%. Results : Of 56 patients under pressure-control ACV, Tdiee increased more than 10% in 6 patients (11%), unchanged in 8 patients (14%) and decreased more than 10% in 42 patients (75%). During the first week of ventilation, Tdiee decreased in both groups : Low (difference, -7.4% ; 95% confidence interval [CI], -10.1% to -4.6% ; p < 0.001) and High group (difference, -5.2% ; 95% CI, -8.5% to -2.0% ; p = 0.049). Maximum Tdiee variation from baseline did not differ between Low (-15.8% ; interquartile range [IQR], -22.3 to -1.5) and High group (-16.7% ; IQR, -22.6 to -11.1, p = 0.676). Conclusions : During ACV, maximum variation in Tdiee was not associated with proportion of controlled ventilation higher than 25%. J. Med. Invest. 67 : 332-337, August, 2020.
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Affiliation(s)
- Taiga Itagaki
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Nobuto Nakanishi
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Takuya Takashima
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yoshitoyo Ueno
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Natsuki Tane
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yumiko Tsunano
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Toshiyuki Nunomura
- Division of Critical Care Center, Kochi Red Cross Hospital, Kochi, Japan
| | - Jun Oto
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, Tokushima, Japan
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32
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Varón-Vega F, Hernández Á, López M, Cáceres E, Giraldo-Cadavid LF, Uribe-Hernandez AM, Crevoisier S. [Usefulness of diaphragmatic ultrasound in predicting extubation success]. Med Intensiva 2019; 45:226-233. [PMID: 31870509 DOI: 10.1016/j.medin.2019.10.007] [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: 07/22/2019] [Revised: 09/16/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of diaphragmatic ultrasound in predicting extubation success. DESIGN A diagnostic accuracy study was carried out. SCOPE Intensive Care Unit of an Academic hospital in the city of Bogotá (Colombia). PATIENTS OR PARTICIPANTS A consecutive sample of patients >18 years of age subjected to invasive mechanical ventilation for >48h. INTERVENTIONS Diaphragmatic ultrasound evaluation at the end of spontaneous ventilation testing. MAIN VARIABLES OF INTEREST Diaphragmatic excursion (DE, cm), inspiration time (TPIAdia, s), diaphragm contraction speed (DE/TPIAdia, cm/s) and total time (Ttot, s) were evaluated, together with thickening fraction (TFdi, %). RESULTS A total of 84 patients were included, 79.8% (n=67) with successful extubation and 20.2% (n=17) with failed extubation. The variable with the best discriminatory capacity in predicting extubation success was diaphragm contraction speed, with AUC-ROC 0.70 (p=0.008). CONCLUSIONS Diaphragm contraction speed exhibited acceptable discriminatory capacity. Ultrasound could be part of a multifactorial approach in the extubation process.
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Affiliation(s)
- F Varón-Vega
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia; Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Departamento de Anestesiología y Cuidados Intensivos, Universidad de Navarra, Pamplona, España
| | - Á Hernández
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - M López
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - E Cáceres
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - L F Giraldo-Cadavid
- Departamento de Investigación, Fundación Neumológica Colombiana, Bogotá, Colombia; Departamento de Epidemiología y de Medicina Interna, Universidad de La Sabana, Chía, Colombia
| | - A M Uribe-Hernandez
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia; Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Departamento de Investigación, Fundación Neumológica Colombiana, Bogotá, Colombia.
| | - S Crevoisier
- Medicina Crítica y Cuidado Intensivo, Universidad de La Sabana, Chía, Colombia
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Widing CH, Pellegrini M, Larsson A, Perchiazzi G. The Effects of Positive End-Expiratory Pressure on Transpulmonary Pressure and Recruitment-Derecruitment During Neurally Adjusted Ventilator Assist: A Continuous Computed Tomography Study in an Animal Model of Acute Respiratory Distress Syndrome. Front Physiol 2019; 10:1392. [PMID: 31824326 PMCID: PMC6882775 DOI: 10.3389/fphys.2019.01392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/28/2019] [Indexed: 01/22/2023] Open
Abstract
Background Whether spontaneous breathing (SB) should be used in early acute respiratory distress syndrome (ARDS) is questioned because it may cause ventilator-induced lung injury (VILI) by tidal high strain/stress and recruitment/derecruitment (R/D). However, SB has shown beneficial effects when used appropriately. We hypothesized that high levels of positive end-expiratory pressure (PEEP), during assisted SB, would prevent tidal R/D, reducing ventilatory variation and respiratory rate while potentially increasing transpulmonary pressure (PTP). The aim was to test this hypothesis in experimental mild ARDS during continuous SB using neurally adjusted ventilator assist (NAVA) and uninterrupted computed tomography (CT) exposure. Methods Mild experimental ARDS (PaO2/FiO2-ratio of 250) was induced in anesthetized pigs (n = 5), ventilated using uninterrupted NAVA. PEEP was changed in steps of 3 cmH2O, from 0 to 15 and back to 0 cmH2O. Dynamic CT scans, ventilatory parameters, and esophageal pressure were acquired simultaneously. PTP and R/D were calculated and compared among PEEP levels. Results When increasing PEEP from 0 to 15 cmH2O, tidal R/D decreased from 4.3 ± 5.9 to 1.1 ± 0.7% (p < 0.01), breath-to-breath variability decreased, and PTP increased from 11.4 ± 3.7 to 29.7 ± 14.1 cmH2O (R2 = 0.96). Conclusion This study shows that injurious phenomena like R/D and high PTP are present in NAVA at the two extremes of the PEEP spectrum. Willing to titrate PEEP to limit these phenomena, the physician must choose the best compromise between restraining the R/D or PTP.
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Affiliation(s)
- Carl Hannes Widing
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,NU-Hospital Organization, Trollhättan, Sweden
| | - Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Department of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Department of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Department of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
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34
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Expiratory muscle dysfunction in critically ill patients: towards improved understanding. Intensive Care Med 2019; 45:1061-1071. [PMID: 31236639 PMCID: PMC6667683 DOI: 10.1007/s00134-019-05664-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/30/2019] [Indexed: 12/13/2022]
Abstract
Introduction This narrative review summarizes current knowledge on the physiology and pathophysiology of expiratory muscle function in ICU patients, as shared by academic professionals from multidisciplinary, multinational backgrounds, who include clinicians, clinical physiologists and basic physiologists. Results The expiratory muscles, which include the abdominal wall muscles and some of the rib cage muscles, are an important component of the respiratory muscle pump and are recruited in the presence of high respiratory load or low inspiratory muscle capacity. Recruitment of the expiratory muscles may have beneficial effects, including reduction in end-expiratory lung volume, reduction in transpulmonary pressure and increased inspiratory muscle capacity. However, severe weakness of the expiratory muscles may develop in ICU patients and is associated with worse outcomes, including difficult ventilator weaning and impaired airway clearance. Several techniques are available to assess expiratory muscle function in the critically ill patient, including gastric pressure and ultrasound. Conclusion The expiratory muscles are the "neglected component" of the respiratory muscle pump. Expiratory muscles are frequently recruited in critically ill ventilated patients, but a fundamental understanding of expiratory muscle function is still lacking in these patients.
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