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Cruces P, Retamal J, Damián A, Lago G, Blasina F, Oviedo V, Medina T, Pérez A, Vaamonde L, Dapueto R, González-Dambrauskas S, Serra A, Monteverde-Fernandez N, Namías M, Martínez J, Hurtado DE. A machine-learning regional clustering approach to understand ventilator-induced lung injury: a proof-of-concept experimental study. Intensive Care Med Exp 2024; 12:60. [PMID: 38954052 PMCID: PMC11220131 DOI: 10.1186/s40635-024-00641-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND The spatiotemporal progression and patterns of tissue deformation in ventilator-induced lung injury (VILI) remain understudied. Our aim was to identify lung clusters based on their regional mechanical behavior over space and time in lungs subjected to VILI using machine-learning techniques. RESULTS Ten anesthetized pigs (27 ± 2 kg) were studied. Eight subjects were analyzed. End-inspiratory and end-expiratory lung computed tomography scans were performed at the beginning and after 12 h of one-hit VILI model. Regional image-based biomechanical analysis was used to determine end-expiratory aeration, tidal recruitment, and volumetric strain for both early and late stages. Clustering analysis was performed using principal component analysis and K-Means algorithms. We identified three different clusters of lung tissue: Stable, Recruitable Unstable, and Non-Recruitable Unstable. End-expiratory aeration, tidal recruitment, and volumetric strain were significantly different between clusters at early stage. At late stage, we found a step loss of end-expiratory aeration among clusters, lowest in Stable, followed by Unstable Recruitable, and highest in the Unstable Non-Recruitable cluster. Volumetric strain remaining unchanged in the Stable cluster, with slight increases in the Recruitable cluster, and strong reduction in the Unstable Non-Recruitable cluster. CONCLUSIONS VILI is a regional and dynamic phenomenon. Using unbiased machine-learning techniques we can identify the coexistence of three functional lung tissue compartments with different spatiotemporal regional biomechanical behavior.
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Affiliation(s)
- Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen Dr. Luis Valentín Ferrada, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Andrés Damián
- Centro Uruguayo de Imagenología Molecular (CUDIM), Montevideo, Uruguay
- Unidad Académica de Medicina Nuclear e Imagenología Molecular, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Graciela Lago
- Centro Uruguayo de Imagenología Molecular (CUDIM), Montevideo, Uruguay
- Academia Nacional de Medicina, Montevideo, Uruguay
| | - Fernanda Blasina
- Unidad Académica de Neonatología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tania Medina
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen Dr. Luis Valentín Ferrada, Santiago, Chile
| | - Agustín Pérez
- Department of Structural and Geotechnical Engineering, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lucía Vaamonde
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Rosina Dapueto
- Centro Uruguayo de Imagenología Molecular (CUDIM), Montevideo, Uruguay
| | - Sebastian González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Alberto Serra
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Centro Asistencial del Sindicato Médico del Uruguay (CASMU), Montevideo, Uruguay
| | - Nicolas Monteverde-Fernandez
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Cuidados Intensivos Pediátricos y Neonatales (CINP), Medica Uruguaya, Montevideo, Uruguay
| | - Mauro Namías
- Fundación Centro Diagnóstico Nuclear, Buenos Aires, Argentina
| | - Javier Martínez
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Hospital Central de las Fuerzas Armadas (HCFFAA), Montevideo, Uruguay
| | - Daniel E Hurtado
- Department of Structural and Geotechnical Engineering, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
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Tonelli R, Rizzoni R, Grasso S, Cortegiani A, Ball L, Samarelli AV, Fantini R, Bruzzi G, Tabbì L, Cerri S, Manicardi L, Andrisani D, Gozzi F, Castaniere I, Smit MR, Paulus F, Bos LDJ, Clini E, Marchioni A. Stress-strain curve and elastic behavior of the fibrotic lung with usual interstitial pneumonia pattern during protective mechanical ventilation. Sci Rep 2024; 14:13158. [PMID: 38849437 PMCID: PMC11161630 DOI: 10.1038/s41598-024-63670-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/30/2024] [Indexed: 06/09/2024] Open
Abstract
Patients with acute exacerbation of lung fibrosis with usual interstitial pneumonia (EUIP) pattern are at increased risk for ventilator-induced lung injury (VILI) and mortality when exposed to mechanical ventilation (MV). Yet, lack of a mechanical model describing UIP-lung deformation during MV represents a research gap. Aim of this study was to develop a constitutive mathematical model for UIP-lung deformation during lung protective MV based on the stress-strain behavior and the specific elastance of patients with EUIP as compared to that of acute respiratory distress syndrome (ARDS) and healthy lung. Partitioned lung and chest wall mechanics were assessed for patients with EUIP and primary ARDS (1:1 matched based on body mass index and PaO2/FiO2 ratio) during a PEEP trial performed within 24 h from intubation. Patient's stress-strain curve and the lung specific elastance were computed and compared with those of healthy lungs, derived from literature. Respiratory mechanics were used to fit a novel mathematical model of the lung describing mechanical-inflation-induced lung parenchyma deformation, differentiating the contributions of elastin and collagen, the main components of lung extracellular matrix. Five patients with EUIP and 5 matched with primary ARDS were included and analyzed. Global strain was not different at low PEEP between the groups. Overall specific elastance was significantly higher in EUIP as compared to ARDS (28.9 [22.8-33.2] cmH2O versus 11.4 [10.3-14.6] cmH2O, respectively). Compared to ARDS and healthy lung, the stress/strain curve of EUIP showed a steeper increase, crossing the VILI threshold stress risk for strain values greater than 0.55. The contribution of elastin was prevalent at lower strains, while the contribution of collagen was prevalent at large strains. The stress/strain curve for collagen showed an upward shift passing from ARDS and healthy lungs to EUIP lungs. During MV, patients with EUIP showed different respiratory mechanics, stress-strain curve and specific elastance as compared to ARDS patients and healthy subjects and may experience VILI even when protective MV is applied. According to our mathematical model of lung deformation during mechanical inflation, the elastic response of UIP-lung is peculiar and different from ARDS. Our data suggest that patients with EUIP experience VILI with ventilatory setting that are lung-protective for patients with ARDS.
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Affiliation(s)
- Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Raffaella Rizzoni
- Department of Engineering, University of Ferrara, via Saragat 1, Ferrara, Italy.
| | - Salvatore Grasso
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Ionica (DiMePre-J) Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Bari, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Anna Valeria Samarelli
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Giulia Bruzzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Stefania Cerri
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Linda Manicardi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Dario Andrisani
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Filippo Gozzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Marry R Smit
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
| | - Alessandro Marchioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Laboratory of Cell Therapies and Respiratory Medicine, Department of Medical and Surgical Sciences for Children and Adults, University Hospital of Modena, Modena, Italy
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Seybold B, Deutsch AM, Deutsch BL, Simeliunas E, Weigand MA, Fiedler-Kalenka MO, Kalenka A. Differential Effects of Intra-Abdominal Hypertension and ARDS on Respiratory Mechanics in a Porcine Model. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:843. [PMID: 38929460 PMCID: PMC11205316 DOI: 10.3390/medicina60060843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Intra-abdominal hypertension (IAH) and acute respiratory distress syndrome (ARDS) are common concerns in intensive care unit patients with acute respiratory failure (ARF). Although both conditions lead to impairment of global respiratory parameters, their underlying mechanisms differ substantially. Therefore, a separate assessment of the different respiratory compartments should reveal differences in respiratory mechanics. Materials and Methods: We prospectively investigated alterations in lung and chest wall mechanics in 18 mechanically ventilated pigs exposed to varying levels of intra-abdominal pressures (IAP) and ARDS. The animals were divided into three groups: group A (IAP 10 mmHg, no ARDS), B (IAP 20 mmHg, no ARDS), and C (IAP 10 mmHg, with ARDS). Following induction of IAP (by inflating an intra-abdominal balloon) and ARDS (by saline lung lavage and injurious ventilation), respiratory mechanics were monitored for six hours. Statistical analysis was performed using one-way ANOVA to compare the alterations within each group. Results: After six hours of ventilation, end-expiratory lung volume (EELV) decreased across all groups, while airway and thoracic pressures increased. Significant differences were noted between group (B) and (C) regarding alterations in transpulmonary pressure (TPP) (2.7 ± 0.6 vs. 11.3 ± 2.1 cmH2O, p < 0.001), elastance of the lung (EL) (8.9 ± 1.9 vs. 29.9 ± 5.9 cmH2O/mL, p = 0.003), and elastance of the chest wall (ECW) (32.8 ± 3.2 vs. 4.4 ± 1.8 cmH2O/mL, p < 0.001). However, global respiratory parameters such as EELV/kg bodyweight (-6.1 ± 1.3 vs. -11.0 ± 2.5 mL/kg), driving pressure (12.5 ± 0.9 vs. 13.2 ± 2.3 cmH2O), and compliance of the respiratory system (-21.7 ± 2.8 vs. -19.5 ± 3.4 mL/cmH2O) did not show significant differences among the groups. Conclusions: Separate measurements of lung and chest wall mechanics in pigs with IAH or ARDS reveals significant differences in TPP, EL, and ECW, whereas global respiratory parameters do not differ significantly. Therefore, assessing the compartments of the respiratory system separately could aid in identifying the underlying cause of ARF.
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Affiliation(s)
- Benjamin Seybold
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
| | - Anna M. Deutsch
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Barbara Luise Deutsch
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Asklepios Klinik Wandsbek, 22043 Hamburg, Germany
| | - Emilis Simeliunas
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Department of Anesthesiology and Intensive Care Medicine, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
| | - Markus A. Weigand
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), 69120 Heidelberg, Germany
| | - Mascha O. Fiedler-Kalenka
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), 69120 Heidelberg, Germany
| | - Armin Kalenka
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Hospital Bergstrasse, 64646 Heppenheim, Germany
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4
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Becker AP, Mang S, Rixecker T, Lepper PM. [COVID-19 in the intensive care unit]. Pneumologie 2024; 78:330-345. [PMID: 38759701 DOI: 10.1055/a-1854-2693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
The acute respiratory failure as well as ARDS (acute respiratory distress syndrome) have challenged clinicians since the initial description over 50 years ago. Various causes can lead to ARDS and therapeutic approaches for ARDS/ARF are limited to the support or replacement of organ functions and the prevention of therapy-induced consequences. In recent years, triggered by the SARS-CoV-2 pathogen, numerous cases of acute lung failure (C-ARDS) have emerged. The pathophysiological processes of classical ARDS and C-ARDS are essentially similar. In their final stages of inflammation, both lead to a disruption of the blood-air barrier. Treatment strategies for C-ARDS, like classical ARDS, focus on supporting or replacing organ functions and preventing consequential damage. This article summarizes the treatment strategies in the intensive care unit.
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5
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Simonte R, Cammarota G, Vetrugno L, De Robertis E, Longhini F, Spadaro S. Advanced Respiratory Monitoring during Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:2541. [PMID: 38731069 PMCID: PMC11084162 DOI: 10.3390/jcm13092541] [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: 03/17/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Advanced respiratory monitoring encompasses a diverse range of mini- or noninvasive tools used to evaluate various aspects of respiratory function in patients experiencing acute respiratory failure, including those requiring extracorporeal membrane oxygenation (ECMO) support. Among these techniques, key modalities include esophageal pressure measurement (including derived pressures), lung and respiratory muscle ultrasounds, electrical impedance tomography, the monitoring of diaphragm electrical activity, and assessment of flow index. These tools play a critical role in assessing essential parameters such as lung recruitment and overdistention, lung aeration and morphology, ventilation/perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator synchrony. In contrast to conventional methods, advanced respiratory monitoring offers a deeper understanding of pathological changes in lung aeration caused by underlying diseases. Moreover, it allows for meticulous tracking of responses to therapeutic interventions, aiding in the development of personalized respiratory support strategies aimed at preserving lung function and respiratory muscle integrity. The integration of advanced respiratory monitoring represents a significant advancement in the clinical management of acute respiratory failure. It serves as a cornerstone in scenarios where treatment strategies rely on tailored approaches, empowering clinicians to make informed decisions about intervention selection and adjustment. By enabling real-time assessment and modification of respiratory support, advanced monitoring not only optimizes care for patients with acute respiratory distress syndrome but also contributes to improved outcomes and enhanced patient safety.
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Affiliation(s)
- Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Università della Magna Graecia, 88100 Catanzaro, Italy
- Anesthesia and Intensive Care Unit, “R. Dulbecco” University Hospital, 88100 Catanzaro, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44100 Ferrara, Italy;
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6
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Vivodtzev I, Delorme M, Lellouche F. Mechanical Insufflation-Exsufflation: When the "Art of Coughing" Becomes Science. Chest 2024; 165:764-765. [PMID: 38599748 DOI: 10.1016/j.chest.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 04/12/2024] Open
Affiliation(s)
- Isabelle Vivodtzev
- Neurophysiologie Respiratoire Expérimentale et Clinique, Faculté de Médecine Sorbonne Université, Paris, France; Neuroscience Paris Seine, Régénération et croissance de l'axone, Sorbonne Université, Paris, France.
| | - Mathieu Delorme
- AFM-Téléthon, Direction des Actions Médicales, 91000, Evry, France; Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec City, QC, Canada
| | - François Lellouche
- Neuroscience Paris Seine, Régénération et croissance de l'axone, Sorbonne Université, Paris, France
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Geitner CM, Köglmeier LJ, Frerichs I, Langguth P, Lindner M, Schädler D, Weiler N, Becher T, Wall WA. Pressure- and time-dependent alveolar recruitment/derecruitment in a spatially resolved patient-specific computational model for injured human lungs. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2024; 40:e3787. [PMID: 38037251 DOI: 10.1002/cnm.3787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/28/2023] [Accepted: 10/16/2023] [Indexed: 12/02/2023]
Abstract
We present a novel computational model for the dynamics of alveolar recruitment/derecruitment (RD), which reproduces the underlying characteristics typically observed in injured lungs. The basic idea is a pressure- and time-dependent variation of the stress-free reference volume in reduced dimensional viscoelastic elements representing the acinar tissue. We choose a variable reference volume triggered by critical opening and closing pressures in a time-dependent manner from a straightforward mechanical point of view. In the case of (partially and progressively) collapsing alveolar structures, the volume available for expansion during breathing reduces and vice versa, eventually enabling consideration of alveolar collapse and reopening in our model. We further introduce a method for patient-specific determination of the underlying critical parameters of the new alveolar RD dynamics when integrated into the tissue elements, referred to as terminal units, of a spatially resolved physics-based lung model that simulates the human respiratory system in an anatomically correct manner. Relevant patient-specific parameters of the terminal units are herein determined based on medical image data and the macromechanical behavior of the lung during artificial ventilation. We test the whole modeling approach for a real-life scenario by applying it to the clinical data of a mechanically ventilated patient. The generated lung model is capable of reproducing clinical measurements such as tidal volume and pleural pressure during various ventilation maneuvers. We conclude that this new model is an important step toward personalized treatment of ARDS patients by considering potentially harmful mechanisms-such as cyclic RD and overdistension-and might help in the development of relevant protective ventilation strategies to reduce ventilator-induced lung injury (VILI).
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Affiliation(s)
- Carolin M Geitner
- Institute for Computational Mechanics, Department of Engineering Physics & Computation, TUM School of Engineering and Design, Technical University of Munich, Garching b. Muenchen, Germany
| | - Lea J Köglmeier
- Institute for Computational Mechanics, Department of Engineering Physics & Computation, TUM School of Engineering and Design, Technical University of Munich, Garching b. Muenchen, Germany
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Patrick Langguth
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Dirk Schädler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Norbert Weiler
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Wolfgang A Wall
- Institute for Computational Mechanics, Department of Engineering Physics & Computation, TUM School of Engineering and Design, Technical University of Munich, Garching b. Muenchen, Germany
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8
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Camporota L, Rose L, Andrews PL, Nieman GF, Habashi NM. Airway pressure release ventilation for lung protection in acute respiratory distress syndrome: an alternative way to recruit the lungs. Curr Opin Crit Care 2024; 30:76-84. [PMID: 38085878 DOI: 10.1097/mcc.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW Airway pressure release ventilation (APRV) is a modality of ventilation in which high inspiratory continuous positive airway pressure (CPAP) alternates with brief releases. In this review, we will discuss the rationale for APRV as a lung protective strategy and then provide a practical introduction to initiating APRV using the time-controlled adaptive ventilation (TCAV) method. RECENT FINDINGS APRV using the TCAV method uses an extended inspiratory time and brief expiratory release to first stabilize and then gradually recruit collapsed lung (over hours/days), by progressively 'ratcheting' open a small volume of collapsed tissue with each breath. The brief expiratory release acts as a 'brake' preventing newly recruited units from re-collapsing, reversing the main drivers of ventilator-induced lung injury (VILI). The precise timing of each release is based on analysis of expiratory flow and is set to achieve termination of expiratory flow at 75% of the peak expiratory flow. Optimization of the release time reflects the changes in elastance and, therefore, is personalized (i.e. conforms to individual patient pathophysiology), and adaptive (i.e. responds to changes in elastance over time). SUMMARY APRV using the TCAV method is a paradigm shift in protective lung ventilation, which primarily aims to stabilize the lung and gradually reopen collapsed tissue to achieve lung homogeneity eliminating the main mechanistic drivers of VILI.
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Affiliation(s)
- Luigi Camporota
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences
| | - Louise Rose
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust
- Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, UK
| | - Penny L Andrews
- Department of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Gary F Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York, USA
| | - Nader M Habashi
- Department of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 162] [Impact Index Per Article: 162.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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10
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Dong D, Jing C, Zong Y, Wang Y, Ren J. Effect of different titration methods on right heart function and prognosis in patients with acute respiratory distress syndrome. Heart Lung 2023; 61:127-135. [PMID: 37263145 DOI: 10.1016/j.hrtlng.2023.05.009] [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: 12/08/2022] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a common disease in intensive critical care(ICU), and the use of positive end-expiratory pressure(PEEP) during mechanical ventilation can increase the right heart afterload and eventually cause right heart dysfunction. For these factors causing acute cor pulmonale(ACP), especially inappropriate mechanical ventilation settings, it is important to explore the effect of PEEP on right heart function. OBJECTIVE To investigate the effects of three titration methods on right heart function and prognosis in patients with ARDS. METHODS Observational, prospective study in which ARDS patients were enrolled into three distinct PEEP-titration strategies groups: guide, transpulmonary pressure-oriented and driving pressure-oriented. Prognostic indicators, right heart systolic and diastolic echocardiographic function indices, ventilatory parameters, blood gas analysis results, and respiratory mechanics Monitoring indices were collated and analyzed statistically by STATA 15 software. RESULTS A total of 62 ARDS patients were enrolled into guide (G) group (n=40) for whom titrated PEEP values were 9±2cm H2O, driving pressure-oriented (DPO) group (n=12) with titrated PEEP values of 10±2cm H2O and transpulmonary pressure-oriented (TPO) group (n=10) with titrated PEEP values of 12±3cm H2O. Values were significantly higher for TPO than for G (p=0.616) or DPO (p=0.011). Compliance was significantly increased after 72 h in the TPO and DPO groups compared with the G group (p<0.001). Mean airway pressure at end-inspiratory obstruction (p=0.047), tricuspid annular plane systolic excursion (TAPSE, p<0.001) and right ventricular area change fraction (RVFAC, p=0.049) were all higher in the TPO and DPO groups than in the G group. E/A indices were significantly better in the TPO group than in the G or DPO groups (p=0.046). No significant differences in 28 day mortality were found among the three groups. Multivariate logistic regression analysis revealed that lung compliance and transpulmonary pressure-oriented PEEP titration method was negatively correlated to the increase in right ventricular systolic dysfunction. CONCLUSION Transpulmonary pressure-oriented PEEP titration improves oxygenation and pulmonary function and causes less right heart strain when compared to other PEEP-titration methods during mechanical ventilation of ARDS patients.
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Affiliation(s)
- Daoran Dong
- Department of ICU, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Chengqiao Jing
- Department of ICU, Shaanxi Provincial People's Hospital, Xi'an, China.
| | - Yuan Zong
- Department of ICU, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Yan Wang
- Department of ICU, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Jiawei Ren
- Department of Pharmacy, Shaanxi Provincial People's Hospital, Xi'an, China
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11
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Braithwaite SA, van Hooijdonk E, van der Kaaij NP. Ventilation during ex vivo lung perfusion, a review. Transplant Rev (Orlando) 2023; 37:100762. [PMID: 37099887 DOI: 10.1016/j.trre.2023.100762] [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: 11/21/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023]
Abstract
Evidence suggests that ventilation during ex vivo lung perfusion (EVLP) with a 'one-size-fits-all' strategy has the potential to cause lung injury which may only become clinically relevant in marginal lung allografts. EVLP induced- or accelerated lung injury is a dynamic and cumulative process reflecting the interplay of a number of factors. Stress and strain in lung tissue caused by positive pressure ventilation may be exacerbated by the altered properties of lung tissue in an EVLP setting. Any pre-existing injury may alter the ability of lung allografts to accommodate set ventilation and perfusion techniques on EVLP leading to further injury. This review will examine the effects of ventilation on donor lungs in the setting of EVLP. A framework for developing a protective ventilation technique will be proposed.
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Affiliation(s)
- Sue A Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Q04.2.317, Postbus 85500, Utrecht 3508, GA, the Netherlands.
| | - Elise van Hooijdonk
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Room E03.511, Heidelberglaan 100, Utrecht 3584, CX, the Netherlands
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Room E03.511, Heidelberglaan 100, Utrecht 3584, CX, the Netherlands
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12
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Sklienka P, Frelich M, Burša F. Patient Self-Inflicted Lung Injury-A Narrative Review of Pathophysiology, Early Recognition, and Management Options. J Pers Med 2023; 13:593. [PMID: 37108979 PMCID: PMC10146629 DOI: 10.3390/jpm13040593] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Patient self-inflicted lung injury (P-SILI) is a life-threatening condition arising from excessive respiratory effort and work of breathing in patients with lung injury. The pathophysiology of P-SILI involves factors related to the underlying lung pathology and vigorous respiratory effort. P-SILI might develop both during spontaneous breathing and mechanical ventilation with preserved spontaneous respiratory activity. In spontaneously breathing patients, clinical signs of increased work of breathing and scales developed for early detection of potentially harmful effort might help clinicians prevent unnecessary intubation, while, on the contrary, identifying patients who would benefit from early intubation. In mechanically ventilated patients, several simple non-invasive methods for assessing the inspiratory effort exerted by the respiratory muscles were correlated with respiratory muscle pressure. In patients with signs of injurious respiratory effort, therapy aimed to minimize this problem has been demonstrated to prevent aggravation of lung injury and, therefore, improve the outcome of such patients. In this narrative review, we accumulated the current information on pathophysiology and early detection of vigorous respiratory effort. In addition, we proposed a simple algorithm for prevention and treatment of P-SILI that is easily applicable in clinical practice.
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Affiliation(s)
- Peter Sklienka
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, 17. listopadu 1790, 70800 Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
- Institute of Physiology and Pathophysiology, Department of Intensive Care Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
| | - Michal Frelich
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, 17. listopadu 1790, 70800 Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
| | - Filip Burša
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, 17. listopadu 1790, 70800 Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
- Institute of Physiology and Pathophysiology, Department of Intensive Care Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
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13
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Nelson TM, Quiros KAM, Dominguez EC, Ulu A, Nordgren TM, Eskandari M. Diseased and healthy murine local lung strains evaluated using digital image correlation. Sci Rep 2023; 13:4564. [PMID: 36941463 PMCID: PMC10026788 DOI: 10.1038/s41598-023-31345-w] [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: 12/07/2022] [Accepted: 03/09/2023] [Indexed: 03/22/2023] Open
Abstract
Tissue remodeling in pulmonary disease irreversibly alters lung functionality and impacts quality of life. Mechanical ventilation is amongst the few pulmonary interventions to aid respiration, but can be harmful or fatal, inducing excessive regional (i.e., local) lung strains. Previous studies have advanced understanding of diseased global-level lung response under ventilation, but do not adequately capture the critical local-level response. Here, we pair a custom-designed pressure-volume ventilator with new applications of digital image correlation, to directly assess regional strains in the fibrosis-induced ex-vivo mouse lung, analyzed via regions of interest. We discuss differences between diseased and healthy lung mechanics, such as distensibility, heterogeneity, anisotropy, alveolar recruitment, and rate dependencies. Notably, we compare local and global compliance between diseased and healthy states by assessing the evolution of pressure-strain and pressure-volume curves resulting from various ventilation volumes and rates. We find fibrotic lungs are less-distensible, with altered recruitment behaviors and regional strains, and exhibit disparate behaviors between local and global compliance. Moreover, these diseased characteristics show volume-dependence and rate trends. Ultimately, we demonstrate how fibrotic lungs may be particularly susceptible to damage when contrasted to the strain patterns of healthy counterparts, helping to advance understanding of how ventilator induced lung injury develops.
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Affiliation(s)
- T M Nelson
- Department of Mechanical Engineering, University of California, Riverside, CA, USA
| | - K A M Quiros
- Department of Mechanical Engineering, University of California, Riverside, CA, USA
| | - E C Dominguez
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
- Environmental Toxicology Graduate Program, University of California Riverside, Riverside, CA, USA
| | - A Ulu
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
| | - T M Nordgren
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
- Environmental Toxicology Graduate Program, University of California Riverside, Riverside, CA, USA
- BREATHE Center, School of Medicine, University of California, Riverside, CA, USA
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - M Eskandari
- Department of Mechanical Engineering, University of California, Riverside, CA, USA.
- BREATHE Center, School of Medicine, University of California, Riverside, CA, USA.
- Department of Bioengineering, University of California, Riverside, CA, USA.
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14
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Practical Aspects of Esophageal Pressure Monitoring in Patients with Acute Respiratory Distress Syndrome. J Pers Med 2023; 13:jpm13010136. [PMID: 36675797 PMCID: PMC9867326 DOI: 10.3390/jpm13010136] [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: 12/17/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/12/2023] Open
Abstract
Esophageal pressure (Pes) monitoring is a minimally invasive advanced respiratory monitoring method with the potential to guide ventilation support management. Pes monitoring enables the separation of lung and chest wall mechanics and estimation of transpulmonary pressure, which is recognized as an important risk factor for lung injury during both spontaneous breathing and mechanical ventilation. Appropriate balloon positioning, calibration, and measurement techniques are important to avoid inaccurate results. Both the approach of using absolute expiratory Pes values and the approach based on tidal Pes difference have shown promising results for ventilation adjustments, with the potential to decrease the risk of ventilator-induced lung injury.
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15
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An Updated Review of Driving-Pressure Guided Ventilation Strategy and Its Clinical Application. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6236438. [PMID: 35958824 PMCID: PMC9363222 DOI: 10.1155/2022/6236438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 06/19/2022] [Accepted: 07/16/2022] [Indexed: 11/17/2022]
Abstract
Traditional lung-protective ventilation strategies (LPVS) are currently used to reduce the incidence of postoperative pulmonary complications (PPCs), including low tidal volume (VT), positive end-expiratory pressure (PEEP), low inspiratory plateau pressure (Pplat), permissive hypercapnia, and recruitment maneuver (RM). However, a meta-analysis showed that high driving pressure was closely associated with the incidence of PPCs, but not with PEEP or VT, which led to the driving pressure-guided ventilation strategy. Some studies have proved that the driving pressure-guided ventilation strategy is superior to the traditional LPVS in reducing the incidence of PPCs. The purpose of this review is to present the current research progress and application of driving pressure-guided ventilation strategy.
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16
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Rezoagli E, Laffey JG, Bellani G. Monitoring Lung Injury Severity and Ventilation Intensity during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:346-368. [PMID: 35896391 DOI: 10.1055/s-0042-1748917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure burden by high hospital mortality. No specific pharmacologic treatment is currently available and its ventilatory management is a key strategy to allow reparative and regenerative lung tissue processes. Unfortunately, a poor management of mechanical ventilation can induce ventilation induced lung injury (VILI) caused by physical and biological forces which are at play. Different parameters have been described over the years to assess lung injury severity and facilitate optimization of mechanical ventilation. Indices of lung injury severity include variables related to gas exchange abnormalities, ventilatory setting and respiratory mechanics, ventilation intensity, and the presence of lung hyperinflation versus derecruitment. Recently, specific indexes have been proposed to quantify the stress and the strain released over time using more comprehensive algorithms of calculation such as the mechanical power, and the interaction between driving pressure (DP) and respiratory rate (RR) in the novel DP multiplied by four plus RR [(4 × DP) + RR] index. These new parameters introduce the concept of ventilation intensity as contributing factor of VILI. Ventilation intensity should be taken into account to optimize protective mechanical ventilation strategies, with the aim to reduce intensity to the lowest level required to maintain gas exchange to reduce the potential for VILI. This is further gaining relevance in the current era of phenotyping and enrichment strategies in ARDS.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
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17
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Rivera Palacios A, España JA, Gómez González JF, Salazar Gutierrez G, Ávila Reyes D, Moreno P, Lara Martinez AV, Aguirre-Flórez M, Giraldo-Diaconeasa A. Mechanical power measurement during mechanical ventilation of SARS-CoV-2 critically ill patients. A cohort study. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.5554/22562087.e1037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: The ventilator-induced lung injury (VILI) depends on the amount of energy per minute transferred by the ventilator to the lung measured in Joules, which is called mechanical power. Mechanical power is a development variable probably associated with outcomes in ventilated patients.
Objective: To describe the value of mechanical power in patients with SARS-CoV-2 infection and ventilated for other causes and its relationship between days of mechanical ventilation, length of stay in the intensive care unit (ICU), and mortality.
Methods: A multicenter, analytical, observational cohort study was conducted in patients with SARS-CoV-2 infection who required invasive mechanical ventilation and patients ventilated for other causes for more than 24 hours.
Results: The cohort included 91 patients on mechanical ventilation in three tertiary care centers in the city of Pereira, Colombia. The average value of the mechanical power found was 22.7 ± 1 Joules/min. In the subgroup of patients with SARS-CoV-2 infection, the value of mechanical power was higher 26.8 ± 9 than in the subgroup of patients without a diagnosis of SARS-CoV-2 infection 18.2 ± 1 (p <0.001).
Conclusion: Mechanical power is an important variable to consider during the monitoring of mechanical ventilation. This study found an average value of mechanical power of 22.7 ± 1 Joules/min, being higher in patients with SARS-CoV-2 infection related to longer days of mechanical ventilation and a longer stay in the ICU.
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18
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Tonelli R, Bruzzi G, Manicardi L, Tabbì L, Fantini R, Castaniere I, Andrisani D, Gozzi F, Pellegrino MR, Trentacosti F, Dall’Ara L, Busani S, Franceschini E, Baroncini S, Manco G, Meschiari M, Mussini C, Girardis M, Beghè B, Marchioni A, Clini E. Risk Factors for Pulmonary Air Leak and Clinical Prognosis in Patients With COVID-19 Related Acute Respiratory Failure: A Retrospective Matched Control Study. Front Med (Lausanne) 2022; 9:848639. [PMID: 35433732 PMCID: PMC9008271 DOI: 10.3389/fmed.2022.848639] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background The role of excessive inspiratory effort in promoting alveolar and pleural rupture resulting in air leak (AL) in patients with SARS-CoV-2 induced acute respiratory failure (ARF) while on spontaneous breathing is undetermined. Methods Among all patients with COVID-19 related ARF admitted to a respiratory intensive care unit (RICU) and receiving non-invasive respiratory support, those developing an AL were and matched 1:1 [by means of PaO2/FiO2 ratio, age, body mass index-BMI and subsequent organ failure assessment (SOFA)] with a comparable population who did not (NAL group). Esophageal pressure (ΔPes) and dynamic transpulmonary pressure (ΔPL) swings were compared between groups. Risk factors affecting AL onset were evaluated. The composite outcome of ventilator-free-days (VFD) at day 28 (including ETI, mortality, tracheostomy) was compared between groups. Results Air leak and NAL groups (n = 28) showed similar ΔPes, whereas AL had higher ΔPL (20 [16–21] and 17 [11–20], p = 0.01, respectively). Higher ΔPL (OR = 1.5 95%CI[1–1.8], p = 0.01), positive end-expiratory pressure (OR = 2.4 95%CI[1.2–5.9], p = 0.04) and pressure support (OR = 1.8 95%CI[1.1–3.5], p = 0.03), D-dimer on admission (OR = 2.1 95%CI[1.3–9.8], p = 0.03), and features suggestive of consolidation on computed tomography scan (OR = 3.8 95%CI[1.1–15], p = 0.04) were all significantly associated with AL. A lower VFD score resulted in a higher risk (HR = 3.7 95%CI [1.2–11.3], p = 0.01) in the AL group compared with NAL. RICU stay and 90-day mortality were also higher in the AL group compared with NAL. Conclusion In spontaneously breathing patients with COVID-19 related ARF, higher levels of ΔPL, blood D-dimer, NIV delivery pressures and a consolidative lung pattern were associated with AL onset.
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Affiliation(s)
- Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Bruzzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Linda Manicardi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Dario Andrisani
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Filippo Gozzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Rosaria Pellegrino
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Fabiana Trentacosti
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Lorenzo Dall’Ara
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Stefano Busani
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | | | - Serena Baroncini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Gianrocco Manco
- Department of Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Cristina Mussini
- Infectious Diseases Unit, University Hospital of Modena, Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Bianca Beghè
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Alessandro Marchioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- *Correspondence: Alessandro Marchioni,
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
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19
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Wang Y, Fang X, Yang Y, Chen L, Xiong W, Song L, Li B, Zhou T, Yu Y, Yang X, Shu H, Yuan S, Yao S, Shang Y. Death-Associated Protein Kinase 1 Promotes Alveolar Epithelial Cell Apoptosis and Ventilator-Induced Lung Injury Through P53 Pathway. Shock 2022; 57:140-150. [PMID: 34265832 DOI: 10.1097/shk.0000000000001831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Mechanical stretch-induced alveolar epithelial cell (AEC) apoptosis participates in the onset of ventilator-induced lung injury (VILI). In this study, we explored whether death-associated protein kinase 1 (DAPK1) mediated cyclic stretch (CS)-induced AEC apoptosis and VILI though P53 pathway. MATERIALS AND METHODS AEC apoptosis was induced by CS using the FX-5000T Flexercell Tension Plus system. C57BL/6 mouse received high tidal volume ventilation to build VILI model. DAPK1 inhibitor, P53 inhibitor, or DAPK1 plasmid was used to regulate the expression of DAPK1 and P53, respectively. Flow cytometery was performed to assay cell apoptosis and the changes of mitochondrial membrane potential (MMP); immunoblotting was adopted to analyze related protein expression. The binding of related proteins was detected by coimmunoprecipitation; AEC apoptosis in vivo was determined by immunohistochemistry assay. RESULTS CS promoted AEC apoptosis, increased DAPK1 and P53 expression, and induced the binding of DAPK1 and P53; inhibition of DAPK1 or P53 reduced CS-induced AEC apoptosis, suppressed the expression of Bax, increased Bcl-2 level, and stabilized MMP; AEC apoptosis and the level of P53 were both increased after overexpressing of DAPK1. Moreover, DAPK1 plasmid transfection also promoted the expression of Bax and the change of MMP, but decreased the level of Bcl-2. Inhibition of DAPK1 or P53 in vivo alleviated high tidal volume ventilation-induced AEC apoptosis and lung injury. CONCLUSIONS DAPK1 contributes to AEC apoptosis and the onset of VILI though P53 and its intrinsic pro-apoptotic pathway. Inhibition of DAPK1 or P53 alleviates high tidal volume ventilation-induced lung injury and AEC apoptosis.
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Affiliation(s)
- Yaxin Wang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiangzhi Fang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yiyi Yang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lin Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Xiong
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Limin Song
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bo Li
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ting Zhou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shiying Yuan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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20
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Positive end-expiratory pressure individualization guided by continuous end-expiratory lung volume monitoring during laparoscopic surgery. J Clin Monit Comput 2021; 36:1557-1567. [PMID: 34966951 DOI: 10.1007/s10877-021-00800-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
To determine whether end-expiratory lung volume measured with volumetric capnography (EELVCO2) can individualize positive end-expiratory pressure (PEEP) setting during laparoscopic surgery. We studied patients undergoing laparoscopic surgery subjected to Fowler (F-group; n = 20) or Trendelenburg (T-group; n = 20) positions. EELVCO2 was measured at 0° supine (baseline), during capnoperitoneum (CP) at 0° supine, during CP with Fowler (head up + 20°) or Trendelenburg (head down - 30°) positions and after CP back to 0° supine. PEEP was adjusted to preserve baseline EELVCO2 during and after CP. Baseline EELVCO2 was statistically similar to predicted FRC in both groups. At supine and CP, EELVCO2 decreased from baseline values in F-group [median and IQR 2079 (768) to 1545 (725) mL; p = 0.0001] and in T-group [2164 (789) to 1870 (940) mL; p = 0.0001]. Change in body position maintained EELVCO2 unchanged in both groups. PEEP adjustments from 5.6 (1.1) to 10.0 (2.5) cmH2O in the F-group (p = 0.0001) and from 5.6 (0.9) to 10.0 (2.6) cmH2O in T-group (p = 0.0001) were necessary to reach baseline EELVCO2 values. EELVCO2 increased close to baseline with PEEP in the F-group [1984 (600) mL; p = 0.073] and in the T-group [2175 (703) mL; p = 0.167]. After capnoperitoneum and back to 0° supine, PEEP needed to maintain EELVCO2 was similar to baseline PEEP in F-group [5.9 (1.8) cmH2O; p = 0.179] but slightly higher in the T-group [6.5 (2.2) cmH2O; p = 0.006]. Those new PEEP values gave EELVCO2 similar to baseline in the F-group [2039 (980) mL; p = 0.370] and in the T-group [2150 (715) mL; p = 0.881]. Breath-by-breath noninvasive EELVCO2 detected changes in lung volume induced by capnoperitoneum and body position and was useful to individualize the level of PEEP during laparoscopy.Trial registry: Clinicaltrials.gov NCT03693352. Protocol started 1st October 2018.
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21
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Lavizzari A, Veneroni C, Beretta F, Ottaviani V, Fumagalli C, Tossici M, Colnaghi M, Mosca F, Dellacà RL. Oscillatory mechanics at birth for identifying infants requiring surfactant: a prospective, observational trial. Respir Res 2021; 22:314. [PMID: 34930247 PMCID: PMC8686669 DOI: 10.1186/s12931-021-01906-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/25/2021] [Indexed: 12/29/2022] Open
Abstract
Background Current criteria for surfactant administration assume that hypoxia is a direct marker of lung-volume de-recruitment. We first introduced an early, non-invasive assessment of lung mechanics by the Forced Oscillation Technique (FOT) and evaluated its role in predicting the need for surfactant therapy. Objectives To evaluate whether lung reactance (Xrs) assessment by FOT within 2 h of birth identifies infants who would need surfactant within 24 h; to eventually determine Xrs performance and a cut-off value for early detection of infants requiring surfactant. Methods We conducted a prospective, observational, non-randomized study in our tertiary NICU in Milan. Eligible infants were born between 27+0 and 34+6 weeks’ gestation, presenting respiratory distress after birth. Exclusion criteria: endotracheal intubation at birth, major malformations participation in other interventional trials, parental consent denied. We assessed Xrs during nasal CPAP at 5 cmH2O at 10 Hz within 2 h of life, recording flow and pressure tracing through a Fabian Ventilator for off-line analysis. Clinicians were blinded to FOT results. Results We enrolled 61 infants, with a median [IQR] gestational age of 31.9 [30.3; 32.9] weeks and birth weight 1490 [1230; 1816] g; 2 infants were excluded from the analysis for set-up malfunctioning. 14/59 infants received surfactant within 24 h. Xrs predicted surfactant need with a cut-off − 33.4 cmH2O*s/L and AUC-ROC = 0.86 (0.76–0.96), with sensitivity 0.85 and specificity 0.83. An Xrs cut-off value of − 23.3 cmH2O*s/L identified infants needing surfactant or respiratory support > 28 days with AUC-ROC = 0.89 (0.81–0.97), sensitivity 0.86 and specificity 0.77. Interestingly, 12 infants with Xrs < − 23.3 cmH2O*s/L (i.e. de-recruited lungs) did not receive surfactant and subsequently required prolonged respiratory support. Conclusion Xrs assessed within 2 h of life predicts surfactant need and respiratory support duration in preterm infants. The possible role of Xrs in improving the individualization of respiratory management in preterm infants deserves further investigation.
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Affiliation(s)
- Anna Lavizzari
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy.
| | - Chiara Veneroni
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
| | - Francesco Beretta
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy
| | - Valeria Ottaviani
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
| | - Claudia Fumagalli
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy
| | - Marta Tossici
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
| | - Mariarosa Colnaghi
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Via Commenda 12, 20135, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Raffaele L Dellacà
- Dipartimento di Elettronica, Informazione e Bioingegneria-DEIB Laboratorio di Tecnologie Biomediche-TechRes Lab, Politecnico di Milano University, Milan, Italy
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22
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Carteaux G, Parfait M, Combet M, Haudebourg AF, Tuffet S, Mekontso Dessap A. Patient-Self Inflicted Lung Injury: A Practical Review. J Clin Med 2021; 10:jcm10122738. [PMID: 34205783 PMCID: PMC8234933 DOI: 10.3390/jcm10122738] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with severe lung injury usually have a high respiratory drive, resulting in intense inspiratory effort that may even worsen lung damage by several mechanisms gathered under the name “patient-self inflicted lung injury” (P-SILI). Even though no clinical study has yet demonstrated that a ventilatory strategy to limit the risk of P-SILI can improve the outcome, the concept of P-SILI relies on sound physiological reasoning, an accumulation of clinical observations and some consistent experimental data. In this review, we detail the main pathophysiological mechanisms by which the patient’s respiratory effort could become deleterious: excessive transpulmonary pressure resulting in over-distension; inhomogeneous distribution of transpulmonary pressure variations across the lung leading to cyclic opening/closing of nondependent regions and pendelluft phenomenon; increase in the transvascular pressure favoring the aggravation of pulmonary edema. We also describe potentially harmful patient-ventilator interactions. Finally, we discuss in a practical way how to detect in the clinical setting situations at risk for P-SILI and to what extent this recognition can help personalize the treatment strategy.
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Affiliation(s)
- Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
- Correspondence:
| | - Mélodie Parfait
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Margot Combet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
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23
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Pierrakos C, Smit MR, Hagens LA, Heijnen NFL, Hollmann MW, Schultz MJ, Paulus F, Bos LDJ. Assessment of the Effect of Recruitment Maneuver on Lung Aeration Through Imaging Analysis in Invasively Ventilated Patients: A Systematic Review. Front Physiol 2021; 12:666941. [PMID: 34149448 PMCID: PMC8212037 DOI: 10.3389/fphys.2021.666941] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/20/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Recruitment maneuvers (RMs) have heterogeneous effects on lung aeration and have adverse side effects. We aimed to identify morphological, anatomical, and functional imaging characteristics that might be used to predict the RMs on lung aeration in invasively ventilated patients. Methods: We performed a systemic review. Studies included invasively ventilated patients who received an RM and in whom re-aeration was examined with chest computed tomography (CT), electrical impedance tomography (EIT), and lung ultrasound (LUS) were included. Results: Twenty studies were identified. Different types of RMs were applied. The amount of re-aerated lung tissue after an RM was highly variable between patients in all studies, irrespective of the used imaging technique and the type of patients (ARDS or non-ARDS). Imaging findings suggesting a non-focal morphology (i.e., radiologic findings consistent with attenuations with diffuse or patchy loss of aeration) were associated with higher likelihood of recruitment and lower chance of overdistention than a focal morphology (i.e., radiological findings suggestive of lobar or segmental loss of aeration). This was independent of the used imaging technique but only observed in patients with ARDS. In patients without ARDS, the results were inconclusive. Conclusions: ARDS patients with imaging findings suggestive of non-focal morphology show most re-aeration of previously consolidated lung tissue after RMs. The role of imaging techniques in predicting the effect of RMs on re-aeration in patients without ARDS remains uncertain.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht, Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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24
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Kotani T, Shono A. Roles of Electrical Impedance Tomography in Determining a Lung Protective Strategy for Acute Respiratory Distress Syndrome in the Era of Coronavirus Disease 2019. JMA J 2021; 4:81-85. [PMID: 33997440 PMCID: PMC8119178 DOI: 10.31662/jmaj.2021-0014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/08/2021] [Indexed: 12/14/2022] Open
Abstract
Electrical impedance tomography (EIT) is noninvasive and can be used at the bedside for real-time evaluation to identify ventilation distribution of infected lungs. This review briefly describes the basic principle of EIT and summarizes the latest findings on its potential contribution to lung protective strategies in coronavirus disease 2019 patients. Additionally, experimental approaches for detecting the distribution of pulmonary blood flow in coronavirus disease 2019 patients are presented. The findings underscore the role of EIT in determining lung protective strategies for coronavirus disease 2019-associated acute respiratory distress syndrome.
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Affiliation(s)
- Toru Kotani
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Atsuko Shono
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
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25
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Habashi NM, Camporota L, Gatto LA, Nieman G. Functional pathophysiology of SARS-CoV-2-induced acute lung injury and clinical implications. J Appl Physiol (1985) 2021; 130:877-891. [PMID: 33444117 PMCID: PMC7984238 DOI: 10.1152/japplphysiol.00742.2020] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 02/08/2023] Open
Abstract
The worldwide pandemic caused by the SARS-CoV-2 virus has resulted in over 84,407,000 cases, with over 1,800,000 deaths when this paper was submitted, with comorbidities such as gender, race, age, body mass, diabetes, and hypertension greatly exacerbating mortality. This review will analyze the rapidly increasing knowledge of COVID-19-induced lung pathophysiology. Although controversial, the acute respiratory distress syndrome (ARDS) associated with COVID-19 (CARDS) seems to present as two distinct phenotypes: type L and type H. The "L" refers to low elastance, ventilation/perfusion ratio, lung weight, and recruitability, and the "H" refers to high pulmonary elastance, shunt, edema, and recruitability. However, the LUNG-SAFE (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) and ESICM (European Society of Intensive Care Medicine) Trials Groups have shown that ∼13% of the mechanically ventilated non-COVID-19 ARDS patients have the type-L phenotype. Other studies have shown that CARDS and ARDS respiratory mechanics overlap and that standard ventilation strategies apply to these patients. The mechanisms causing alterations in pulmonary perfusion could be caused by some combination of 1) renin-angiotensin system dysregulation, 2) thrombosis caused by loss of endothelial barrier, 3) endothelial dysfunction causing loss of hypoxic pulmonary vasoconstriction perfusion control, and 4) hyperperfusion of collapsed lung tissue that has been directly measured and supported by a computational model. A flowchart has been constructed highlighting the need for personalized and adaptive ventilation strategies, such as the time-controlled adaptive ventilation method, to set and adjust the airway pressure release ventilation mode, which recently was shown to be effective at improving oxygenation and reducing inspiratory fraction of oxygen, vasopressors, and sedation in patients with COVID-19.
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Affiliation(s)
- Nader M Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, St Thomas' Hospital, London, United Kingdom
| | - Louis A Gatto
- Department of Surgery, Upstate Medical University, Syracuse, New York
| | - Gary Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York
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26
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Allado E, Poussel M, Valentin S, Kimmoun A, Levy B, Nguyen DT, Rumeau C, Chenuel B. The Fundamentals of Respiratory Physiology to Manage the COVID-19 Pandemic: An Overview. Front Physiol 2021; 11:615690. [PMID: 33679424 PMCID: PMC7930571 DOI: 10.3389/fphys.2020.615690] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
The growing coronavirus disease (COVID-19) crisis has stressed worldwide healthcare systems probably as never before, requiring a tremendous increase of the capacity of intensive care units to handle the sharp rise of patients in critical situation. Since the dominant respiratory feature of COVID-19 is worsening arterial hypoxemia, eventually leading to acute respiratory distress syndrome (ARDS) promptly needing mechanical ventilation, a systematic recourse to intubation of every hypoxemic patient may be difficult to sustain in such peculiar context and may not be deemed appropriate for all patients. Then, it is essential that caregivers have a solid knowledge of physiological principles to properly interpret arterial oxygenation, to intubate at the satisfactory moment, to adequately manage mechanical ventilation, and, finally, to initiate ventilator weaning, as safely and as expeditiously as possible, in order to make it available for the next patient. Through the expected mechanisms of COVID-19-induced hypoxemia, as well as the notion of silent hypoxemia often evoked in COVID-19 lung injury and its potential parallelism with high altitude pulmonary edema, from the description of hemoglobin oxygen affinity in patients with severe COVID-19 to the interest of the prone positioning in order to treat severe ARDS patients, this review aims to help caregivers from any specialty to handle respiratory support following recent knowledge in the pathophysiology of respiratory SARS-CoV-2 infection.
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Affiliation(s)
- Edem Allado
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
| | - Mathias Poussel
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
| | - Simon Valentin
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Département de Pneumologie, CHRU-Nancy, Nancy, France
| | - Antoine Kimmoun
- Médecine Intensive et Réanimation Brabois, CHRU-Nancy, Nancy, France.,INSERM U1116, Université de Lorraine, Nancy, France
| | - Bruno Levy
- Médecine Intensive et Réanimation Brabois, CHRU-Nancy, Nancy, France.,INSERM U1116, Université de Lorraine, Nancy, France
| | - Duc Trung Nguyen
- ORL et Chirurgie Cervico-Faciale, CHRU-Nancy, Nancy, France.,INSERM U1254-IADI, Université de Lorraine, Nancy, France
| | - Cécile Rumeau
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,ORL et Chirurgie Cervico-Faciale, CHRU-Nancy, Nancy, France
| | - Bruno Chenuel
- EA 3450 DevAH-Développement, Adaptation et Handicap, Régulations cardio-respiratoires et de la motricité, Université de Lorraine, Nancy, France.,Explorations Fonctionnelles Respiratoires et de l'Aptitude à l'Exercice, Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, CHRU-Nancy, Nancy, France
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27
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Mittermaier M, Pickerodt P, Kurth F, de Jarcy LB, Uhrig A, Garcia C, Machleidt F, Pergantis P, Weber S, Li Y, Breitbart A, Bremer F, Knape P, Dewey M, Doellinger F, Weber-Carstens S, Slutsky AS, Kuebler WM, Suttorp N, Müller-Redetzky H. Evaluation of PEEP and prone positioning in early COVID-19 ARDS. EClinicalMedicine 2020; 28:100579. [PMID: 33073217 PMCID: PMC7547915 DOI: 10.1016/j.eclinm.2020.100579] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/10/2020] [Accepted: 09/16/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In face of the Coronavirus Disease (COVID)-19 pandemic, best practice for mechanical ventilation in COVID-19 associated Acute Respiratory Distress Syndrome (ARDS) is intensely debated. Specifically, the rationale for high positive end-expiratory pressure (PEEP) and prone positioning in early COVID-19 ARDS has been questioned. METHODS The first 23 consecutive patients with COVID-19 associated respiratory failure transferred to a single ICU were assessed. Eight were excluded: five were not invasively ventilated and three received veno-venous ECMO support. The remaining 15 were assessed over the first 15 days of mechanical ventilation. Best PEEP was defined by maximal oxygenation and was determined by structured decremental PEEP trials comprising the monitoring of oxygenation, airway pressures and trans-pulmonary pressures. In nine patients the impact of prone positioning on oxygenation was investigated. Additionally, the effects of high PEEP and prone positioning on pulmonary opacities in serial chest x-rays were determined by applying a semiquantitative scoring-system. This investigation is part of the prospective observational PA-COVID-19 study. FINDINGS Patients responded to initiation of invasive high PEEP ventilation with markedly improved oxygenation, which was accompanied by reduced pulmonary opacities within 6 h of mechanical ventilation. Decremental PEEP trials confirmed the need for high PEEP (17.9 (SD ± 3.9) mbar) for optimal oxygenation, while driving pressures remained low. Prone positioning substantially increased oxygenation (p<0.01). INTERPRETATION In early COVID-19 ARDS, substantial PEEP values were required for optimizing oxygenation. Pulmonary opacities resolved during mechanical ventilation with high PEEP suggesting recruitment of lung volume. FUNDING German Research Foundation, German Federal Ministry of Education and Research.
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Affiliation(s)
- Mirja Mittermaier
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Philipp Pickerodt
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Florian Kurth
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Laure Bosquillon de Jarcy
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexander Uhrig
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Carmen Garcia
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Machleidt
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Panagiotis Pergantis
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Susanne Weber
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yaosi Li
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Astrid Breitbart
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Bremer
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Philipp Knape
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Marc Dewey
- Berlin Institute of Health, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Doellinger
- Department of Radiology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Arthur S. Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Keenan Research Center for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wolfgang M. Kuebler
- Keenan Research Center for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Physiology, Berlin, Germany
- Department of Surgery and Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Holger Müller-Redetzky
- Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Division of Pulmonary Inflammation, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Corresponding author at: Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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28
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Nieman GF, Al-Khalisy H, Kollisch-Singule M, Satalin J, Blair S, Trikha G, Andrews P, Madden M, Gatto LA, Habashi NM. A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung. Front Physiol 2020; 11:227. [PMID: 32265734 PMCID: PMC7096584 DOI: 10.3389/fphys.2020.00227] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/27/2020] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) causes a heterogeneous lung injury and remains a serious medical problem, with one of the only treatments being supportive care in the form of mechanical ventilation. It is very difficult, however, to mechanically ventilate the heterogeneously damaged lung without causing secondary ventilator-induced lung injury (VILI). The acutely injured lung becomes time and pressure dependent, meaning that it takes more time and pressure to open the lung, and it recollapses more quickly and at higher pressure. Current protective ventilation strategies, ARDSnet low tidal volume (LVt) and the open lung approach (OLA), have been unsuccessful at further reducing ARDS mortality. We postulate that this is because the LVt strategy is constrained to ventilating a lung with a heterogeneous mix of normal and focalized injured tissue, and the OLA, although designed to fully open and stabilize the lung, is often unsuccessful at doing so. In this review we analyzed the pathophysiology of ARDS that renders the lung susceptible to VILI. We also analyzed the alterations in alveolar and alveolar duct mechanics that occur in the acutely injured lung and discussed how these alterations are a key mechanism driving VILI. Our analysis suggests that the time component of each mechanical breath, at both inspiration and expiration, is critical to normalize alveolar mechanics and protect the lung from VILI. Animal studies and a meta-analysis have suggested that the time-controlled adaptive ventilation (TCAV) method, using the airway pressure release ventilation mode, eliminates the constraints of ventilating a lung with heterogeneous injury, since it is highly effective at opening and stabilizing the time- and pressure-dependent lung. In animal studies it has been shown that by “casting open” the acutely injured lung with TCAV we can (1) reestablish normal expiratory lung volume as assessed by direct observation of subpleural alveoli; (2) return normal parenchymal microanatomical structural support, known as alveolar interdependence and parenchymal tethering, as assessed by morphometric analysis of lung histology; (3) facilitate regeneration of normal surfactant function measured as increases in surfactant proteins A and B; and (4) significantly increase lung compliance, which reduces the pathologic impact of driving pressure and mechanical power at any given tidal volume.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Hassan Al-Khalisy
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, United States
| | | | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Sarah Blair
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Girish Trikha
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Penny Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Maria Madden
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Louis A Gatto
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Biological Sciences, SUNY Cortland, Cortland, NY, United States
| | - Nader M Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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29
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Van Hecke D, Bidgoli JS, Van der Linden P. Does Lung Compliance Optimization Through PEEP Manipulations Reduce the Incidence of Postoperative Hypoxemia in Laparoscopic Bariatric Surgery? A Randomized Trial. Obes Surg 2020; 29:1268-1275. [PMID: 30612327 DOI: 10.1007/s11695-018-03662-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In obese patients (OP), the best intraoperative ventilation strategy remains to be defined. Dynamic lung compliance (Cdyn) and dead space fraction are indicators of efficient ventilation at an optimal positive end-expiratory pressure (PEEP). Herein, we investigated whether intraoperative dynamic lung compliance optimization through PEEP manipulations affects the incidence of postoperative hypoxemia (SpO2 < 90%) in OP undergoing laparoscopic bariatric surgery (LBS). METHODS This was a single-center, prospective, randomized controlled study conducted from July 2013 to December 2015. After obtaining institutional review board approval and informed consent, 100 OP undergoing LBS under volume-controlled ventilation (tidal volume 8 mL/kg of ideal body weight) were randomized according to the PEEP level maintained during the surgery. In the control group, a PEEP of 10 cm H2O was maintained, while in the intervention group, the PEEP was adapted to achieve the best dynamic lung compliance. Anesthesia and analgesia were standardized. The patients received supplemental nasal oxygen on the first postoperative day and were monitored up to the second postoperative day with a portable pulse oximeter. RESULTS Demographics were similar between groups. There was no difference in the incidence of hypoxemia during the first 2 postoperative days (control: 1.3%; intervention: 2.1%; p = 0.264). CONCLUSIONS The incidence of postoperative hypoxemia was not reduced by an open-lung approach with protective ventilation strategy in obese patients undergoing LBS. A pragmatic application of a PEEP level of 10 cm H2O was comparable to individual PEEP titration in these patients. TRIAL REGISTRATION Clinicaltrials.gov identifier, NCT02579798; https://clinicaltrials.gov/ct2/show/NCT02579798.
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Affiliation(s)
- Delphine Van Hecke
- Department of Anaesthesiology, CUB Erasme, Université Libre de Bruxelles, 1070, Brussels, Belgium.
| | - Javad S Bidgoli
- Department of Anaesthesiology, CHU Brugmann-HUDERF, Université Libre de Bruxelles, 1090, Brussels, Belgium
| | - Philippe Van der Linden
- Department of Anaesthesiology, CHU Brugmann-HUDERF, Université Libre de Bruxelles, 1090, Brussels, Belgium
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30
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Brandão JC, Lessa MA, Motta-Ribeiro G, Hashimoto S, Paula LF, Torsani V, Le L, Bao X, Eikermann M, Dahl DM, Deng H, Tabatabaei S, Amato MBP, Vidal Melo MF. Global and Regional Respiratory Mechanics During Robotic-Assisted Laparoscopic Surgery: A Randomized Study. Anesth Analg 2019; 129:1564-1573. [PMID: 31743177 DOI: 10.1213/ane.0000000000004289] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pneumoperitoneum and nonphysiological positioning required for robotic surgery increase cardiopulmonary risk because of the use of larger airway pressures (Paws) to maintain tidal volume (VT). However, the quantitative partitioning of respiratory mechanics and transpulmonary pressure (PL) during robotic surgery is not well described. We tested the following hypothesis: (1) the components of driving pressure (transpulmonary and chest wall components) increase in a parallel fashion at robotic surgical stages (Trendelenburg and robot docking); and (2) deep, when compared to routine (moderate), neuromuscular blockade modifies those changes in PLs as well as in regional respiratory mechanics. METHODS We studied 35 American Society of Anesthesiologists (ASA) I-II patients undergoing elective robotic surgery. Airway and esophageal balloon pressures and respiratory flows were measured to calculate respiratory mechanics. Regional lung aeration and ventilation was assessed with electrical impedance tomography and level of neuromuscular blockade with acceleromyography. During robotic surgical stages, 2 crossover randomized groups (conditions) of neuromuscular relaxation were studied: Moderate (1 twitch in the train-of-four stimulation) and Deep (1-2 twitches in the posttetanic count). RESULTS Pneumoperitoneum was associated with increases in driving pressure, tidal changes in PL, and esophageal pressure (Pes). Steep Trendelenburg position during robot docking was associated with further worsening of the respiratory mechanics. The fraction of driving pressures that partitioned to the lungs decreased from baseline (63% ± 15%) to Trendelenburg position (49% ± 14%, P < .001), due to a larger increase in chest wall elastance (Ecw; 12.7 ± 7.6 cm H2O·L) than in lung elastance (EL; 4.3 ± 5.0 cm H2O·L, P < .001). Consequently, from baseline to Trendelenburg, the component of Paw affecting the chest wall increased by 6.6 ± 3.1 cm H2O, while PLs increased by only 3.4 ± 3.1 cm H2O (P < .001). PL and driving pressures were larger at surgery end than at baseline and were accompanied by dorsal aeration loss. Deep neuromuscular blockade did not change respiratory mechanics, regional aeration and ventilation, and hemodynamics. CONCLUSIONS In robotic surgery with pneumoperitoneum, changes in ventilatory driving pressures during Trendelenburg and robot docking are distributed less to the lungs than to the chest wall as compared to routine mechanical ventilation for supine patients. This effect of robotic surgery derives from substantially larger increases in Ecw than ELs and reduces the risk of excessive PLs. Deep neuromuscular blockade does not meaningfully change global or regional lung mechanics.
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Affiliation(s)
- Julio C Brandão
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care and Pain Medicine, UNIFESP, São Paulo, Brazil
| | - Marcos A Lessa
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Laboratory of Cardiovascular Investigation, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
| | - Gabriel Motta-Ribeiro
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Soshi Hashimoto
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luis Felipe Paula
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vinicius Torsani
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, Sao Paulo, Brazil
| | - Linh Le
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Xiaodong Bao
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hao Deng
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shahin Tabatabaei
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcelo B P Amato
- Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, Sao Paulo, Brazil
| | - Marcos F Vidal Melo
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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31
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Eskandari M, Nordgren TM, O'Connell GD. Mechanics of pulmonary airways: Linking structure to function through constitutive modeling, biochemistry, and histology. Acta Biomater 2019; 97:513-523. [PMID: 31330329 DOI: 10.1016/j.actbio.2019.07.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/07/2019] [Accepted: 07/11/2019] [Indexed: 12/24/2022]
Abstract
Breathing involves fluid-solid interactions in the lung; however, the lack of experimental data inhibits combining the mechanics of air flow to airway deformation, challenging the understanding of how biomaterial constituents contribute to tissue response. As such, lung mechanics research is increasingly focused on exploring the relationship between structure and function. To address these needs, we characterize mechanical properties of porcine airways using uniaxial tensile experiments, accounting for bronchial orientation- and location- dependency. Structurally-reinforced constitutive models are developed to incorporate the role of collagen and elastin fibers embedded within the extrafibrillar matrix. The strain-energy function combines a matrix description (evaluating six models: compressible NeoHookean, unconstrained Ogden, uncoupled Mooney-Rivlin, incompressible Ogden, incompressible Demiray and incompressible NeoHookean), superimposed with non-linear fibers (evaluating two models: exponential and polynomial). The best constitutive formulation representative of all bronchial regions is determined based on curve-fit results to experimental data, accounting for uniqueness and sensitivity. Glycosaminoglycan and collagen composition, alongside tissue architecture, indicate fiber form to be primarily responsible for observed airway anisotropy and heterogeneous mechanical behavior. To the authors' best knowledge, this study is the first to formulate a structurally-motivated constitutive model, augmented with biochemical analysis and microstructural observations, to investigate the mechanical function of proximal and distal bronchi. Our systematic pulmonary tissue characterization provides a necessary foundation for understanding pulmonary mechanics; furthermore, these results enable clinical translation through simulations of airway obstruction in disease, fluid-structure interaction insights during breathing, and potentially, predictive capabilities for medical interventions. STATEMENT OF SIGNIFICANCE: The advancement of pulmonary research relies on investigating the biomechanical response of the bronchial tree. Experiments demonstrating the non-linear, heterogeneous, and anisotropic material behavior of porcine airways are used to develop a structural constitutive model representative of proximal and distal bronchial behavior. Calibrated material parameters exhibit regional variation in biomaterial properties, initially hypothesized to originate from tissue constituents. Further exploration through biochemical and histological analysis indicates mechanical function is primarily governed by microstructural form. The results of this study can be directly used in finite element and fluid-structure interaction models to enable physiologically relevant and more accurate computational simulations aimed to help diagnose and monitor pulmonary disease.
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Affiliation(s)
- Mona Eskandari
- Department of Mechanical Engineering, University of California at Riverside, Riverside, CA 92521, USA; Department of Bioengineering, University of California at Riverside, Riverside, CA 92521, USA; BREATHE Center School of Medicine, University of California at Riverside, Riverside, CA 92521, USA; Department of Mechanical Engineering, University of California at Berkeley, Berkeley, CA 94720, USA.
| | - Tara M Nordgren
- Division of Biomedical Sciences, University of California at Riverside, Riverside, CA 92521, USA; BREATHE Center School of Medicine, University of California at Riverside, Riverside, CA 92521, USA
| | - Grace D O'Connell
- Department of Mechanical Engineering, University of California at Berkeley, Berkeley, CA 94720, USA; Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA 94143, USA
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32
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Bitker L, Costes N, Le Bars D, Lavenne F, Orkisz M, Hernandez Hoyos M, Benzerdjeb N, Devouassoux M, Richard JC. Noninvasive quantification of macrophagic lung recruitment during experimental ventilation-induced lung injury. J Appl Physiol (1985) 2019; 127:546-558. [PMID: 31169472 DOI: 10.1152/japplphysiol.00825.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Macrophagic lung infiltration is pivotal in the development of lung biotrauma because of ventilation-induced lung injury (VILI). We assessed the performance of [11C](R)-PK11195, a positron emission tomography (PET) radiotracer binding the translocator protein, to quantify macrophage lung recruitment during experimental VILI. Pigs (n = 6) were mechanically ventilated under general anesthesia, using protective ventilation settings (baseline). Experimental VILI was performed by titrating tidal volume to reach a transpulmonary end-inspiratory pressure (∆PL) of 35-40 cmH2O. We acquired PET/computed tomography (CT) lung images at baseline and after 4 h of VILI. Lung macrophages were quantified in vivo by the standardized uptake value (SUV) of [11C](R)-PK11195 measured in PET on the whole lung and in six lung regions and ex vivo on lung pathology at the end of experiment. Lung mechanics were extracted from CT images to assess their association with the PET signal. ∆PL increased from 9 ± 1 cmH2O under protective ventilation, to 36 ± 6 cmH2O during experimental VILI. Compared with baseline, whole-lung [11C](R)-PK11195 SUV significantly increased from 1.8 ± 0.5 to 2.9 ± 0.5 after experimental VILI. Regional [11C](R)-PK11195 SUV was positively associated with the magnitude of macrophage recruitment in pathology (P = 0.03). Compared with baseline, whole-lung CT-derived dynamic strain and tidal hyperinflation increased significantly after experimental VILI, from 0.6 ± 0 to 2.0 ± 0.4, and 1 ± 1 to 43 ± 19%, respectively. On multivariate analysis, both were significantly associated with regional [11C](R)-PK11195 SUV. [11C](R)-PK11195 lung uptake (a proxy of lung inflammation) was increased by experimental VILI and was associated with the magnitude of dynamic strain and tidal hyperinflation.NEW & NOTEWORTHY We assessed the performance of [11C](R)-PK11195, a translocator protein-specific positron emission tomography (PET) radiotracer, to quantify macrophage lung recruitment during experimental ventilation-induced lung injury (VILI). In this proof-of-concept study, we showed that the in vivo quantification of [11C](R)-PK11195 lung uptake in PET reflected the magnitude of macrophage lung recruitment after VILI. Furthermore, increased [11C](R)-PK11195 lung uptake was associated with harmful levels of dynamic strain and tidal hyperinflation applied to the lungs.
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Affiliation(s)
- Laurent Bitker
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
| | | | - Didier Le Bars
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,CERMEP - Imagerie du Vivant, Bron, France
| | | | - Maciej Orkisz
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
| | - Marcela Hernandez Hoyos
- Systems and Computing Engineering Department, School of Engineering, Universidad de los Andes, Bogota, Colombia
| | - Nazim Benzerdjeb
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,Centre d'Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Mojgan Devouassoux
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,Centre d'Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
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33
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Scaramuzzo G, Broche L, Pellegrini M, Porra L, Derosa S, Tannoia AP, Marzullo A, Borges JB, Bayat S, Bravin A, Larsson A, Perchiazzi G. The Effect of Positive End-Expiratory Pressure on Lung Micromechanics Assessed by Synchrotron Radiation Computed Tomography in an Animal Model of ARDS. J Clin Med 2019; 8:E1117. [PMID: 31357677 PMCID: PMC6723999 DOI: 10.3390/jcm8081117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/17/2019] [Accepted: 07/25/2019] [Indexed: 02/06/2023] Open
Abstract
Modern ventilatory strategies are based on the assumption that lung terminal airspaces act as isotropic balloons that progressively accommodate gas. Phase contrast synchrotron radiation computed tomography (PCSRCT) has recently challenged this concept, showing that in healthy lungs, deflation mechanisms are based on the sequential de-recruitment of airspaces. Using PCSRCT scans in an animal model of acute respiratory distress syndrome (ARDS), this study examined whether the numerosity (ASnum) and dimension (ASdim) of lung airspaces change during a deflation maneuver at decreasing levels of positive end-expiratory pressure (PEEP) at 12, 9, 6, 3, and 0 cmH2O. Deflation was associated with significant reduction of ASdim both in the whole lung section (passing from from 13.1 ± 2.0 at PEEP 12 to 7.6 ± 4.2 voxels at PEEP 0) and in single concentric regions of interest (ROIs). However, the regression between applied PEEP and ASnum was significant in the whole slice (ranging from 188 ± 52 at PEEP 12 to 146.4 ± 96.7 at PEEP 0) but not in the single ROIs. This mechanism of deflation in which reduction of ASdim is predominant, differs from the one observed in healthy conditions, suggesting that the peculiar alveolar micromechanics of ARDS might play a role in the deflation process.
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Affiliation(s)
- Gaetano Scaramuzzo
- Department of Morphology, Surgery and Experimental Medicine, Ferrara University, 44121 Ferrara, Italy
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Ludovic Broche
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, 75185 Uppsala, Sweden
| | - Liisa Porra
- Department of Physics, University of Helsinki, FI-00014 Helsinki, Finland
- Helsinki University Hospital, FI-00029 Helsinki, Finland
| | - Savino Derosa
- Department of Emergency and Organ Transplant, Bari University, 70124 Bari, Italy
| | | | - Andrea Marzullo
- Department of Emergency and Organ Transplant, Bari University, 70124 Bari, Italy
| | - João Batista Borges
- Centre for Human and Applied Physiological Sciences, Faculty of Sciences and Medicine, King's College, London WC2R 2LS, UK
| | - Sam Bayat
- The European Synchrotron Radiation Facility, 38043 Grenoble, France
- INSERM UA7, Synchrotron Radiation for Biomedicine (STROBE) Laboratory, University of Grenoble Alpes, 38043 Grenoble, France
| | - Alberto Bravin
- The European Synchrotron Radiation Facility, 38043 Grenoble, France
| | - Anders Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden.
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, 75185 Uppsala, Sweden.
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Williams EC, Motta-Ribeiro GC, Vidal Melo MF. Driving Pressure and Transpulmonary Pressure: How Do We Guide Safe Mechanical Ventilation? Anesthesiology 2019; 131:155-163. [PMID: 31094753 PMCID: PMC6639048 DOI: 10.1097/aln.0000000000002731] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The physiological concept, pathophysiological implications and clinical relevance and application of driving pressure and transpulmonary pressure to prevent ventilator-induced lung injury are discussed.
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Affiliation(s)
- Elizabeth C Williams
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Current Affiliation: Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland (E.C.W.)
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35
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Lovisari F, Fodor GH, Peták F, Habre W, Bayat S. Effect of PEEP and I:E ratio on cerebral oxygenation in ARDS: an experimental study in anesthetized rabbit. BMC Anesthesiol 2019; 19:110. [PMID: 31216981 PMCID: PMC6582519 DOI: 10.1186/s12871-019-0782-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 06/09/2019] [Indexed: 12/03/2022] Open
Abstract
Background Although PEEP and inversed I:E ratio have been shown to improve gas exchange in ARDS, both can adversely affect systemic hemodynamics and cerebral perfusion. The goal of this study was to assess how changes in PEEP and I:E ratio affect systemic and cerebral oxygenation and perfusion in normal and injured lung. Methods Eight anesthetized Chinchilla-Bastard rabbits were ventilated at baseline with pressure-regulated volume control mode, VT = 6 ml/kg, PEEP = 6 cmH2O, FIO2 = 0.4; respiratory rate set for ETCO2 = 5.5%, and I:E = 1:2, 1:1 or 2:1 in random order. Ultrasonic carotid artery flow (CF), arterial (PaO2), jugular venous blood gases and near infrared spectroscopic cerebral oxygenation (∆HBO2) were recorded for each experimental condition. After induced lung injury, the animals were ventilated with PEEP = 9 followed by 6 cmH2O. Results At baseline, inverse-ratio ventilation (IRV) significantly reduced cerebral oxygenation (∆O2HB; − 27 at 1:2; − 15 at 1:1 vs. 0.27 μmol/L at 2:1; p < 0.05), due to a significant reduction in mean arterial pressure and CF without modifying gas exchange. In injured lung, IRV improved gas exchange but decreased cerebral perfusion without affecting brain oxygenation. The higher PEEP level, however, improved PaO2 (67.5 ± 19.3 vs. 42.2 ± 8.4, p < 0.05), resulting in an improved ∆HBO2 (− 13.8 ± 14.7 vs. –43.5 ± 21.3, p < 0.05), despite a drop in CF. Conclusions Our data suggest that unlike moderate PEEP, IRV is not effective in improving brain oxygenation in ARDS. In normal lung, IRV had a deleterious effect on brain oxygenation, which is relevant in anesthetized patients. Electronic supplementary material The online version of this article (10.1186/s12871-019-0782-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Federica Lovisari
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland.,University of Milano-Bicocca, Milan, Italy
| | - Gergely H Fodor
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Walid Habre
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland.,Pediatric Anesthesia Unit, Geneva Children's Hospital, Geneva, Switzerland
| | - Sam Bayat
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland. .,Inserm UA7 STROBE Laboratory, University of Grenoble, Grenoble, France. .,Department of Clinical Physiology, Sleep and Exercise, Grenoble University Hospital, Grenoble, France.
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36
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Vasques F, Sanderson B, Barrett NA, Camporota L. Monitoring of regional lung ventilation using electrical impedance tomography. Minerva Anestesiol 2019; 85:1231-1241. [PMID: 30945516 DOI: 10.23736/s0375-9393.19.13477-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Among recent lung imaging techniques and devices, electrical impedance tomography (EIT) can provide dynamic information on the distribution regional lung ventilation. EIT images possess a high temporal and functional resolution allowing the visualization of dynamic physiological and pathological changes on a breath-by-breath basis. EIT detects changes in electric impedance (i.e., changes in gas/fluid ratio) and describes them in real time, both visually through images and waveforms, and numerically, allowing the clinician to monitor disease evolution and response to treatment. The use of EIT in clinical practice is supported by several studies demonstrating a good correlation between impedance tomography data and other validated methods of measuring lung volume. In this review, we will provide an overview on the rationale, basic functioning and most common applications of EIT in the management of mechanically ventilated patients.
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Affiliation(s)
- Francesco Vasques
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK.,Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Barnaby Sanderson
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK.,Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK.,Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK - .,Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
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Sasaki M, Yamaguchi Y, Miyashita T, Matsuda Y, Ohtsuka M, Yamaguchi O, Goto T. Simulation of pressure support for spontaneous breathing trials in neonates. Intensive Care Med Exp 2019; 7:10. [PMID: 30737561 PMCID: PMC6368635 DOI: 10.1186/s40635-019-0223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 01/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endotracheal tubes used for neonates are not as resistant to breathing as originally anticipated; therefore, spontaneous breathing trials (SBTs) with continuous positive airway pressure (CPAP), without pressure support (PS), are recommended. However, PS extubation criteria have predetermined pressure values for each endotracheal tube diameter (PS 10 cmH2O with 3.0- and 3.5-mm tubes or PS 8 cmH2O with 4.0-mm tubes). This study aimed to assess the validity of these SBT criteria for neonates, using an artificial lung simulator, ASL 5000™ lung simulator, and a SERVO-i Universal™ ventilator (minute volume, 240-360 mL/kg/min; tidal volume, 30 mL; respiratory rate, 24-36/min; lung compliance, 0.5 mL/cmH2O/kg; resistance, 40 cmH2O/L/s) in an intensive care unit. We simulated a spontaneous breathing test in a 3-kg neonate after cardiac surgery with 3.0-3.5-mm endotracheal tubes. We measured the work of breathing (WOB), trigger work, and parameters of pressure support ventilation (PSV), T-piece breathing, or ASL 5000™ alone. RESULTS WOB displayed respiratory rate dependency under intubation. PS compensating tube resistance fluctuated with respiratory rate. At a respiratory rate of 24/min, the endotracheal tube did not greatly influence WOB under PSV and the regression line of WOB converged with the WOB of ASL 5000™ alone under PS 1 cmH2O; however, at 36/min, endotracheal tube was resistant to breathing under PSV because trigger work increased exponentially with PS ≤ 9 cmH2O. The regression line of WOB under PSV converged with the WOB of T-piece breathing under PS 1 cmH2O. Furthermore, PS compensating endotracheal tube resistance was 6 cmH2O. The WOB of ASL 5000™ alone approached that of respiratory distress syndrome (RDS); however, the pressure of patient effort was normal physiological range at PS 10 cmH2O. PS equalizing WOB under PSV with that after extubation depended on the respiratory rate and upper airway resistance. If WOB after extubation equaled that of T-piece breathing, the PS was 0 cmH2O regardless of the respiratory rates. If WOB after extubation approximated to that of ASL 5000™ alone, the PS depended on the respiratory rate. CONCLUSION SBT strategies should be selected per neonatal respiratory rates and upper airway resistance.
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Affiliation(s)
- Makoto Sasaki
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan.
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Tetsuya Miyashita
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Yuko Matsuda
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Masahide Ohtsuka
- Department of Critical Care Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Osamu Yamaguchi
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-004, Japan
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Shono A, Kotani T. Clinical implication of monitoring regional ventilation using electrical impedance tomography. J Intensive Care 2019; 7:4. [PMID: 30680219 PMCID: PMC6339287 DOI: 10.1186/s40560-019-0358-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 01/09/2019] [Indexed: 11/10/2022] Open
Abstract
Mechanical ventilation can initiate ventilator-associated lung injury (VALI) and contribute to the development of multiple organ dysfunction. Although a lung protective strategy limiting both tidal volume and plateau pressure reduces VALI, uneven intrapulmonary gas distribution is still capable of increasing regional stress and strain, especially in non-homogeneous lungs, such as during acute respiratory distress syndrome. Real-time monitoring of regional ventilation may prevent inhomogeneous ventilation, leading to a reduction in VALI. Electrical impedance tomography (EIT) is a technique performed at the patient's bedside. It is noninvasive and radiation-free and provides dynamic tidal images of gas distribution. Studies have reported that EIT provides useful information both in animal and clinical studies during mechanical ventilation. EIT has been shown to be useful during lung recruitment, titration of positive end-expiratory pressure, lung volume estimation, and evaluation of homogeneity of gas distribution in a single EIT measure or in combination with multiple EIT measures. EIT-guided mechanical ventilation preserved the alveolar architecture and maintained oxygenation and lung mechanics better than low-tidal volume ventilation in animal models. However, careful assessment is required for data analysis owing to the limited understanding of the results of EIT interpretation. Previous studies indicate monitoring regional ventilation by EIT is feasible in the intensive care setting and has potential to lead to lung protective ventilation. Further clinical studies are warranted to evaluate whether monitoring of regional ventilation using EIT can shorten the duration of ventilation or improve mortality in patients with acute respiratory distress syndrome.
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Affiliation(s)
- Atsuko Shono
- 1Department of Anesthesiology, Shimane University, 89-1 Enya-cho, Izumo City, Shimane 693-8501 Japan
| | - Toru Kotani
- 2Department of Intensive Care Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666 Japan
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39
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The Acute Respiratory Distress Syndrome: Diagnosis and Management. PRACTICAL TRENDS IN ANESTHESIA AND INTENSIVE CARE 2018 2019. [PMCID: PMC7122583 DOI: 10.1007/978-3-319-94189-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by a new acute onset of hypoxemia secondary to a pulmonary edema of non-cardiogenic origin, bilateral lung opacities and reduction in respiratory system compliance after an insult direct or indirect to lungs. Its first description was in 1970s, and then several shared definitions tried to describe this clinical entity; the last one, known as Berlin definition, brought an improvement in predictive ability for mortality. In the present chapter, the diagnostic workup of the syndrome will be presented with particular attention to microbiological investigations which represent a milestone in the diagnostic process and to imaging techniques such as CT scan and lung ultrasound. Despite the treatment is mainly based on supportive strategies, attention should be applied to assure adequate respiratory gas exchange while minimizing the risk of ventilator-induced lung injury (VILI) onset. Therefore will be described several therapeutic approaches to ARDS, including noninvasive mechanical ventilation (NIMV), high-flow nasal cannulas (HFNC) and invasive ventilation with particular emphasis to risks and benefits of mechanical ventilation, PEEP optimization and lung protective ventilation strategies. Rescue techniques, such as permissive hypercapnia, prone positioning, neuromuscular blockade, inhaled vasodilators, corticosteroids, recruitment maneuvers and extracorporeal life support, will also be reviewed. Finally, the chapter will deal with the mechanical ventilation weaning process with particular emphasis on extrapulmonary factors such as neurologic, diaphragmatic or cardiovascular alterations which can lead to weaning failure.
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40
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Wienhold SM, Macrì M, Nouailles G, Dietert K, Gurtner C, Gruber AD, Heimesaat MM, Lienau J, Schumacher F, Kleuser B, Opitz B, Suttorp N, Witzenrath M, Müller-Redetzky HC. Ventilator-induced lung injury is aggravated by antibiotic mediated microbiota depletion in mice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:282. [PMID: 30373626 PMCID: PMC6206919 DOI: 10.1186/s13054-018-2213-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibiotic exposure alters the microbiota, which can impact the inflammatory immune responses. Critically ill patients frequently receive antibiotic treatment and are often subjected to mechanical ventilation, which may induce local and systemic inflammatory responses and development of ventilator-induced lung injury (VILI). The aim of this study was to investigate whether disruption of the microbiota by antibiotic therapy prior to mechanical ventilation affects pulmonary inflammatory responses and thereby the development of VILI. METHODS Mice underwent 6-8 weeks of enteral antibiotic combination treatment until absence of cultivable bacteria in fecal samples was confirmed. Control mice were housed equally throughout this period. VILI was induced 3 days after completing the antibiotic treatment protocol, by high tidal volume (HTV) ventilation (34 ml/kg; positive end-expiratory pressure = 2 cmH2O) for 4 h. Differences in lung function, oxygenation index, pulmonary vascular leakage, macroscopic assessment of lung injury, and leukocyte and lymphocyte differentiation were assessed. Control groups of mice ventilated with low tidal volume and non-ventilated mice were analyzed accordingly. RESULTS Antibiotic-induced microbiota depletion prior to HTV ventilation led to aggravation of VILI, as shown by increased pulmonary permeability, increased oxygenation index, decreased pulmonary compliance, enhanced macroscopic lung injury, and increased cytokine/chemokine levels in lung homogenates. CONCLUSIONS Depletion of the microbiota by broad-spectrum antibiotics prior to HTV ventilation renders mice more susceptible to developing VILI, which could be clinically relevant for critically ill patients frequently receiving broad-spectrum antibiotics.
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Affiliation(s)
- Sandra-Maria Wienhold
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mario Macrì
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Present address: Scuola di specializzazione in Anestesia, Rianimazione e Terapia Intensiva, Università degli Studi di Milano, Milan, Italy
| | - Geraldine Nouailles
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kristina Dietert
- Department of Veterinary Pathology, Freie Universität Berlin, Berlin, Germany
| | - Corinne Gurtner
- Department of Veterinary Pathology, Freie Universität Berlin, Berlin, Germany.,Present address: Institute of Animal Pathology, Department of Infectious Diseases and Pathobiology, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Achim D Gruber
- Department of Veterinary Pathology, Freie Universität Berlin, Berlin, Germany
| | - Markus M Heimesaat
- Institute for Microbiology and Infection Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jasmin Lienau
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Fabian Schumacher
- Department of Nutritional Toxicology, Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany.,Department of Molecular Biology, University of Duisburg-Essen, Essen, Germany
| | - Burkhard Kleuser
- Department of Nutritional Toxicology, Institute of Nutritional Science, University of Potsdam, Nuthetal, Germany
| | - Bastian Opitz
- Department of Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Witzenrath
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. .,Department of Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - Holger C Müller-Redetzky
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Infectious Diseases and Pulmonary Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
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41
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Baedorf Kassis E, Loring SH, Talmor D. Should we titrate peep based on end-expiratory transpulmonary pressure?-yes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:390. [PMID: 30460264 DOI: 10.21037/atm.2018.06.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ventilator management of patients with acute respiratory distress syndrome (ARDS) has been characterized by implementation of basic physiology principles by minimizing harmful distending pressures and preventing lung derecruitment. Such strategies have led to significant improvements in outcomes. Positive end expiratory pressure (PEEP) is an important part of a lung protective strategy but there is no standardized method to set PEEP level. With widely varying types of lung injury, body habitus and pulmonary mechanics, the use of esophageal manometry has become important for personalization and optimization of mechanical ventilation in patients with ARDS. Esophageal manometry estimates pleural pressures, and can be used to differentiate the chest wall and lung (transpulmonary) contributions to the total respiratory system mechanics. Elevated pleural pressures may result in negative transpulmonary pressures at end expiration, leading to lung collapse. Measuring the esophageal pressures and adjusting PEEP to make transpulmonary pressures positive can decrease atelectasis, derecruitment of lung, and cyclical opening and closing of airways and alveoli, thus optimizing lung mechanics and oxygenation. Although there is some spatial and positional artifact, esophageal pressures in numerous animal and human studies in healthy, obese and critically ill patients appear to be a good estimate for the "effective" pleural pressure. Multiple studies have illustrated the benefit of using esophageal pressures to titrate PEEP in patients with obesity and with ARDS. Esophageal pressure monitoring provides a window into the unique physiology of a patient and helps improve clinical decision making at the bedside.
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Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen H Loring
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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de Vries H, Jonkman A, Shi ZH, Spoelstra-de Man A, Heunks L. Assessing breathing effort in mechanical ventilation: physiology and clinical implications. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:387. [PMID: 30460261 DOI: 10.21037/atm.2018.05.53] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent studies have shown both beneficial and detrimental effects of patient breathing effort in mechanical ventilation. Quantification of breathing effort may allow the clinician to titrate ventilator support to physiological levels of respiratory muscle activity. In this review we will describe the physiological background and methodological issues of the most frequently used methods to quantify breathing effort, including esophageal pressure measurement, the work of breathing, the pressure-time-product, electromyography and ultrasound. We will also discuss the level of breathing effort that may be considered optimal during mechanical ventilation at different stages of critical illness.
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Affiliation(s)
- Heder de Vries
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Angélique Spoelstra-de Man
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
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Marchioni A, Tonelli R, Ball L, Fantini R, Castaniere I, Cerri S, Luppi F, Malerba M, Pelosi P, Clini E. Acute exacerbation of idiopathic pulmonary fibrosis: lessons learned from acute respiratory distress syndrome? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:80. [PMID: 29566734 PMCID: PMC5865285 DOI: 10.1186/s13054-018-2002-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/19/2018] [Indexed: 12/12/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a fibrotic lung disease characterized by progressive loss of lung function and poor prognosis. The so-called acute exacerbation of IPF (AE-IPF) may lead to severe hypoxemia requiring mechanical ventilation in the intensive care unit (ICU). AE-IPF shares several pathophysiological features with acute respiratory distress syndrome (ARDS), a very severe condition commonly treated in this setting.A review of the literature has been conducted to underline similarities and differences in the management of patients with AE-IPF and ARDS.During AE-IPF, diffuse alveolar damage and massive loss of aeration occurs, similar to what is observed in patients with ARDS. Differently from ARDS, no studies have yet concluded on the optimal ventilatory strategy and management in AE-IPF patients admitted to the ICU. Notwithstanding, a protective ventilation strategy with low tidal volume and low driving pressure could be recommended similarly to ARDS. The beneficial effect of high levels of positive end-expiratory pressure and prone positioning has still to be elucidated in AE-IPF patients, as well as the precise role of other types of respiratory assistance (e.g., extracorporeal membrane oxygenation) or innovative therapies (e.g., polymyxin-B direct hemoperfusion). The use of systemic drugs such as steroids or immunosuppressive agents in AE-IPF is controversial and potentially associated with an increased risk of serious adverse reactions.Common pathophysiological abnormalities and similar clinical needs suggest translating to AE-IPF the lessons learned from the management of ARDS patients. Studies focused on specific therapeutic strategies during AE-IPF are warranted.
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Affiliation(s)
- Alessandro Marchioni
- University Hospital of Modena, Pneumology Unit and Center for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Roberto Tonelli
- University Hospital of Modena, Pneumology Unit and Center for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Lorenzo Ball
- San Martino Policlinico Hospital, IRCCS for Oncology, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Riccardo Fantini
- University Hospital of Modena, Pneumology Unit and Center for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- University Hospital of Modena, Pneumology Unit and Center for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Stefania Cerri
- University Hospital of Modena, Pneumology Unit and Center for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Fabrizio Luppi
- University Hospital of Modena, Pneumology Unit and Center for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Mario Malerba
- San Andrea Hospital-ASL Vercelli, Pneumology Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
| | - Enrico Clini
- University Hospital of Modena, Pneumology Unit and Center for Rare Lung Diseases, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
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Wise R, Bishop D, Joynt G, Rodseth R. Perioperative ARDS and lung injury: for anaesthesia and beyond. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1449463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Robert Wise
- Perioperative Research Unit, Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg, University of KwaZulu-Natal, Discipline of Anaesthesiology and Critical Care, Durban, South Africa
| | - David Bishop
- Perioperative Research Unit, Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg, University of KwaZulu-Natal, Discipline of Anaesthesiology and Critical Care, Durban, South Africa
| | - Gavin Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Reitze Rodseth
- Perioperative Research Unit, Metropolitan Department of Anaesthetics, Critical Care and Pain Management, Pietermaritzburg, University of KwaZulu-Natal, Discipline of Anaesthesiology and Critical Care, Durban, South Africa
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
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Esophageal pressure: research or clinical tool? Med Klin Intensivmed Notfmed 2017; 113:13-20. [PMID: 29134245 DOI: 10.1007/s00063-017-0372-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
Esophageal manometry has traditionally been utilized for respiratory physiology research, but clinicians have recently found numerous applications within the intensive care unit. Esophageal pressure (PEs) is a surrogate for pleural pressures (PPl), and the difference between airway pressure (PAO) and PEs provides a good estimate for the pressure across the lung also known as the transpulmonary pressure (PL). Differentiating the effects of mechanical ventilation and spontaneous breathing on the respiratory system, chest wall, and across the lung allows for improved personalization in clinical decision making. Measuring PL in acute respiratory distress syndrome (ARDS) may help set positive end expiratory pressure (PEEP) to prevent derecruitment and atelectrauma, while assuring peak pressures do not cause over distension during tidal breathing and recruitment maneuvers. Monitoring PEs allows improved insight into patient-ventilator interactions and may help in decisions to adjust sedation and paralytics to correct dyssynchrony. Intrinsic PEEP (auto-PEEP) may be monitored using esophageal manometry, which may also improve patient comfort and synchrony with the ventilator. Finally, during weaning, PEs may be used to better predict weaning success and allow for rapid intervention during failure. Improved consistency in definition and terminology and further outcomes research is needed to encourage more widespread adoption; however, with clear clinical benefit and increased ease of use, it appears time to reintroduce basic physiology into personalized ventilator management in the intensive care unit.
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Quantification of Age-Related Lung Tissue Mechanics under Mechanical Ventilation. Med Sci (Basel) 2017; 5:medsci5040021. [PMID: 29099037 PMCID: PMC5753650 DOI: 10.3390/medsci5040021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 01/30/2023] Open
Abstract
Elderly patients with obstructive lung diseases often receive mechanical ventilation to support their breathing and restore respiratory function. However, mechanical ventilation is known to increase the severity of ventilator-induced lung injury (VILI) in the elderly. Therefore, it is important to investigate the effects of aging to better understand the lung tissue mechanics to estimate the severity of ventilator-induced lung injuries. Two age-related geometric models involving human bronchioles from generation G10 to G23 and alveolar sacs were developed. The first is for a 50-year-old (normal) and second is for an 80-year old (aged) model. Lung tissue mechanics of normal and aged models were investigated under mechanical ventilation through computational simulations. Results obtained indicated that lung tissue strains during inhalation (t = 0.2 s) decreased by about 40% in the alveolar sac (G23) and 27% in the bronchiole (G20), respectively, for the 80-year-old as compared to the 50-year-old. The respiratory mechanics parameters (work of breathing per unit volume and maximum tissue strain) over G20 and G23 for the 80-year-old decreased by about 64% (three-fold) and 80% (four-fold), respectively, during the mechanical ventilation breathing cycle. However, there was a significant increase (by about threefold) in lung compliance for the 80-year-old in comparison to the 50-year-old. These findings from the computational simulations demonstrated that lung mechanical characteristics are significantly compromised in aging tissues, and these effects were quantified in this study.
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Abstract
The main goals of assessing respiratory system mechanical function are to evaluate the lung function through a variety of methods and to detect early signs of abnormalities that could affect the patient's outcomes. In ventilated patients, it has become increasingly important to recognize whether respiratory function has improved or deteriorated, whether the ventilator settings match the patient's demand, and whether the selection of ventilator parameters follows a lung-protective strategy. Ventilator graphics, esophageal pressure, intra-abdominal pressure, and electric impedance tomography are some of the best-known monitoring tools to obtain measurements and adequately evaluate the respiratory system mechanical function.
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Kim J, Heise RL, Reynolds AM, Pidaparti RM. Aging effects on airflow dynamics and lung function in human bronchioles. PLoS One 2017; 12:e0183654. [PMID: 28846719 PMCID: PMC5573216 DOI: 10.1371/journal.pone.0183654] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 08/08/2017] [Indexed: 01/09/2023] Open
Abstract
Background and objective The mortality rate for patients requiring mechanical ventilation is about 35% and this rate increases to about 53% for the elderly. In general, with increasing age, the dynamic lung function and respiratory mechanics are compromised, and several experiments are being conducted to estimate these changes and understand the underlying mechanisms to better treat elderly patients. Materials and methods Human tracheobronchial (G1 ~ G9), bronchioles (G10 ~ G22) and alveolar sacs (G23) geometric models were developed based on reported anatomical dimensions for a 50 and an 80-year-old subject. The aged model was developed by altering the geometry and material properties of the model developed for the 50-year-old. Computational simulations using coupled fluid-solid analysis were performed for geometric models of bronchioles and alveolar sacs under mechanical ventilation to estimate the airflow and lung function characteristics. Findings The airway mechanical characteristics decreased with aging, specifically a 38% pressure drop was observed for the 80-year-old as compared to the 50-year-old. The shear stress on airway walls increased with aging and the highest shear stress was observed in the 80-year-old during inhalation. A 50% increase in peak strain was observed for the 80-year-old as compared to the 50-year-old during exhalation. The simulation results indicate that there is a 41% increase in lung compliance and a 35%-50% change in airway mechanical characteristics for the 80-year-old in comparison to the 50-year-old. Overall, the airway mechanical characteristics as well as lung function are compromised due to aging. Conclusion Our study demonstrates and quantifies the effects of aging on the airflow dynamics and lung capacity. These changes in the aging lung are important considerations for mechanical ventilation parameters in elderly patients. Realistic geometry and material properties need to be included in the computational models in future studies.
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Affiliation(s)
- JongWon Kim
- College of Engineering, University of Georgia, Athens, Georgia, United States of America
| | - Rebecca L. Heise
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, United States of America
- The VCU Johnson Center, Virginia Commonwealth University Medical Center, Richmond, Virginia, United States of America
| | - Angela M. Reynolds
- The VCU Johnson Center, Virginia Commonwealth University Medical Center, Richmond, Virginia, United States of America
- Department of Mathematics & Applied Mathematics, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Ramana M. Pidaparti
- College of Engineering, University of Georgia, Athens, Georgia, United States of America
- * E-mail:
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Roth CJ, Yoshihara L, Wall WA. A simplified parametrised model for lung microstructures capable of mimicking realistic geometrical and mechanical properties. Comput Biol Med 2017; 89:104-114. [PMID: 28800439 DOI: 10.1016/j.compbiomed.2017.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/16/2022]
Abstract
The respiratory zone of mammalian lungs contains several millions of so-called alveoli. The geometrical and mechanical properties of this microstructure are crucial for respiration and influence the macroscopic behaviour of the entire organ in health and disease. Hence, if computational models are sought to gain more insight into lung behaviour, predict lung states in certain scenarios or suggest better treatment options in early stages of respiratory dysfunction, an adequate representation of this microstructure is essential. However, investigating the real alveolar architecture requires complex medical-imaging methods and would be computationally extremely expensive. Even worse, there is currently no way of obtaining the real patient-specific microstructure in vivo. Hence, we present a fast and easy to compute parametrised model of lung microstructures based on tetrakaidecahedra which can represent both geometrical and mechanical properties of the parenchyma. We show that gas transport pathways and stress and strain distributions are comparable to real alveolar microstructures and even capable of capturing variations present in biology. The created parametrised lung microstructure models can be utilized in finite element simulations to study, e.g., alveolar flow phenomena, particle deposition, or alveolar stresses and strains during mechanical ventilation. Due to the simpler geometry of the parametrised microgeometries compared to imaging-based microstructures, remarkable savings in CPU time can be achieved. We show that our model requires a minimum of 10% of the computational time for computing the same strain state in structural mechanics simulations compared to imaging-based alveolar microstructures.
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Affiliation(s)
- Christian J Roth
- Institute for Computational Mechanics, Technical University of Munich, Boltzmannstrasse 15, 85748, Garching b. München, Germany
| | - Lena Yoshihara
- Institute for Computational Mechanics, Technical University of Munich, Boltzmannstrasse 15, 85748, Garching b. München, Germany.
| | - Wolfgang A Wall
- Institute for Computational Mechanics, Technical University of Munich, Boltzmannstrasse 15, 85748, Garching b. München, Germany
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Loring SH, Topulos GP, Hubmayr RD. Transpulmonary Pressure: The Importance of Precise Definitions and Limiting Assumptions. Am J Respir Crit Care Med 2017; 194:1452-1457. [PMID: 27606837 DOI: 10.1164/rccm.201512-2448cp] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Recent studies applying the principles of respiratory mechanics to respiratory disease have used inconsistent and mutually exclusive definitions of the term "transpulmonary pressure." By the traditional definition, transpulmonary pressure is the pressure across the whole lung, including the intrapulmonary airways, (i.e., the pressure difference between the opening to the pulmonary airway and the pleural surface). However, more recently transpulmonary pressure has also been defined as the pressure across only the lung tissue (i.e., the pressure difference between the alveolar space and the pleural surface), traditionally known as the "elastic recoil pressure of the lung." Multiple definitions of the same term, and failure to recognize their underlying assumptions, have led to different interpretations of lung physiology and conclusions about appropriate therapy for patients. It is our view that many current controversies in the physiological interpretation of disease are caused by the lack of consistency in the definitions of these common physiological terms. In this article, we discuss the historical uses of these terms and recent misconceptions that may have resulted when these terms were confused. These misconceptions include assertions that normal pleural pressure must be negative (subatmospheric) and that a pressure in the pleural space may not be substantially positive when a subject is relaxed with an open airway. We urge specificity and uniformity when using physiological terms to define the physical state of the lungs, the chest wall, and the integrated respiratory system.
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Affiliation(s)
- Stephen H Loring
- 1 Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - George P Topulos
- 2 Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Rolf D Hubmayr
- 3 Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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