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Gaulton TG, Xin Y, Victor M, Nova A, Cereda M. Imaging the pulmonary vasculature in acute respiratory distress syndrome. Nitric Oxide 2024; 147:6-12. [PMID: 38588918 PMCID: PMC11253040 DOI: 10.1016/j.niox.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by a redistribution of regional lung perfusion that impairs gas exchange. While speculative, experimental evidence suggests that perfusion redistribution may contribute to regional inflammation and modify disease progression. Unfortunately, tools to visualize and quantify lung perfusion in patients with ARDS are lacking. This review explores recent advances in perfusion imaging techniques that aim to understand the pulmonary circulation in ARDS. Dynamic contrast-enhanced computed tomography captures first-pass kinetics of intravenously injected dye during continuous scan acquisitions. Different contrast characteristics and kinetic modeling have improved its topographic measurement of pulmonary perfusion with high spatial and temporal resolution. Dual-energy computed tomography can map the pulmonary blood volume of the whole lung with limited radiation exposure, enabling its application in clinical research. Electrical impedance tomography can obtain serial topographic assessments of perfusion at the bedside in response to treatments such as inhaled nitric oxide and prone position. Ongoing technological improvements and emerging techniques will enhance lung perfusion imaging and aid its incorporation into the care of patients with ARDS.
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Affiliation(s)
- Timothy G Gaulton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Yi Xin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcus Victor
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Electronics Engineering Division, Aeronautics Institute of Technology, Sao Paulo, Brazil
| | - Alice Nova
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
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Harbut P, Campoccia Jalde F, Dahlberg M, Forsgren A, Andersson E, Lundholm A, Janc J, Lesnik P, Suchanski M, Zatorski P, Trzebicki J, Skalec T, Günther M. Improved oxygenation in prone positioning of mechanically ventilated patients with COVID-19 acute respiratory distress syndrome is associated with decreased pulmonary shunt fraction: a prospective multicenter study. Eur J Med Res 2023; 28:597. [PMID: 38102699 PMCID: PMC10725003 DOI: 10.1186/s40001-023-01559-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Prone position is used in acute respiratory distress syndrome and in coronavirus disease 2019 (Covid-19) acute respiratory distress syndrome (ARDS). However, physiological mechanisms remain unclear. The aim of this study was to determine whether improved oxygenation was related to pulmonary shunt fraction (Q's/Q't), alveolar dead space (Vd/Vtalv) and ventilation/perfusion mismatch (V'A/Q'). METHODS This was an international, prospective, observational, multicenter, cohort study, including six intensive care units in Sweden and Poland and 71 mechanically ventilated adult patients. RESULTS Prone position increased PaO2:FiO2 after 30 min, by 78% (83-148 mm Hg). The effect persisted 120 min after return to supine (p < 0.001). The oxygenation index decreased 30 min after prone positioning by 43% (21-12 units). Q's/Q't decreased already after 30 min in the prone position by 17% (0.41-0.34). The effect persisted 120 min after return to supine (p < 0.005). Q's/Q't and PaO2:FiO2 were correlated both in prone (Beta -137) (p < 0.001) and in the supine position (Beta -270) (p < 0.001). V'A/Q' was unaffected and did not correlate to PaO2:FiO2 (p = 0.8). Vd/Vtalv increased at 120 min by 11% (0.55-0.61) (p < 0.05) and did not correlate to PaO2:FiO2 (p = 0.3). The ventilatory ratio increased after 30 min in the prone position by 58% (1.9-3.0) (p < 0.001). PaO2:FiO2 at baseline predicted PaO2:FiO2 at 30 min after proning (Beta 1.3) (p < 0.001). CONCLUSIONS Improved oxygenation by prone positioning in COVID-19 ARDS patients was primarily associated with a decrease in pulmonary shunt fraction. Dead space remained high and the global V'A/Q' measure could not explain the differences in gas exchange.
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Affiliation(s)
- Piotr Harbut
- Department of Clinical Sciences Danderyd, Karolinska Institutet, Stockholm, Sweden
| | - Francesca Campoccia Jalde
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Thoracic Anesthesia and Intensive Care Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders Forsgren
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden
| | - Elisabeth Andersson
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden
| | - Andreas Lundholm
- Department of Clinical Sciences Danderyd, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | | | | | - Mattias Günther
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden.
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Martin KT, Xin Y, Gaulton TG, Victor M, Santiago RR, Kim T, Morais CCA, Kazimi AA, Connell M, Gerard SE, Herrmann J, Mueller AL, Lenart A, Shen J, Khan SS, Petrov M, Reutlinger K, Rozenberg K, Amato M, Berra L, Cereda M. Electrical Impedance Tomography Identifies Evolution of Regional Perfusion in a Porcine Model of Acute Respiratory Distress Syndrome. Anesthesiology 2023; 139:815-826. [PMID: 37566686 PMCID: PMC10840641 DOI: 10.1097/aln.0000000000004731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
BACKGROUND Bedside electrical impedance tomography could be useful to visualize evolving pulmonary perfusion distributions when acute respiratory distress syndrome worsens or in response to ventilatory and positional therapies. In experimental acute respiratory distress syndrome, this study evaluated the agreement of electrical impedance tomography and dynamic contrast-enhanced computed tomography perfusion distributions at two injury time points and in response to increased positive end-expiratory pressure (PEEP) and prone position. METHODS Eleven mechanically ventilated (VT 8 ml · kg-1) Yorkshire pigs (five male, six female) received bronchial hydrochloric acid (3.5 ml · kg-1) to invoke lung injury. Electrical impedance tomography and computed tomography perfusion images were obtained at 2 h (early injury) and 24 h (late injury) after injury in supine position with PEEP 5 and 10 cm H2O. In eight animals, electrical impedance tomography and computed tomography perfusion imaging were also conducted in the prone position. Electrical impedance tomography perfusion (QEIT) and computed tomography perfusion (QCT) values (as percentages of image total) were compared in eight vertical regions across injury stages, levels of PEEP, and body positions using mixed-effects linear regression. The primary outcome was agreement between QEIT and QCT, defined using limits of agreement and Pearson correlation coefficient. RESULTS Pao2/Fio2 decreased over the course of the experiment (healthy to early injury, -253 [95% CI, -317 to -189]; early to late injury, -88 [95% CI, -151 to -24]). The limits of agreement between QEIT and QCT were -4.66% and 4.73% for the middle 50% quantile of average regional perfusion, and the correlation coefficient was 0.88 (95% CI, 0.86 to 0.90]; P < 0.001). Electrical impedance tomography and computed tomography showed similar perfusion redistributions over injury stages and in response to increased PEEP. QEIT redistributions after positional therapy underestimated QCT in ventral regions and overestimated QCT in dorsal regions. CONCLUSIONS Electrical impedance tomography closely approximated computed tomography perfusion measures in experimental acute respiratory distress syndrome, in the supine position, over injury progression and with increased PEEP. Further validation is needed to determine the accuracy of electrical impedance tomography in measuring perfusion redistributions after positional changes. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Kevin T Martin
- Department of Anesthesia and Perioperative Care, University of California San Francisco, CA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Timothy G Gaulton
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Marcus Victor
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Electronics Engineering Division, Aeronautics Institute of Technology, São Paulo, Brazil
| | - Roberta R Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Taehwan Kim
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Caio C A Morais
- Department of Physical Therapy, Federal University of Pernambuco, Recife, Brazil
| | - Aubrey A Kazimi
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Marc Connell
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Sarah E Gerard
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
| | - Jacob Herrmann
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
| | - Ariel L Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Austin Lenart
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiacheng Shen
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Sherbano S Khan
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Mihail Petrov
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristan Reutlinger
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Karina Rozenberg
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Marcelo Amato
- Department of Cardio-Pulmonary, University of São Paulo, São Paulo, Brazil
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Motta-Ribeiro GC, Winkler T, Costa ELV, de Prost N, Tucci MR, Vidal Melo MF. Worsening of lung perfusion to tissue density distributions during early acute lung injury. J Appl Physiol (1985) 2023; 135:239-250. [PMID: 37289955 PMCID: PMC10393328 DOI: 10.1152/japplphysiol.00028.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/12/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023] Open
Abstract
Lung perfusion magnitude and distribution are essential for oxygenation and, potentially, lung inflammation and protection during acute respiratory distress syndrome (ARDS). Yet, perfusion patterns and their relationship to inflammation are unknown pre-ARDS. We aimed to assess perfusion/density ratios and spatial perfusion-density distributions and associate these to lung inflammation, during early lung injury in large animals at different physiological conditions caused by different systemic inflammation and positive end-expiratory pressure (PEEP) levels. Sheep were protectively ventilated (16-24 h) and imaged for lung density, pulmonary capillary perfusion (13Nitrogen-saline), and inflammation (18F-fluorodeoxyglucose) using positron emission and computed tomography. We studied four conditions: permissive atelectasis (PEEP = 0 cmH2O); and ARDSNet low-stretch PEEP-setting strategy with supine moderate or mild endotoxemia, and prone mild endotoxemia. Perfusion/density heterogeneity increased pre-ARDS in all groups. Perfusion redistribution to density depended on ventilation strategy and endotoxemia level, producing more atelectasis in mild than moderate endotoxemia (P = 0.010) with the oxygenation-based PEEP-setting strategy. The spatial distribution of 18F-fluorodeoxyglucose uptake was related to local Q/D (P < 0.001 for Q/D group interaction). Moderate endotoxemia yielded markedly low/zero perfusion in normal-low density lung, with 13Nitrogen-saline perfusion indicating nondependent capillary obliteration. Prone animals' perfusion was remarkably homogeneously distributed with density. Lung perfusion redistributes heterogeneously to density during pre-ARDS protective ventilation in animals. This is associated with increased inflammation, nondependent capillary obliteration, and lung derecruitment susceptibility depending on endotoxemia level and ventilation strategy.NEW & NOTEWORTHY Perfusion redistribution does not follow lung density redistribution in the first 16-24 h of systemic endotoxemia and protective tidal volume mechanical ventilation. The same oxygenation-based positive end-expiratory pressure (PEEP)-setting strategy can lead at different endotoxemia levels to different perfusion redistributions, PEEP values, and lung aerations, worsening lung biomechanical conditions. During early acute lung injury, regional perfusion-to-tissue density ratio is associated with increased neutrophilic inflammation, and susceptibility to nondependent capillary occlusion and lung derecruitment, potentially marking and/or driving lung injury.
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Affiliation(s)
- Gabriel C Motta-Ribeiro
- Biomedical Engineering Program, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tilo Winkler
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Eduardo L V Costa
- Divisão de Pneumologia, Faculdade de Medicina, Instituto do Coração (Incor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
- Instituto de Ensino e Pesquisa do Hospital Sírio Libanês, São Paulo, Brazil
| | - Nicolas de Prost
- Hôpitaux Universitaires Henri Mondor and Université Paris Est Créteil and INSERM - Unité U955, Créteil, France
| | - Mauro R Tucci
- Divisão de Pneumologia, Faculdade de Medicina, Instituto do Coração (Incor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York, United States
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Xin Y, Kim T, Winkler T, Brix G, Gaulton T, Gerard SE, Herrmann J, Martin KT, Victor M, Reutlinger K, Amato M, Berra L, Kalra MK, Cereda M. Improving pulmonary perfusion assessment by dynamic contrast-enhanced computed tomography in an experimental lung injury model. J Appl Physiol (1985) 2023; 134:1496-1507. [PMID: 37167261 PMCID: PMC10228674 DOI: 10.1152/japplphysiol.00159.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/24/2023] [Accepted: 05/11/2023] [Indexed: 05/13/2023] Open
Abstract
Pulmonary perfusion has been poorly characterized in acute respiratory distress syndrome (ARDS). Optimizing protocols to measure pulmonary blood flow (PBF) via dynamic contrast-enhanced (DCE) computed tomography (CT) could improve understanding of how ARDS alters pulmonary perfusion. In this study, comparative evaluations of injection protocols and tracer-kinetic analysis models were performed based on DCE-CT data measured in ventilated pigs with and without lung injury. Ten Yorkshire pigs (five with lung injury, five healthy) were anesthetized, intubated, and mechanically ventilated; lung injury was induced by bronchial hydrochloric acid instillation. Each DCE-CT scan was obtained during a 30-s end-expiratory breath-hold. Reproducibility of PBF measurements was evaluated in three pigs. In eight pigs, undiluted and diluted Isovue-370 were separately injected to evaluate the effect of contrast viscosity on estimated PBF values. PBF was estimated with the peak-enhancement and the steepest-slope approach. Total-lung PBF was estimated in two healthy pigs to compare with cardiac output measured invasively by thermodilution in the pulmonary artery. Repeated measurements in the same animals yielded a good reproducibility of computed PBF maps. Injecting diluted isovue-370 resulted in smaller contrast-time curves in the pulmonary artery (P < 0.01) and vein (P < 0.01) without substantially diminishing peak signal intensity (P = 0.46 in the pulmonary artery) compared with the pure contrast agent since its viscosity is closer to that of blood. As compared with the peak-enhancement model, PBF values estimated by the steepest-slope model with diluted contrast were much closer to the cardiac output (R2 = 0.82) as compared with the peak-enhancement model. DCE-CT using the steepest-slope model and diluted contrast agent provided reliable quantitative estimates of PBF.NEW & NOTEWORTHY Dynamic contrast-enhanced CT using a lower-viscosity contrast agent in combination with tracer-kinetic analysis by the steepest-slope model improves pulmonary blood flow measurements and assessment of regional distributions of lung perfusion.
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Affiliation(s)
- Yi Xin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Taehwan Kim
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Tilo Winkler
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Gunnar Brix
- Department of Medical and Occupational Radiation Protection, Federal Office for Radiation Protection, Salzgitter, Germany
| | - Timothy Gaulton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Sarah E Gerard
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Jacob Herrmann
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Kevin T Martin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Marcus Victor
- Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Electronics Engineering Division, Aeronautics Institute of Technology, Sao Paulo, Brazil
| | - Kristan Reutlinger
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Marcelo Amato
- Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Mannudeep K Kalra
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Radiology, Harvard Medical School, Boston, Massachusetts, United States
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, United States
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Battaglini D, Ciaravolo E, Caiffa S, Delpiano L, Ball L, Vena A, Giacobbe DR, Bassetti M, Matta B, Pelosi P, Robba C. Systemic and Cerebral Effects of Physiotherapy in Mechanically Ventilated Subjects. Respir Care 2023; 68:452-461. [PMID: 36810363 PMCID: PMC10173117 DOI: 10.4187/respcare.10227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Physiotherapy may result in better functional outcomes, shorter duration of delirium, and more ventilator-free days. The effects of physiotherapy on different subpopulations of mechanically ventilated patients on respiratory and cerebral function are still unclear. We evaluated the effect of physiotherapy on systemic gas exchange and hemodynamics as well as on cerebral oxygenation and hemodynamics in mechanically ventilated subjects with and without COVID-19 pneumonia. METHODS This was an observational study in critically ill subjects with and without COVID-19 who underwent protocolized physiotherapy (including respiratory and rehabilitation physiotherapy) and neuromonitoring of cerebral oxygenation and hemodynamics. PaO2 /FIO2 , PaCO2 , hemodynamics (mean arterial pressure [MAP], mm Hg; heart rate, beats/min), and cerebral physiologic parameters (noninvasive intracranial pressure, cerebral perfusion pressure using transcranial Doppler, and cerebral oxygenation using near-infrared spectroscopy) were assessed before (T0) and immediately after physiotherapy (T1). RESULTS Thirty-one subjects were included (16 with COVID-19 and 15 without COVID-19). Physiotherapy improved PaO2 /FIO2 in the overall population (T1 = 185 [108-259] mm Hg vs T0 = 160 [97-231] mm Hg, P = .02) and in the subjects with COVID-19 (T1 = 119 [89-161] mm Hg vs T0 = 110 [81-154] mm Hg, P = .02) and decreased the PaCO2 in the COVID-19 group only (T1 = 40 [38-44] mm Hg vs T0 = 43 [38-47] mm Hg, P = .03). Physiotherapy did not affect cerebral hemodynamics, whereas increased the arterial oxygen part of hemoglobin both in the overall population (T1 = 3.1% [-1.3 to 4.9] vs T0 = 1.1% [-1.8 to 2.6], P = .007) and in the non-COVID-19 group (T1 = 3.7% [0.5-6.3] vs T0 = 0% [-2.2 to 2.8], P = .02). Heart rate was higher after physiotherapy in the overall population (T1 = 87 [75-96] beats/min vs T0 = 78 [72-92] beats/min, P = .044) and in the COVID-19 group (T1 = 87 [81-98] beats/min vs T0 = 77 [72-91] beats/min, P = .01), whereas MAP increased in the COVID-19 group only (T1 = 87 [82-83] vs T0 = 83 [76-89], P = .030). CONCLUSIONS Protocolized physiotherapy improved gas exchange in subjects with COVID-19, whereas it improved cerebral oxygenation in non-COVID-19 subjects.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Elena Ciaravolo
- Anesthesia and Emergency Department, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Salvatore Caiffa
- Intensive Care Respiratory Physiotherapy, Rehabilitation and Functional Education, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Lara Delpiano
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Antonio Vena
- Department of Health Sciences, University of Genoa, Genoa, Italy; and Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Daniele R Giacobbe
- Department of Health Sciences, University of Genoa, Genoa, Italy; and Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, Genoa, Italy; and Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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7
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Mlček M, Borges JB, Otáhal M, Alcala GC, Hladík D, Kuriščák E, Tejkl L, Amato M, Kittnar O. Real-time effects of lateral positioning on regional ventilation and perfusion in an experimental model of acute respiratory distress syndrome. Front Physiol 2023; 14:1113568. [PMID: 37020459 PMCID: PMC10067565 DOI: 10.3389/fphys.2023.1113568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/01/2023] [Indexed: 03/22/2023] Open
Abstract
Low-volume lung injury encompasses local concentration of stresses in the vicinity of collapsed regions in heterogeneously ventilated lungs. We aimed to study the effects on ventilation and perfusion distributions of a sequential lateral positioning (30°) strategy using electrical impedance tomography imaging in a porcine experimental model of early acute respiratory distress syndrome (ARDS). We hypothesized that such strategy, including a real-time individualization of positive end-expiratory pressure (PEEP) whenever in lateral positioning, would provide attenuation of collapse in the dependent lung regions. A two-hit injury acute respiratory distress syndrome experimental model was established by lung lavages followed by injurious mechanical ventilation. Then, all animals were studied in five body positions in a sequential order, 15 min each: Supine 1; Lateral Left; Supine 2; Lateral Right; Supine 3. The following functional images were analyzed by electrical impedance tomography: ventilation distributions and regional lung volumes, and perfusion distributions. The induction of the acute respiratory distress syndrome model resulted in a marked fall in oxygenation along with low regional ventilation and compliance of the dorsal half of the lung (gravitational-dependent in supine position). Both the regional ventilation and compliance of the dorsal half of the lung greatly increased along of the sequential lateral positioning strategy, and maximally at its end. In addition, a corresponding improvement of oxygenation occurred. In conclusion, our sequential lateral positioning strategy, with sufficient positive end-expiratory pressure to prevent collapse of the dependent lung units during lateral positioning, provided a relevant diminution of collapse in the dorsal lung in a porcine experimental model of early acute respiratory distress syndrome.
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Affiliation(s)
- Mikuláš Mlček
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - João Batista Borges
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
- *Correspondence: João Batista Borges,
| | - Michal Otáhal
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Glasiele Cristina Alcala
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Dominik Hladík
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Eduard Kuriščák
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - Leoš Tejkl
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - Marcelo Amato
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Otomar Kittnar
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
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8
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Zubieta-Calleja GR, Zubieta-DeUrioste N, de Jesús Montelongo F, Sanchez MGR, Campoverdi AF, Rocco PRM, Battaglini D, Ball L, Pelosi P. Morphological and functional findings in COVID-19 lung disease as compared to Pneumonia, ARDS, and High-Altitude Pulmonary Edema. Respir Physiol Neurobiol 2023; 309:104000. [PMID: 36460252 PMCID: PMC9707029 DOI: 10.1016/j.resp.2022.104000] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/18/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022]
Abstract
Coronavirus disease-2019 (COVID-19) may severely affect respiratory function and evolve to life-threatening hypoxia. The clinical experience led to the implementation of standardized protocols assuming similarity to severe acute respiratory syndrome (SARS-CoV-2). Understanding the histopathological and functional patterns is essential to better understand the pathophysiology of COVID-19 and then develop new therapeutic strategies. Epithelial and endothelial cell damage can result from the virus attack, thus leading to immune-mediated response. Pulmonary histopathological findings show the presence of Mallory bodies, alveolar coating cells with nuclear atypia, reactive pneumocytes, reparative fibrosis, intra-alveolar hemorrhage, moderate inflammatory infiltrates, micro-abscesses, microthrombus, hyaline membrane fragments, and emphysema-like lung areas. COVID-19 patients may present different respiratory stages from silent to critical hypoxemia, are associated with the degree of pulmonary parenchymal involvement, thus yielding alteration of ventilation and perfusion relationships. This review aims to: discuss the morphological (histopathological and radiological) and functional findings of COVID-19 compared to acute interstitial pneumonia, acute respiratory distress syndrome (ARDS), and high-altitude pulmonary edema (HAPE), four entities that share common clinical traits, but have peculiar pathophysiological features with potential implications to their clinical management.
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Affiliation(s)
| | | | - Felipe de Jesús Montelongo
- Critical and Neurointensive Care Unit and Pathology Department, Hospital General de Ecatepec “Las Américas”, Instituto de Salud del Estado de México, México
| | - Manuel Gabriel Romo Sanchez
- Critical and Neurointensive Care Unit and Pathology Department, Hospital General de Ecatepec “Las Américas”, Instituto de Salud del Estado de México, México
| | | | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil,COVID-19 Virus Network, Ministry of Science, Technology, and Innovation, Brasilia, Brazil
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy,Corresponding author
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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9
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Dilken O, Rezoagli E, Yartaş Dumanlı G, Ürkmez S, Demirkıran O, Dikmen Y. Effect of prone positioning on end-expiratory lung volume, strain and oxygenation change over time in COVID-19 acute respiratory distress syndrome: A prospective physiological study. Front Med (Lausanne) 2022; 9:1056766. [PMID: 36530873 PMCID: PMC9755177 DOI: 10.3389/fmed.2022.1056766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/21/2022] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Prone position (PP) is a recommended intervention in severe classical acute respiratory distress syndrome (ARDS). Changes in lung resting volume, respiratory mechanics and gas exchange during a 16-h cycle of PP in COVID-19 ARDS has not been yet elucidated. METHODS Patients with severe COVID-19 ARDS were enrolled between May and September 2021 in a prospective cohort study in a University Teaching Hospital. Lung resting volume was quantitatively assessed by multiple breath nitrogen wash-in/wash-out technique to measure the end-expiratory lung volume (EELV). Timepoints included the following: Baseline, Supine Position (S1); start of PP (P0), and every 4-h (P4; P8; P12) until the end of PP (P16); and Supine Position (S2). Respiratory mechanics and gas exchange were assessed at each timepoint. MEASUREMENTS AND MAIN RESULTS 40 mechanically ventilated patients were included. EELV/predicted body weight (PBW) increased significantly over time. The highest increase was observed at P4. The highest absolute EELV/PBW values were observed at the end of the PP (P16 vs S1; median 33.5 ml/kg [InterQuartileRange, 28.2-38.7] vs 23.4 ml/kg [18.5-26.4], p < 0.001). Strain decreased immediately after PP and remained stable between P4 and P16. PaO2/FiO2 increased during PP reaching the highest level at P12 (P12 vs S1; 163 [138-217] vs 81 [65-97], p < 0.001). EELV/PBW, strain and PaO2/FiO2 decreased at S2 although EELV/PBW and PaO2/FiO2 were still significantly higher as compared to S1. Both absolute values over time and changes of strain and PaO2/FiO2 at P16 and S2 versus S1 were strongly associated with EELV/PBW levels. CONCLUSION In severe COVID-19 ARDS, EELV steadily increased over a 16-h cycle of PP peaking at P16. Strain gradually decreased, and oxygenation improved over time. Changes in strain and oxygenation at the end of PP and back to SP were strongly associated with changes in EELV/PBW. Whether the change in EELV and oxygenation during PP may play a role on outcomes in COVID-ARDS deserves further investigation. CLINICAL TRIAL REGISTRATION [www.ClinicalTrials.gov], identifier [NCT04818164].
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Affiliation(s)
- Olcay Dilken
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, ECMO Center, ASST Monza, San Gerardo University Teaching Hospital, Monza, Italy
| | - Güleren Yartaş Dumanlı
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Seval Ürkmez
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Oktay Demirkıran
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Yalım Dikmen
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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10
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González-Ruiz FJ, Lazcano-Díaz EA, Baeza Herrera LA, Villalobos-Pedroza M, Toledo Alemán EL, Zuñiga-Salcedo MG, Cruz-Rodríguez C, López-Polanco A, Torres-Pulido A, Sierra-González de Cossio A, Cota Apodaca LA, Manzur-Sandoval D. Endotheliitis, Shunts, and Ventilation-Perfusion Mismatch in Coronavirus Disease 2019: A Literature Review of Disease Mechanisms. Ann Med Surg (Lond) 2022; 78:103820. [PMID: 35600188 PMCID: PMC9112604 DOI: 10.1016/j.amsu.2022.103820] [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: 03/27/2022] [Revised: 05/14/2022] [Accepted: 05/15/2022] [Indexed: 10/27/2022] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 pandemic has continued to impact global health. However, while immunity acquired by vaccines has been developed, 40% of the world's population has still not been vaccinated. Economic problems associated with acquiring novel therapies, misinformation, and differences in treatment protocols have generated catastrophic results, especially in low-resource countries. Understanding the pathophysiological aspects of coronavirus disease and the therapeutic strategies that have been validated to date is essential for successful medical care. In this review, I summarize the historical aspects of the virus, molecules involved in infecting the host, and consequences of viral interactions with and in tissues.
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Affiliation(s)
- Francisco J. González-Ruiz
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
| | - Emmanuel A. Lazcano-Díaz
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
| | - Luis A. Baeza Herrera
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
| | | | - Enma L. Toledo Alemán
- Department of Cardiovascular Diseases, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, Mexico
| | - Miriam G. Zuñiga-Salcedo
- Department of Cardiovascular Diseases, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, Mexico
| | - Camelia Cruz-Rodríguez
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
| | - Alexandra López-Polanco
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
| | - Abraham Torres-Pulido
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
| | | | - Luis A. Cota Apodaca
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
| | - Daniel Manzur-Sandoval
- Department of Cardiovascular Critical Care, National Institute of Cardiology “Dr. Ignacio Chávez,”, Mexico City, México
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11
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Ball L, Silva PL, Giacobbe DR, Bassetti M, Zubieta-Calleja GR, Rocco PRM, Pelosi P. Understanding the pathophysiology of typical acute respiratory distress syndrome and severe COVID-19. Expert Rev Respir Med 2022; 16:437-446. [PMID: 35341424 PMCID: PMC9115784 DOI: 10.1080/17476348.2022.2057300] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction Typical acute respiratory distress syndrome (ARDS) and severe coronavirus-19 (COVID-19) pneumonia share complex pathophysiology, a high mortality rate, and an unmet need for efficient therapeutics. Areas covered This review discusses the current advances in understanding the pathophysiologic mechanisms underlying typical ARDS and severe COVID-19 pneumonia, highlighting specific aspects of COVID-19-related acute hypoxemic respiratory failure that require attention. Two models have been proposed to describe the mechanisms of respiratory failure associated with typical ARDS and severe COVID-19 pneumonia. Expert opinion ARDS is defined as a syndrome rather than a distinct pathologic entity. There is great heterogeneity regarding the pathophysiologic, clinical, radiologic, and biological phenotypes in patients with ARDS, challenging clinicians, and scientists to discover new therapies. COVID-19 has been described as a cause of pulmonary ARDS and has reopened many questions regarding the pathophysiology of ARDS itself. COVID-19 lung injury involves direct viral epithelial cell damage and thrombotic and inflammatory reactions. There are some differences between ARDS and COVID-19 lung injury in aspects of aeration distribution, perfusion, and pulmonary vascular responses.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | | | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
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12
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Pelosi P, Tonelli R, Torregiani C, Baratella E, Confalonieri M, Battaglini D, Marchioni A, Confalonieri P, Clini E, Salton F, Ruaro B. Different Methods to Improve the Monitoring of Noninvasive Respiratory Support of Patients with Severe Pneumonia/ARDS Due to COVID-19: An Update. J Clin Med 2022; 11:1704. [PMID: 35330029 PMCID: PMC8952765 DOI: 10.3390/jcm11061704] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 02/07/2023] Open
Abstract
The latest guidelines for the hospital care of patients affected by coronavirus disease 2019 (COVID-19)-related acute respiratory failure have moved towards the widely accepted use of noninvasive respiratory support (NIRS) as opposed to early intubation at the pandemic onset. The establishment of severe COVID-19 pneumonia goes through different pathophysiological phases that partially resemble typical acute respiratory distress syndrome (ARDS) and have been categorized into different clinical-radiological phenotypes. These can variably benefit on the application of external positive end-expiratory pressure (PEEP) during noninvasive mechanical ventilation, mainly due to variable levels of lung recruitment ability and lung compliance during different phases of the disease. A growing body of evidence suggests that intense respiratory effort producing excessive negative pleural pressure swings (Ppl) plays a critical role in the onset and progression of lung and diaphragm damage in patients treated with noninvasive respiratory support. Routine respiratory monitoring is mandatory to avoid the nasty continuation of NIRS in patients who are at higher risk for respiratory deterioration and could benefit from early initiation of invasive mechanical ventilation instead. Here we propose different monitoring methods both in the clinical and experimental settings adapted for this purpose, although further research is required to allow their extensive application in clinical practice. We reviewed the needs and available tools for clinical-physiological monitoring that aims at optimizing the ventilatory management of patients affected by acute respiratory distress syndrome due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection.
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Affiliation(s)
- Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy; (P.P.); (D.B.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 16132 Genoa, Italy
| | - Roberto Tonelli
- Respiratory Diseases Unit and Center for Rare Lung Disease, Department of Surgical and Medical Sciences SMECHIMAI, University of Modena Reggio Emilia, 41121 Modena, Italy; (R.T.); (A.M.); (E.C.)
- Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, 41121 Modena, Italy
| | - Chiara Torregiani
- Pulmonology Department, Cattinara Hospital, University of Trieste, 34127 Trieste, Italy; (C.T.); (M.C.); (P.C.); (F.S.)
| | - Elisa Baratella
- Department of Radiology, Cattinara Hospital, University of Trieste, 34127 Trieste, Italy;
| | - Marco Confalonieri
- Pulmonology Department, Cattinara Hospital, University of Trieste, 34127 Trieste, Italy; (C.T.); (M.C.); (P.C.); (F.S.)
| | - Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy; (P.P.); (D.B.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 16132 Genoa, Italy
| | - Alessandro Marchioni
- Respiratory Diseases Unit and Center for Rare Lung Disease, Department of Surgical and Medical Sciences SMECHIMAI, University of Modena Reggio Emilia, 41121 Modena, Italy; (R.T.); (A.M.); (E.C.)
| | - Paola Confalonieri
- Pulmonology Department, Cattinara Hospital, University of Trieste, 34127 Trieste, Italy; (C.T.); (M.C.); (P.C.); (F.S.)
| | - Enrico Clini
- Respiratory Diseases Unit and Center for Rare Lung Disease, Department of Surgical and Medical Sciences SMECHIMAI, University of Modena Reggio Emilia, 41121 Modena, Italy; (R.T.); (A.M.); (E.C.)
| | - Francesco Salton
- Pulmonology Department, Cattinara Hospital, University of Trieste, 34127 Trieste, Italy; (C.T.); (M.C.); (P.C.); (F.S.)
| | - Barbara Ruaro
- Pulmonology Department, Cattinara Hospital, University of Trieste, 34127 Trieste, Italy; (C.T.); (M.C.); (P.C.); (F.S.)
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13
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Gierhardt M, Pak O, Walmrath D, Seeger W, Grimminger F, Ghofrani HA, Weissmann N, Hecker M, Sommer N. Impairment of hypoxic pulmonary vasoconstriction in acute respiratory distress syndrome. Eur Respir Rev 2021; 30:30/161/210059. [PMID: 34526314 DOI: 10.1183/16000617.0059-2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/05/2021] [Indexed: 12/29/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a serious complication of severe systemic or local pulmonary inflammation, such as caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ARDS is characterised by diffuse alveolar damage that leads to protein-rich pulmonary oedema, local alveolar hypoventilation and atelectasis. Inadequate perfusion of these areas is the main cause of hypoxaemia in ARDS. High perfusion in relation to ventilation (V/Q<1) and shunting (V/Q=0) is not only caused by impaired hypoxic pulmonary vasoconstriction but also redistribution of perfusion from obstructed lung vessels. Rebalancing the pulmonary vascular tone is a therapeutic challenge. Previous clinical trials on inhaled vasodilators (nitric oxide and prostacyclin) to enhance perfusion to high V/Q areas showed beneficial effects on hypoxaemia but not on mortality. However, specific patient populations with pulmonary hypertension may profit from treatment with inhaled vasodilators. Novel treatment targets to decrease perfusion in low V/Q areas include epoxyeicosatrienoic acids and specific leukotriene receptors. Still, lung protective ventilation and prone positioning are the best available standard of care. This review focuses on disturbed perfusion in ARDS and aims to provide basic scientists and clinicians with an overview of the vascular alterations and mechanisms of V/Q mismatch, current therapeutic strategies, and experimental approaches.
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Affiliation(s)
- Mareike Gierhardt
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Department of Lung Development and Remodeling, Max Planck Institute for Heart and Lung Research, Member of the German Center for Lung Research (DZL), Member of the Cardio-Pulmonary Institute (CPI) Bad Nauheim, Germany
| | - Oleg Pak
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Dieter Walmrath
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| | - Werner Seeger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Instituto de Investigación en Biomedicina de Buenos Aires (IBioBA) - CONICET - Partner Institute of the Max Planck Society, Buenos Aires, Argentina.,Institute for Lung Health (ILH), Giessen, Germany
| | - Friedrich Grimminger
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Hossein A Ghofrani
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Norbert Weissmann
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany
| | - Matthias Hecker
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Both authors contributed equally
| | - Natascha Sommer
- Dept of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany.,Excellence Cluster Cardio-Pulmonary Institute (CPI), Giessen, Germany.,Both authors contributed equally
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14
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Sinha P, Bos LD. Pathophysiology of the Acute Respiratory Distress Syndrome: Insights from Clinical Studies. Crit Care Clin 2021; 37:795-815. [PMID: 34548134 PMCID: PMC8149201 DOI: 10.1016/j.ccc.2021.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Pratik Sinha
- Division of Clinical and Translational Research, Department of Anesthesia, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8054, St Louis, MO 63110, USA.
| | - Lieuwe D Bos
- Department of Respiratory Medicine, Infection and Immunity, Amsterdam University Medical Center, AMC, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands
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15
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He H, Chi Y, Long Y, Yuan S, Zhang R, Yang Y, Frerichs I, Möller K, Fu F, Zhao Z. Three broad classifications of acute respiratory failure etiologies based on regional ventilation and perfusion by electrical impedance tomography: a hypothesis-generating study. Ann Intensive Care 2021; 11:134. [PMID: 34453622 PMCID: PMC8401348 DOI: 10.1186/s13613-021-00921-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/19/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The aim of this study was to validate whether regional ventilation and perfusion data measured by electrical impedance tomography (EIT) with saline bolus could discriminate three broad acute respiratory failure (ARF) etiologies. METHODS Perfusion image was generated from EIT-based impedance-time curves caused by 10 ml 10% NaCl injection during a respiratory hold. Ventilation image was captured before the breath holding period under regular mechanical ventilation. DeadSpace%, Shunt% and VQMatch% were calculated based on lung perfusion and ventilation images. Ventilation and perfusion maps were divided into four cross-quadrants (lower left and right, upper left and right). Regional distribution defects of each quadrant were scored as 0 (distribution% ≥ 15%), 1 (15% > distribution% ≥ 10%) and 2 (distribution% < 10%). Data percentile distributions in the control group and clinical simplicity were taken into consideration when defining the scores. Overall defect scores (DefectV, DefectQ and DefectV+Q) were the sum of four cross-quadrants of the corresponding images. RESULTS A total of 108 ICU patients were prospectively included: 93 with ARF and 15 without as a control. PaO2/FiO2 was significantly correlated with VQMatch% (r = 0.324, P = 0.001). Three broad etiologies of ARF were identified based on clinical judgment: pulmonary embolism-related disease (PED, n = 14); diffuse lung involvement disease (DLD, n = 21) and focal lung involvement disease (FLD, n = 58). The PED group had a significantly higher DeadSpace% [40(24)% vs. 14(15)%, PED group vs. the rest of the subjects; median(interquartile range); P < 0.0001] and DefectQ score than the other groups [1(1) vs. 0(1), PED vs. the rest; P < 0.0001]. The DLD group had a significantly lower DefectV+Q score than the PED and FLD groups [0(1) vs. 2.5(2) vs. 3(3), DLD vs. PED vs. FLD; P < 0.0001]. The FLD group had a significantly higher DefectV score than the other groups [2(2) vs. 0(1), FLD vs. the rest; P < 0.0001]. The area under the receiver operating characteristic (AUC) for using DeadSpace% to identify PED was 0.894 in all ARF patients. The AUC for using the DefectV+Q score to identify DLD was 0.893. The AUC for using the DefectV score to identify FLD was 0.832. CONCLUSIONS Our study showed that it was feasible to characterize three broad etiologies of ARF with EIT-based regional ventilation and perfusion. Further study is required to validate clinical applicability of this method. Trial registration clinicaltrials, NCT04081142. Registered 9 September 2019-retrospectively registered, https://clinicaltrials.gov/show/NCT04081142 .
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Zhang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yingying Yang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China
| | - Zhanqi Zhao
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany.
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China.
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16
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Lung distribution of gas and blood volume in critically ill COVID-19 patients: a quantitative dual-energy computed tomography study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:214. [PMID: 34154635 PMCID: PMC8215486 DOI: 10.1186/s13054-021-03610-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/19/2021] [Indexed: 12/17/2022]
Abstract
Background Critically ill COVID-19 patients have pathophysiological lung features characterized by perfusion abnormalities. However, to date no study has evaluated whether the changes in the distribution of pulmonary gas and blood volume are associated with the severity of gas-exchange impairment and the type of respiratory support (non-invasive versus invasive) in patients with severe COVID-19 pneumonia. Methods This was a single-center, retrospective cohort study conducted in a tertiary care hospital in Northern Italy during the first pandemic wave. Pulmonary gas and blood distribution was assessed using a technique for quantitative analysis of dual-energy computed tomography. Lung aeration loss (reflected by percentage of normally aerated lung tissue) and the extent of gas:blood volume mismatch (percentage of non-aerated, perfused lung tissue—shunt; aerated, non-perfused dead space; and non-aerated/non-perfused regions) were evaluated in critically ill COVID-19 patients with different clinical severity as reflected by the need for non-invasive or invasive respiratory support. Results Thirty-five patients admitted to the intensive care unit between February 29th and May 30th, 2020 were included. Patients requiring invasive versus non-invasive mechanical ventilation had both a lower percentage of normally aerated lung tissue (median [interquartile range] 33% [24–49%] vs. 63% [44–68%], p < 0.001); and a larger extent of gas:blood volume mismatch (43% [30–49%] vs. 25% [14–28%], p = 0.001), due to higher shunt (23% [15–32%] vs. 5% [2–16%], p = 0.001) and non-aerated/non perfused regions (5% [3–10%] vs. 1% [0–2%], p = 0.001). The PaO2/FiO2 ratio correlated positively with normally aerated tissue (ρ = 0.730, p < 0.001) and negatively with the extent of gas-blood volume mismatch (ρ = − 0.633, p < 0.001). Conclusions In critically ill patients with severe COVID-19 pneumonia, the need for invasive mechanical ventilation and oxygenation impairment were associated with loss of aeration and the extent of gas:blood volume mismatch. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03610-9.
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Spinelli E, Kircher M, Stender B, Ottaviani I, Basile MC, Marongiu I, Colussi G, Grasselli G, Pesenti A, Mauri T. Unmatched ventilation and perfusion measured by electrical impedance tomography predicts the outcome of ARDS. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:192. [PMID: 34082795 PMCID: PMC8173510 DOI: 10.1186/s13054-021-03615-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/21/2021] [Indexed: 12/30/2022]
Abstract
Background In acute respiratory distress syndrome (ARDS), non-ventilated perfused regions coexist with non-perfused ventilated regions within lungs. The number of unmatched regions might reflect ARDS severity and affect the risk of ventilation-induced lung injury. Despite pathophysiological relevance, unmatched ventilation and perfusion are not routinely assessed at the bedside. The aims of this study were to quantify unmatched ventilation and perfusion at the bedside by electrical impedance tomography (EIT) investigating their association with mortality in patients with ARDS and to explore the effects of positive end-expiratory pressure (PEEP) on unmatched ventilation and perfusion in subgroups of patients with different ARDS severity based on PaO2/FiO2 and compliance. Methods Prospective observational study in 50 patients with mild (36%), moderate (46%), and severe (18%) ARDS under clinical ventilation settings. EIT was applied to measure the regional distribution of ventilation and perfusion using central venous bolus of saline 5% during end-inspiratory pause. We defined unmatched units as the percentage of only ventilated units plus the percentage of only perfused units. Results Percentage of unmatched units was significantly higher in non-survivors compared to survivors (32[27–47]% vs. 21[17–27]%, p < 0.001). Percentage of unmatched units was an independent predictor of mortality (OR 1.22, 95% CI 1.07–1.39, p = 0.004) with an area under the ROC curve of 0.88 (95% CI 0.79–0.97, p < 0.001). The percentage of ventilation to the ventral region of the lung was higher than the percentage of ventilation to the dorsal region (32 [27–38]% vs. 18 [13–21]%, p < 0.001), while the opposite was true for perfusion (28 [22–38]% vs. 36 [32–44]%, p < 0.001). Higher percentage of only perfused units was correlated with lower dorsal ventilation (r = − 0.486, p < 0.001) and with lower PaO2/FiO2 ratio (r = − 0.293, p = 0.039). Conclusions EIT allows bedside assessment of unmatched ventilation and perfusion in mechanically ventilated patients with ARDS. Measurement of unmatched units could identify patients at higher risk of death and could guide personalized treatment.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Michael Kircher
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | | | - Irene Ottaviani
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Maria C Basile
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Ines Marongiu
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Colussi
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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Mart MF, Ely EW. Coronavirus Disease 2019 Acute Respiratory Distress Syndrome: Guideline-Driven Care Should Be Our Natural Reflex. Crit Care Med 2020; 48:1835-1837. [PMID: 32947476 PMCID: PMC7708507 DOI: 10.1097/ccm.0000000000004627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
- Veterans Affairs Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
- Vanderbilt Center for Quality Aging, Nashville, TN
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Rocksén D, Arborelius UP, Gustavsson J, Günther M. Severe, transient pulmonary ventilation-perfusion mismatch in the lung after porcine high velocity projectile behind armor blunt trauma. Exp Lung Res 2020; 46:271-282. [DOI: 10.1080/01902148.2020.1797246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- David Rocksén
- Department of Neuroscience, section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Ulf P. Arborelius
- Department of Neuroscience, section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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Quirino TDC, Ortolan LDS, Sercundes MK, Marinho CRF, Turato WM, Epiphanio S. Lung aeration in experimental malaria-associated acute respiratory distress syndrome by SPECT/CT analysis. PLoS One 2020; 15:e0233864. [PMID: 32470082 PMCID: PMC7259762 DOI: 10.1371/journal.pone.0233864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 05/13/2020] [Indexed: 01/06/2023] Open
Abstract
Malaria-associated acute respiratory distress syndrome (ARDS) is an inflammatory disease causing alveolar-pulmonary barrier lesion and increased vascular permeability characterized by severe hypoxemia. Computed tomography (CT), among other imaging techniques, allows the morphological and quantitative identification of lung lesions during ARDS. This study aims to identify the onset of malaria-associated ARDS development in an experimental model by imaging diagnosis. Our results demonstrated that ARDS-developing mice presented decreased gaseous exchange and pulmonary insufficiency, as shown by the SPECT/CT technique. The pulmonary aeration disturbance in ARDS-developing mice on the 5th day post infection was characterized by aerated tissues decrease and nonaerated tissue accumulation, demonstrating increased vascular permeability and pleural effusion. The SPECT/CT technique allowed the early diagnosis in the experimental model, as well as the identification of the pulmonary aeration. Notwithstanding, despite the fact that this study contributes to better understand lung lesions during malaria-associated ARDS, further imaging studies are needed.
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Affiliation(s)
- Thatyane de Castro Quirino
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brasil
| | - Luana dos Santos Ortolan
- Departamento de Imunologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brasil
| | - Michelle Klein Sercundes
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brasil
| | | | - Walter Miguel Turato
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brasil
- Centro de Radiofarmácia, Instituto de Pesquisas Energéticas e Nucleares, São Paulo, Brasil
| | - Sabrina Epiphanio
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brasil
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Global and Regional Diagnostic Accuracy of Lung Ultrasound Compared to CT in Patients With Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:1599-1606. [PMID: 31464770 DOI: 10.1097/ccm.0000000000003971] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Lung CT is the reference imaging technique for acute respiratory distress syndrome, but requires transportation outside the intensive care and x-ray exposure. Lung ultrasound is a promising, inexpensive, radiation-free, tool for bedside imaging. Aim of the present study was to compare the global and regional diagnostic accuracy of lung ultrasound and CT scan. DESIGN A prospective, observational study. SETTING Intensive care and radiology departments of a University hospital. PATIENTS Thirty-two sedated, paralyzed acute respiratory distress syndrome patients (age 65 ± 14 yr, body mass index 25.9 ± 6.5 kg/m, and PaO2/FIO2 139 ± 47). INTERVENTIONS Lung CT scan and lung ultrasound were performed at positive end-expiratory pressure 5 cm H2O. A standardized assessment of six regions per hemithorax was used; each region was classified for the presence of normal aeration, alveolar-interstitial syndrome, consolidation, and pleural effusion. Agreement between the two techniques was calculated, and diagnostic variables were assessed for lung ultrasound using lung CT as a reference. MEASUREMENTS AND MAIN RESULTS Global agreement between lung ultrasound and CT ranged from 0.640 (0.391-0.889) to 0.934 (0.605-1.000) and was on average 0.775 (0.577-0.973). The overall sensitivity and specificity of lung ultrasound ranged from 82.7% to 92.3% and from 90.2% to 98.6%, respectively. Similar results were found with regional analysis. The diagnostic accuracy of lung ultrasound was significantly higher when those patterns not reaching the pleural surface were excluded (area under the receiver operating characteristic curve: alveolar-interstitial syndrome 0.854 [0.821-0.887] vs 0.903 [0.852-0.954]; p = 0.049 and consolidation 0.851 [0.818-0.884] vs 0.896 [0.862-0.929]; p = 0.044). CONCLUSIONS Lung ultrasound is a reproducible, sensitive, and specific tool, which allows for bedside detections of the morphologic patterns in acute respiratory distress syndrome. The presence of deep lung alterations may impact the diagnostic performance of this technique.
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Cereda M, Xin Y, Goffi A, Herrmann J, Kaczka DW, Kavanagh BP, Perchiazzi G, Yoshida T, Rizi RR. Imaging the Injured Lung: Mechanisms of Action and Clinical Use. Anesthesiology 2019; 131:716-749. [PMID: 30664057 PMCID: PMC6692186 DOI: 10.1097/aln.0000000000002583] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging-either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.
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Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, ON, Canada
| | - Jacob Herrmann
- Departments of Anesthesia and Biomedical Engineering, University of Iowa, IA
| | - David W. Kaczka
- Departments of Anesthesia, Radiology, and Biomedical Engineering, University of Iowa, IA
| | | | - Gaetano Perchiazzi
- Hedenstierna Laboratory and Uppsala University Hospital, Uppsala University, Sweden
| | - Takeshi Yoshida
- Hospital for Sick Children, University of Toronto, ON, Canada
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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Looking closer at acute respiratory distress syndrome: the role of advanced imaging techniques. Curr Opin Crit Care 2018; 23:30-37. [PMID: 27906709 DOI: 10.1097/mcc.0000000000000380] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Advanced imaging techniques have provided invaluable insights in understanding of acute respiratory distress syndrome (ARDS) and the effect of therapeutic strategies, thanks to the possibility of gaining regional information and moving from simple 'anatomical' information to in-vivo functional imaging. RECENT FINDINGS Computed tomography (CT) led to the understanding of several ARDS mechanisms and interaction with mechanical ventilation. It is nowadays frequently part of routine diagnostic workup, often leading to treatment changes. Moreover, CT is a reference for novel techniques both in clinical and preclinical studies. Bedside transthoracic lung ultrasound allows semiquantitative regional analysis of lung aeration, identifies ARDS lung morphology and response to therapeutic maneuvers. Electrical impedance tomography is a radiation-free, functional, bedside, imaging modality which allows a real-time monitoring of regional ventilation. Finally, positron emission tomography (PET) is a functional imaging technique that allows to trace physiologic processes, by administration of a radioactive molecule. PET with FDG has been applied to patients with ARDS, thanks to its ability to track the inflammatory cells activity. SUMMARY Progresses in lung imaging are key to individualize therapy, diagnosis, and pathophysiological mechanism at play in any patient at any specified time, helping to move toward personalized medicine for ARDS.
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Kamuf J, Garcia-Bardon A, Duenges B, Liu T, Jahn-Eimermacher A, Heid F, David M, Hartmann EK. Endexpiratory lung volume measurement correlates with the ventilation/perfusion mismatch in lung injured pigs. Respir Res 2017; 18:101. [PMID: 28535788 PMCID: PMC5442669 DOI: 10.1186/s12931-017-0585-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 05/15/2017] [Indexed: 12/30/2022] Open
Abstract
Background In acute respiratory respiratory distress syndrome (ARDS) a sustained mismatch of alveolar ventilation and perfusion (VA/Q) impairs the pulmonary gas exchange. Measurement of endexpiratory lung volume (EELV) by multiple breath-nitrogen washout/washin is a non-invasive, bedside technology to assess pulmonary function in mechanically ventilated patients. The present study examines the association between EELV changes and VA/Q distribution and the possibility to predict VA/Q normalization by means of EELV in a porcine model. Methods After approval of the state and institutional animal care committee 12 anesthetized pigs were randomized to ARDS either by bronchoalveolar lavage (n = 6) or oleic acid injection (n = 6). EELV, VA/Q ratios by multiple inert gas elimination and ventilation distribution by electrical impedance tomography were assessed at healthy state and at five different positive endexpiratory pressure (PEEP) steps in ARDS (0, 20, 15, 10, 5 cmH2O; each maintained for 30 min). Results VA/Q, EELV and tidal volume distribution all displayed the PEEP-induced recruitment in ARDS. We found a close correlation between VA/Q < 0.1 (representing shunt and low VA/Q units) and changes in EELV (spearman correlation coefficient −0.79). Logistic regression reveals the potential to predict VA/Q normalization (VA/Q < 0.1 less than 5%) from changes in EELV with an area under the curve of 0.89 with a 95%-CI of 0.81–0.96 in the receiver operating characteristic. Different lung injury models and recruitment characteristics did not influence these findings. Conclusion In a porcine ARDS model EELV measurement depicts PEEP-induced lung recruitment and is strongly associated with normalization of the VA/Q distribution in a model-independent fashion. Determination of EELV could be an intriguing addition in the context of lung protection strategies.
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Affiliation(s)
- Jens Kamuf
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Andreas Garcia-Bardon
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Bastian Duenges
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Tanghua Liu
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Antje Jahn-Eimermacher
- Institute of Medical Biostatistics, Epidemiology and Informatics, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Florian Heid
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Matthias David
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Erik K Hartmann
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
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Henderson WR, Dominelli PB, Molgat-Seon Y, Lipson R, Griesdale DEG, Sekhon M, Ayas N, Sheel AW. Effect of tidal volume and positive end-expiratory pressure on expiratory time constants in experimental lung injury. Physiol Rep 2016; 4:4/5/e12737. [PMID: 26997633 PMCID: PMC4823592 DOI: 10.14814/phy2.12737] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We utilized a multicompartment model to describe the effects of changes in tidal volume (VT) and positive end‐expiratory pressure (PEEP) on lung emptying during passive deflation before and after experimental lung injury. Expiratory time constants (τE) were determined by partitioning the expiratory flow–volume (V˙EV) curve into multiple discrete segments and individually calculating τE for each segment. Under all conditions of PEEP and VT, τE increased throughout expiration both before and after injury. Segmented τE values increased throughout expiration with a slope that was different than zero (P < 0. 01). On average, τE increased by 45.08 msec per segment. When an interaction between injury status and τE segment was included in the model, it was significant (P < 0.05), indicating that later segments had higher τE values post injury than early τE segments. Higher PEEP and VT values were associated with higher τE values. No evidence was found for an interaction between injury status and VT, or PEEP. The current experiment confirms previous observations that τE values are smaller in subjects with injured lungs when compared to controls. We are the first to demonstrate changes in the pattern of τE before and after injury when examined with a multiple compartment model. Finally, increases in PEEP or VT increased τE throughout expiration, but did not appear to have effects that differed between the uninjured and injured state.
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Affiliation(s)
- William R Henderson
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paolo B Dominelli
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yannick Molgat-Seon
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Najib Ayas
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - A William Sheel
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
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Henderson WR, Molgat-Seon Y, Dominelli PB, Brasher PMA, Griesdale DEG, Foster GE, Yacyshyn A, Ayas NT, Sheel AW. Gas density alters expiratory time constants before and after experimental lung injury. Exp Physiol 2016; 100:1217-28. [PMID: 26289254 DOI: 10.1113/ep085205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/17/2015] [Indexed: 01/10/2023]
Abstract
NEW FINDINGS What is the central question of this study? Does the induction of a model of lung injury affect the expiratory time constant (τE) in terms of either total duration or morphology? Does ventilation with gases of different densities alter the duration or morphology of τE either before or after injury? What is the main finding and its importance? The use of sulfur hexafluoride in ventilating gas mixtures lengthens total expiratory time constants before and after lung injury compared with both nitrogen and helium mixtures. Sulfur hexafluoride mixtures also decrease the difference and variability of τE between fast- and slow-emptying compartments before and after injury when compared with nitrogen and helium mixtures. Acute lung injury is characterized by regional heterogeneity of lung resistance and elastance that may lead to regional heterogeneity of expiratory time constants (τE). We hypothesized that increasing airflow resistance by using inhaled sulfur hexafluoride (SF6) would lengthen time constants and decrease their heterogeneity in an experimental model of lung injury when compared with nitrogen or helium mixtures. To overcome the limitations of a single-compartment model, we employed a multisegment model of expiratory gas flow. An experimental model of lung injury was created using intratracheal injection of sodium polyacrylate in anaesthetized and mechanically ventilated female Yorkshire-cross pigs (n = 7). The animals were ventilated with 50% O2 and the remaining 50% as nitrogen (N2), helium (He) or sulfur hexafluoride (SF6). Values for τE decreased with injury and were more variable after injury than before (P < 0.001). Values for τE increased throughout expiration both before and after injury, and the rate of increase in τE was lessened by SF6 (P < 0.001 when compared with N2 both before and after injury). Altering the inhaled gas density did not affect indices of oxygenation, dead space or shunt. The use of SF6 in ventilating gas mixtures lengthens total expiratory time constants before and after lung injury compared with both N2 and He mixtures. Importantly, SF6 mixtures also decrease the difference and variability of τE between fast- and slow-emptying compartments before and after injury when compared with N2 and He mixtures.
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Affiliation(s)
- William R Henderson
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yannick Molgat-Seon
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paolo B Dominelli
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Penelope M A Brasher
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Glen E Foster
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Alexandra Yacyshyn
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | - Najib T Ayas
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - A William Sheel
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
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Petersson J, Glenny RW. Gas exchange and ventilation-perfusion relationships in the lung. Eur Respir J 2014; 44:1023-41. [PMID: 25063240 DOI: 10.1183/09031936.00037014] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This review provides an overview of the relationship between ventilation/perfusion ratios and gas exchange in the lung, emphasising basic concepts and relating them to clinical scenarios. For each gas exchanging unit, the alveolar and effluent blood partial pressures of oxygen and carbon dioxide (PO2 and PCO2) are determined by the ratio of alveolar ventilation to blood flow (V'A/Q') for each unit. Shunt and low V'A/Q' regions are two examples of V'A/Q' mismatch and are the most frequent causes of hypoxaemia. Diffusion limitation, hypoventilation and low inspired PO2 cause hypoxaemia, even in the absence of V'A/Q' mismatch. In contrast to other causes, hypoxaemia due to shunt responds poorly to supplemental oxygen. Gas exchanging units with little or no blood flow (high V'A/Q' regions) result in alveolar dead space and increased wasted ventilation, i.e. less efficient carbon dioxide removal. Because of the respiratory drive to maintain a normal arterial PCO2, the most frequent result of wasted ventilation is increased minute ventilation and work of breathing, not hypercapnia. Calculations of alveolar-arterial oxygen tension difference, venous admixture and wasted ventilation provide quantitative estimates of the effect of V'A/Q' mismatch on gas exchange. The types of V'A/Q' mismatch causing impaired gas exchange vary characteristically with different lung diseases.
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Affiliation(s)
- Johan Petersson
- Section of Anaesthesiology and Intensive Care Medicine, Dept of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden Dept of Anaesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Robb W Glenny
- Dept of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA Dept of Physiology and Biophysics, University of Washington, Seattle, WA, USA
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Acute respiratory distress syndrome induction by pulmonary ischemia-reperfusion injury in large animal models. J Surg Res 2014; 189:274-84. [PMID: 24768138 DOI: 10.1016/j.jss.2014.02.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/17/2014] [Accepted: 02/20/2014] [Indexed: 01/14/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a common critical pulmonary complication after esophagectomy and other thoracic surgeries (e.g., lung transplantation, pulmonary thromboendarterectomy). Direct pulmonary ischemia-reperfusion injury (PIRI) is known to play the main role in induction of ARDS in these cases. Large animal models are an appropriate choice for ARDS as well as PIRI study because of their physiological and anatomic similarities to the human body. With regard to large animal models, we reviewed different methods of inducing in situ direct PIRI and the commonly applied methods for diagnosing and monitoring ARDS or PIRI in an experimental research setting.
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Chiumello D, Froio S, Bouhemad B, Camporota L, Coppola S. Clinical review: Lung imaging in acute respiratory distress syndrome patients--an update. Crit Care 2013; 17:243. [PMID: 24238477 PMCID: PMC4056355 DOI: 10.1186/cc13114] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Over the past 30 years lung imaging has greatly contributed to the current understanding of the pathophysiology and the management of acute respiratory distress syndrome (ARDS). In the past few years, in addition to chest X-ray and lung computed tomography, newer functional lung imaging techniques, such as lung ultrasound, positron emission tomography, electrical impedance tomography and magnetic resonance, have been gaining a role as diagnostic tools to optimize lung assessment and ventilator management in ARDS patients. Here we provide an updated clinical review of lung imaging in ARDS over the past few years to offer an overview of the literature on the available imaging techniques from a clinical perspective.
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Affiliation(s)
- Davide Chiumello
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Sara Froio
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
| | - Belaïd Bouhemad
- Multidisciplinary Critical Care Unit, La Pitié-Salpêtrière Hospital, University Pierre and Marie Curie Paris, Paris, France
| | - Luigi Camporota
- Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Silvia Coppola
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy
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Pouzot C, Richard JC, Gros A, Costes N, Lavenne F, Le Bars D, Guerin C. Noninvasive quantitative assessment of pulmonary blood flow with 18F-FDG PET. J Nucl Med 2013; 54:1653-60. [PMID: 23907755 DOI: 10.2967/jnumed.112.116699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Pulmonary blood flow (PBF) is a critical determinant of oxygenation during acute lung injury (ALI). PET/CT with (18)F-FDG allows the assessment of both lung aeration and neutrophil inflammation as well as an estimation of the regional fraction of blood (FB) if compartmental modeling is used to quantify (18)F-FDG pulmonary uptake. The aim of this study was to validate the use of FB to assess PBF, with PET and compartmental modeling of (15)O-H2O kinetics as a reference method, in both control animals and animals with ALI. For the purpose of studying a wide range of PBF values, supine and prone positions and various positive end-expiratory pressures (PEEPs) and tidal volumes (V(T)s) were selected. METHODS Pigs were randomized into 3 groups in which ALI was induced by HCl inhalation: pigs studied in the supine position with a low PEEP (5 ± 3 [mean ± SD] cm of H2O; n = 9) or a high PEEP (12 ± 1 cm of H2O; n = 8) and pigs studied in the prone position with a low PEEP (6 ± 3 cm of H2O; n = 9). Also included were a control group that did not have ALI (n = 6) and 2 additional groups (n = 6 each) that had a high V(T) to maintain a transpulmonary pressure of greater than or equal to 35 cm of H2O and that either received HCl inhalation or did not receive HCl inhalation. PBF and FB were measured with PET and compartmental modeling of (15)O-H2O and (18)F-FDG kinetics in 10 lung regions along the anterior-to-posterior lung dimension, and both were expressed in each region as a fraction of their values in the whole lung. RESULTS PBF and FB were strongly correlated (R(2) = 0.9), with a slope of the regression line close to unity and a negligible intercept. The mean difference between PBF and FB was 0, and the 95% limits of agreement were -0.035 to 0.035. This good agreement between methods was obtained in both normal and injured lungs and under a wide range of V(T), PEEP, and regional PBF values (7-71 mL/kg, 0-15 cm of H2O, and 24-603 mL·min(-1)·100 mL of lung(-1), respectively). CONCLUSION FB assessed with (18)F-FDG is a good surrogate for PBF in both normal animals and animals with ALI. PET/CT has the potential to be used to study ventilation, perfusion, and lung inflammation with a single tracer.
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Affiliation(s)
- Céline Pouzot
- Service Siamu, VetAgro Sup, Campus Vétérinaire de Lyon, Marcy l'Etoile, France
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TAKAHASHI KAZUHISA, EVES NEILD, PIPER AMANDA, SONG YUANLIN, MAHER TOBYM. Year in review 2011: Acute lung injury, interstitial lung diseases, physiology, sleep and lung cancer. Respirology 2012; 17:554-62. [DOI: 10.1111/j.1440-1843.2012.02127.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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