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Bouchant L, Godet T, Arpajou G, Aupetitgendre L, Cayot S, Guerin R, Jabaudon M, Verlhac C, Blondonnet R, Borao L, Pereira B, Constantin JM, Bazin JE, Futier E, Audard J. Physiological effects and safety of bed verticalization in patients with acute respiratory distress syndrome. Crit Care 2024; 28:262. [PMID: 39103928 DOI: 10.1186/s13054-024-05013-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/29/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Trunk inclination in patients with Acute Respiratory Distress Syndrome (ARDS) in the supine position has gained scientific interest due to its effects on respiratory physiology, including mechanics, oxygenation, ventilation distribution, and efficiency. Changing from flat supine to semi-recumbent increases driving pressure due to decreased respiratory system compliance. Positional adjustments also deteriorate ventilatory efficiency for CO2 removal, particularly in COVID-19-associated ARDS (C-ARDS), indicating likely lung parenchyma overdistension. Tilting the trunk reduces chest wall compliance and, to a lesser extent, lung compliance and transpulmonary driving pressure, with significant hemodynamic and gas exchange implications. METHODS A prospective, pilot physiological study was conducted on early ARDS patients in two ICUs at CHU Clermont-Ferrand, France. The protocol involved 30-min step gradual verticalization from a 30° semi-seated position (baseline) to different levels of inclination (0°, 30°, 60°, and 90°), before returning to the baseline position. Measurements included tidal volume, positive end-expiratory pressure (PEEP), esophageal pressures, and pulmonary artery catheter data. The primary endpoint was the variation in transpulmonary driving pressure through the verticalization procedure. RESULTS From May 2020 through January 2021, 30 patients were included. Transpulmonary driving pressure increased slightly from baseline (median and interquartile range [IQR], 9 [5-11] cmH2O) to the 90° position (10 [7-14] cmH2O; P < 10-2 for the overall effect of position in mixed model). End-expiratory lung volume increased with verticalization, in parallel to decreases in alveolar strain and increased arterial oxygenation. Verticalization was associated with decreased cardiac output and stroke volume, and increased norepinephrine doses and serum lactate levels, prompting interruption of the procedure in two patients. There were no other adverse events such as falls or equipment accidental removals. CONCLUSIONS Verticalization to 90° is feasible in ARDS patients, improving EELV and oxygenation up to 30°, likely due to alveolar recruitment and blood flow redistribution. However, there is a risk of overdistension and hemodynamic instability beyond 30°, necessitating individualized bed angles based on clinical situations. Trial registration ClinicalTrials.gov registration number NCT04371016 , April 24, 2020.
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Affiliation(s)
- Louis Bouchant
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France.
- Department of Healthcare Simulation, Université Clermont Auvergne, Clermont-Ferrand, France.
| | - Gauthier Arpajou
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Lucie Aupetitgendre
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Sophie Cayot
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Renaud Guerin
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
- Université Clermont Auvergne, iGreD, CNRS, INSERM, Clermont-Ferrand, France
| | - Camille Verlhac
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Raiko Blondonnet
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
- Université Clermont Auvergne, iGreD, CNRS, INSERM, Clermont-Ferrand, France
| | - Lucile Borao
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Bruno Pereira
- Direction de la Recherche Clinique et de l'Innovation (DRCI), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Biostatistics Unit, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Assistance Publique-Hôpitaux de Paris (AP-HP), Département Anesthésie et Réanimation, Hôpital Pitié-Salpêtrière, DREAM, Sorbonne Université, Paris, France
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
- Department of Healthcare Simulation, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France
- Université Clermont Auvergne, iGreD, CNRS, INSERM, Clermont-Ferrand, France
| | - Jules Audard
- Department of Perioperative Medicine, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 Place Lucie Et Raymond Aubrac, 63000, Clermont-Ferrand, France.
- Université Clermont Auvergne, iGreD, CNRS, INSERM, Clermont-Ferrand, France.
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Benites MH, Zapata-Canivilo M, Poblete F, Labbe F, Battiato R, Ferre A, Dreyse J, Bugedo G, Bruhn A, Costa ELV, Retamal J. Physiological and clinical effects of trunk inclination adjustment in patients with respiratory failure: a scoping review and narrative synthesis. Crit Care 2024; 28:228. [PMID: 38982466 PMCID: PMC11232125 DOI: 10.1186/s13054-024-05010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/27/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Adjusting trunk inclination from a semi-recumbent position to a supine-flat position or vice versa in patients with respiratory failure significantly affects numerous aspects of respiratory physiology including respiratory mechanics, oxygenation, end-expiratory lung volume, and ventilatory efficiency. Despite these observed effects, the current clinical evidence regarding this positioning manoeuvre is limited. This study undertakes a scoping review of patients with respiratory failure undergoing mechanical ventilation to assess the effect of trunk inclination on physiological lung parameters. METHODS The PubMed, Cochrane, and Scopus databases were systematically searched from 2003 to 2023. INTERVENTIONS Changes in trunk inclination. MEASUREMENTS Four domains were evaluated in this study: 1) respiratory mechanics, 2) ventilation distribution, 3) oxygenation, and 4) ventilatory efficiency. RESULTS After searching the three databases and removing duplicates, 220 studies were screened. Of these, 37 were assessed in detail, and 13 were included in the final analysis, comprising 274 patients. All selected studies were experimental, and assessed respiratory mechanics, ventilation distribution, oxygenation, and ventilatory efficiency, primarily within 60 min post postural change. CONCLUSION In patients with acute respiratory failure, transitioning from a supine to a semi-recumbent position leads to decreased respiratory system compliance and increased airway driving pressure. Additionally, C-ARDS patients experienced an improvement in ventilatory efficiency, which resulted in lower PaCO2 levels. Improvements in oxygenation were observed in a few patients and only in those who exhibited an increase in EELV upon moving to a semi-recumbent position. Therefore, the trunk inclination angle must be accurately reported in patients with respiratory failure under mechanical ventilation.
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Affiliation(s)
- Martín H Benites
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
- Doctorado en Ciencias Médicas, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Fabian Poblete
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
| | - Francisco Labbe
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
| | - Romina Battiato
- Magíster em Bioestadística, Escuela de Salud Pública, Universidad de Chile, Santiago, Chile
| | - Andrés Ferre
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Jorge Dreyse
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo L V Costa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), São Paulo, Brazil
- Hospital Sírio-Libanês, Research and Education Institute, São Paulo, Brazil
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile.
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Ma Y, Zhu C, Ma X, Zhou B, Dong M. Risk factors of acute respiratory distress syndrome in sepsis caused by intra-abdominal infections: A retrospective study. Surgery 2024; 175:1432-1438. [PMID: 38383244 DOI: 10.1016/j.surg.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/22/2023] [Accepted: 01/17/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Intra-abdominal infections are frequently associated with acute respiratory distress syndrome, which significantly affects patient prognosis. However, little is known about the specific risk factors of acute respiratory distress syndrome in sepsis caused by intra-abdominal infections. METHODS This retrospective study included adult patients with intra-abdominal sepsis admitted to the intensive care unit of a tertiary teaching hospital in China between June 2017 and June 2022. Patients were categorized based on the presence or absence of acute respiratory distress syndrome. Data, including vital signs, laboratory values, and severity scores collected within 24 hours of sepsis diagnosis, as well as outcomes within 90 days, were analyzed. Multivariable logistic regression was used to identify independent risk factors associated with acute respiratory distress syndrome. RESULTS A total of 738 patients were included, of whom 218 (29.5%) developed acute respiratory distress syndrome. Patients with acute respiratory distress syndrome were younger, had a higher body mass index and disease severity scores, and exhibited higher proportions of septic shock and hospital-acquired intra-abdominal infections. The mortalities in the intensive care unit and at 28 and 90 days were higher in the acute respiratory distress syndrome group. In the multivariate logistic regression model, age under 65 years (odds ratio [95% confidence interval]: 1.571 [1.093-2.259]), elevated body mass index (2.070 [1.382-3.101] for overweight, 6.994 [3.207-15.255]) for obesity, septic shock (2.043 [1.400-2.980]), procalcitonin (1.009 [1.004-1.015]), hospital-acquired intra-abdominal infections (2.528[1.373-4.657]), and source of intra-abdominal infections (2.170 [1.140-4.128] for biliary tract infection, 0.443 [0.217-0.904] for gastroduodenal perforation) were independently associated with acute respiratory distress syndrome. CONCLUSION In patients with intra-abdominal sepsis, age under 65 years, higher body mass index and procalcitonin, septic shock, hospital-acquired intra-abdominal infections, and biliary tract infection were risk factors for acute respiratory distress syndrome.
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Affiliation(s)
- Yuteng Ma
- Department of Gastrointestinal Surgery, First Hospital of China Medical University, Shenyang, Liaoning Province, China; Department of Critical Care Medicine, First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Chengrui Zhu
- Department of Critical Care Medicine, First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Baosen Zhou
- Department of Clinical Epidemiology, First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ming Dong
- Department of Gastrointestinal Surgery, First Hospital of China Medical University, Shenyang, Liaoning Province, China.
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Wise R, Rodseth R, Párraga-Ros E, Latorre R, López Albors O, Correa-Martín L, M. Sánchez-Margallo F, Eugenia Candanosa-Aranda I, Poelaert J, Castellanos G, L. N. G. Malbrain M. The pathophysiological impact of intra-abdominal hypertension in pigs. PLoS One 2023; 18:e0290451. [PMID: 37639437 PMCID: PMC10461824 DOI: 10.1371/journal.pone.0290451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Intra-abdominal hypertension and abdominal compartment syndrome are common with clinically significant consequences. We investigated the pathophysiological effects of raised IAP as part of a more extensive exploratory animal study. The study design included both pneumoperitoneum and mechanical intestinal obstruction models. METHODS Forty-nine female swine were divided into six groups: a control group (Cr; n = 5), three pneumoperitoneum groups with IAPs of 20mmHg (Pn20; n = 10), 30mmHg (Pn30; n = 10), 40mmHg (Pn40; n = 10), and two mechanical intestinal occlusion groups with IAPs of 20mmHg (MIO20; n = 9) and 30mmHg (MIO30; n = 5). RESULTS There were significant changes (p<0.05) noted in all organ systems, most notably systolic blood pressure (SBP) (p<0.001), cardiac index (CI) (p = 0.003), stroke volume index (SVI) (p<0.001), mean pulmonary airway pressure (MPP) (p<0.001), compliance (p<0.001), pO2 (p = 0.003), bicarbonate (p = 0.041), hemoglobin (p = 0.012), lipase (p = 0.041), total bilirubin (p = 0.041), gastric pH (p<0.001), calculated glomerular filtration rate (GFR) (p<0.001), and urine output (p<0.001). SVV increased progressively as the IAP increased with no obvious changes in intravascular volume status. There were no significant differences between the models regarding their impact on cardiovascular, respiratory, renal and gastrointestinal systems. However, significant differences were noted between the two models at 30mmHg, with MIO30 showing worse metabolic and hematological parameters, and Pn30 and Pn40 showing a more rapid rise in creatinine. CONCLUSIONS This study identified and quantified the impact of intra-abdominal hypertension at different pressures on several organ systems and highlighted the significance of even short-lived elevations. Two models of intra-abdominal pressure were used, with a mechanical obstruction model showing more rapid changes in metabolic and haematological changes. These may represent different underlying cellular and vascular pathophysiological processes, but this remains unclear.
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Affiliation(s)
- Robert Wise
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Discipline of Anaesthesiology, and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, United Kingdom
| | - Reitze Rodseth
- Discipline of Anaesthesiology, and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ester Párraga-Ros
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Rafael Latorre
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Octavio López Albors
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Laura Correa-Martín
- Laparoscopy Department Jesus Uson Minimally Invasive Surgery Centre, Caceres, Spain
| | | | - Irma Eugenia Candanosa-Aranda
- Highlands Teaching and Research Farm, Faculty of Veterinary Medicine, National Autonomous University of Mexico, Queretaro. Mexico
| | - Jan Poelaert
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Gregorio Castellanos
- Department of General Surgery, Virgen de la Arrixaca General University Hospital, Murcia, Spain
| | - Manu L. N. G. Malbrain
- First Department of Anaesthesiology and Intensive Care Medicine, Medical University of Lublin, Lublin, Poland
- Medical Director (CMO), Medical Data Management, Medaman, Geel, Belgium
- International Fluid Academy, Lovenjoel, Belgium
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5
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Selickman J, Marini JJ. Chest wall loading in the ICU: pushes, weights, and positions. Ann Intensive Care 2022; 12:103. [PMID: 36346532 PMCID: PMC9640797 DOI: 10.1186/s13613-022-01076-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Clinicians monitor mechanical ventilatory support using airway pressures—primarily the plateau and driving pressure, which are considered by many to determine the safety of the applied tidal volume. These airway pressures are influenced not only by the ventilator prescription, but also by the mechanical properties of the respiratory system, which consists of the series-coupled lung and chest wall. Actively limiting chest wall expansion through external compression of the rib cage or abdomen is seldom performed in the ICU. Recent literature describing the respiratory mechanics of patients with late-stage, unresolving, ARDS, however, has raised awareness of the potential diagnostic (and perhaps therapeutic) value of this unfamiliar and somewhat counterintuitive practice. In these patients, interventions that reduce resting lung volume, such as loading the chest wall through application of external weights or manual pressure, or placing the torso in a more horizontal position, have unexpectedly improved tidal compliance of the lung and integrated respiratory system by reducing previously undetected end-tidal hyperinflation. In this interpretive review, we first describe underappreciated lung and chest wall interactions that are clinically relevant to both normal individuals and to the acutely ill who receive ventilatory support. We then apply these physiologic principles, in addition to published clinical observation, to illustrate the utility of chest wall modification for the purposes of detecting end-tidal hyperinflation in everyday practice.
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Affiliation(s)
- John Selickman
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| | - John J. Marini
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
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Silva PL, Ball L, Rocco PRM, Pelosi P. Physiological and Pathophysiological Consequences of Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:321-334. [PMID: 35439832 DOI: 10.1055/s-0042-1744447] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mechanical ventilation is a life-support system used to ensure blood gas exchange and to assist the respiratory muscles in ventilating the lung during the acute phase of lung disease or following surgery. Positive-pressure mechanical ventilation differs considerably from normal physiologic breathing. This may lead to several negative physiological consequences, both on the lungs and on peripheral organs. First, hemodynamic changes can affect cardiovascular performance, cerebral perfusion pressure (CPP), and drainage of renal veins. Second, the negative effect of mechanical ventilation (compression stress) on the alveolar-capillary membrane and extracellular matrix may cause local and systemic inflammation, promoting lung and peripheral-organ injury. Third, intra-abdominal hypertension may further impair lung and peripheral-organ function during controlled and assisted ventilation. Mechanical ventilation should be optimized and personalized in each patient according to individual clinical needs. Multiple parameters must be adjusted appropriately to minimize ventilator-induced lung injury (VILI), including: inspiratory stress (the respiratory system inspiratory plateau pressure); dynamic strain (the ratio between tidal volume and the end-expiratory lung volume, or inspiratory capacity); static strain (the end-expiratory lung volume determined by positive end-expiratory pressure [PEEP]); driving pressure (the difference between the respiratory system inspiratory plateau pressure and PEEP); and mechanical power (the amount of mechanical energy imparted as a function of respiratory rate). More recently, patient self-inflicted lung injury (P-SILI) has been proposed as a potential mechanism promoting VILI. In the present chapter, we will discuss the physiological and pathophysiological consequences of mechanical ventilation and how to personalize mechanical ventilation parameters.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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7
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Regli A, Ahmadi-Noorbakhsh S, Musk GC, Reese DJ, Herrmann P, Firth MJ, Pillow JJ. Computed tomographic assessment of lung aeration at different positive end-expiratory pressures in a porcine model of intra-abdominal hypertension and lung injury. Intensive Care Med Exp 2021; 9:52. [PMID: 34608559 PMCID: PMC8489364 DOI: 10.1186/s40635-021-00416-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background Intra-abdominal hypertension (IAH) is common in critically ill patients and is associated with increased morbidity and mortality. High positive end-expiratory pressures (PEEP) can reverse lung volume and oxygenation decline caused by IAH, but its impact on alveolar overdistension is less clear. We aimed to find a PEEP range that would be high enough to reduce atelectasis, while low enough to minimize alveolar overdistention in the presence of IAH and lung injury. Methods Five anesthetized pigs received standardized anesthesia and mechanical ventilation. Peritoneal insufflation of air was used to generate intra-abdominal pressure of 27 cmH2O. Lung injury was created by intravenous oleic acid. PEEP levels of 5, 12, 17, 22, and 27 cmH2O were applied. We performed computed tomography and measured arterial oxygen levels, respiratory mechanics, and cardiac output 5 min after each new PEEP level. The proportion of overdistended, normally aerated, poorly aerated, and non-aerated atelectatic lung tissue was calculated based on Hounsfield units. Results PEEP decreased the proportion of poorly aerated and atelectatic lung, while increasing normally aerated lung. Overdistension increased with each incremental increase in applied PEEP. “Best PEEP” (respiratory mechanics or oxygenation) was higher than the “optimal CT inflation PEEP range” (difference between lower inflection points of atelectatic and overdistended lung) in healthy and injured lungs. Conclusions Our findings in a large animal model suggest that titrating a PEEP to respiratory mechanics or oxygenation in the presence of IAH is associated with increased alveolar overdistension. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00416-5.
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Affiliation(s)
- Adrian Regli
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch Drive, Murdoch, WA, 6150, Australia. .,Medical School, Division of Emergency Medicine, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia. .,Medical School, The University of Notre Dame Australia, 19 Mouat Street, Fremantle, 6959, Australia. .,School of Human Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia.
| | - Siavash Ahmadi-Noorbakhsh
- School of Human Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia
| | - Gabrielle Christine Musk
- Animal Care Services, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia.,School of Veterinary and Life Sciences, Murdoch University, Nyarrie Drive, Murdoch, 6150, Australia
| | - David Joseph Reese
- VetCT Consultants in Telemedicine PTY LTD, 185-187 High Street, Fremantle, 6160, Australia
| | - Peter Herrmann
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Martin Joseph Firth
- Centre for Applied Statistics, Department of Mathematics and Statistics, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia
| | - J Jane Pillow
- School of Human Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia
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8
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Regli A, Reintam Blaser A, De Keulenaer B, Starkopf J, Kimball E, Malbrain MLNG, Van Heerden PV, Davis WA, Palermo A, Dabrowski W, Siwicka-Gieroba D, Barud M, Grigoras I, Ristescu AI, Blejusca A, Tamme K, Maddison L, Kirsimägi Ü, Litvin A, Kazlova A, Filatau A, Pracca F, Sosa G, Santos MD, Kirov M, Smetkin A, Ilyina Y, Gilsdorf D, Ordoñez CA, Caicedo Y, Greiffenstein P, Morgan MM, Bodnar Z, Tidrenczel E, Oliveira G, Albuquerque A, Pereira BM. Intra-abdominal hypertension and hypoxic respiratory failure together predict adverse outcome - A sub-analysis of a prospective cohort. J Crit Care 2021; 64:165-172. [PMID: 33906106 DOI: 10.1016/j.jcrc.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE To assess whether the combination of intra-abdominal hypertension (IAH, intra-abdominal pressure ≥ 12 mmHg) and hypoxic respiratory failure (HRF, PaO2/FiO2 ratio < 300 mmHg) in patients receiving invasive ventilation is an independent risk factor for 90- and 28-day mortality as well as ICU- and ventilation-free days. METHODS Mechanically ventilated patients who had blood gas analyses performed and intra-abdominal pressure measured, were included from a prospective cohort. Subgroups were defined by the absence (Group 1) or the presence of either IAH (Group 2) or HRF (Group 3) or both (Group 4). Mixed-effects regression analysis was performed. RESULTS Ninety-day mortality increased from 16% (Group 1, n = 50) to 30% (Group 2, n = 20) and 27% (Group 3, n = 100) to 49% (Group 4, n = 142), log-rank test p < 0.001. The combination of IAH and HRF was associated with increased 90- and 28-day mortality as well as with fewer ICU- and ventilation-free days. The association with 90-day mortality was no longer present after adjustment for independent variables. However, the association with 28-day mortality, ICU- and ventilation-free days persisted after adjusting for independent variables. CONCLUSIONS In our sub-analysis, the combination of IAH and HRF was not independently associated with 90-day mortality but independently increased the odds of 28-day mortality, and reduced the number of ICU- and ventilation-free days.
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Affiliation(s)
- Adrian Regli
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia; Medical School, The Notre Dame University, Fremantle, WA, Australia; Medical School, The University of Western Australia, Perth, WA, Australia.
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Bart De Keulenaer
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia; School of Surgery, The University of Western Australia, Perth, WA, Australia
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Edward Kimball
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Manu L N G Malbrain
- Faculty of Engineering, Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB), Brussels, Belgium; International Fluid Academy, Lovenjoel, Belgium
| | | | - Wendy A Davis
- Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Annamaria Palermo
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia
| | - Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Dorota Siwicka-Gieroba
- First Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Malgorzata Barud
- First Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Ioana Grigoras
- Grigore T. Popa, University of Medicine and Pharmacy, Iasi, Romania; Regional Institute of Oncology, Iasi, Romania
| | - Anca Irina Ristescu
- Grigore T. Popa, University of Medicine and Pharmacy, Iasi, Romania; Regional Institute of Oncology, Iasi, Romania
| | | | - Kadri Tamme
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Liivi Maddison
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | - Anastasiya Kazlova
- Department of Intensive Care Medicine, Regional Clinical Hospital, Gomel, Belarus
| | - Aliaksandr Filatau
- Department of Intensive Care Medicine, Regional Clinical Hospital, Gomel, Belarus
| | - Francisco Pracca
- Department of Intensive Care Unit, Clinics University Hospital, UDELAR, Montevideo, Uruguay
| | - Gustavo Sosa
- Department of Intensive Care Unit, Clinics University Hospital, UDELAR, Montevideo, Uruguay
| | - Maicol Dos Santos
- Department of Intensive Care Unit, Clinics University Hospital, UDELAR, Montevideo, Uruguay
| | - Mikhail Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Alexey Smetkin
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Yana Ilyina
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Daniel Gilsdorf
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili - Universidad del Valle, Cali, Colombia
| | - Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundacion Valle del Lili, Cali, Colombia
| | | | - Margaret M Morgan
- Louisiana State University Health Sciences Center, New Orleans, United States; UC Health Memorial Hospital Central, Colorado Springs, California, United States
| | - Zsolt Bodnar
- University Hospital of Torrevieja, Torrevieja, Spain; Letterkenny University Hospital, Letterkenny, Ireland
| | - Edit Tidrenczel
- University Hospital of Torrevieja, Torrevieja, Spain; Killybegs Family Health Centre, Killybegs, Ireland
| | - Gina Oliveira
- Polyvalent Intensive Care Unit, Hospitalar Center Tondela-Viseu, Tondela-Viseu, Portugal
| | - Ana Albuquerque
- Polyvalent Intensive Care Unit, Hospitalar Center Tondela-Viseu, Tondela-Viseu, Portugal
| | - Bruno M Pereira
- Postgraduate and Research Division, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, RJ, Brazil; Grupo Surgical, Campinas, SP, Brazil; Terzius Institute of Education, Campinas, SP, Brazil
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Tilmont A, Coiffard B, Yoshida T, Daviet F, Baumstarck K, Brioude G, Hraiech S, Forel JM, Roch A, Brochard L, Papazian L, Guervilly C. Oesophageal pressure as a surrogate of pleural pressure in mechanically ventilated patients. ERJ Open Res 2021; 7:00646-2020. [PMID: 33718491 PMCID: PMC7938048 DOI: 10.1183/23120541.00646-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/02/2020] [Indexed: 11/18/2022] Open
Abstract
Background Oesophageal pressure (Poes) is used to approximate pleural pressure (Ppl) and therefore to estimate transpulmonary pressure (PL). We aimed to compare oesophageal and regional pleural pressures and to calculate transpulmonary pressures in a prospective physiological study on lung transplant recipients during their stay in the intensive care unit of a tertiary university hospital. Methods Lung transplant recipients receiving invasive mechanical ventilation and monitored by oesophageal manometry and dependent and nondependent pleural catheters were investigated during the post-operative period. We performed simultaneous short-time measurements and recordings of oesophageal manometry and pleural pressures. Expiratory and inspiratory PL were computed by subtracting regional Ppl or Poes from airway pressure; inspiratory PL was also calculated with the elastance ratio method. Results 16 patients were included. Among them, 14 were analysed. Oesophageal pressures correlated with dependent and nondependent pleural pressures during expiration (R2=0.71, p=0.005 and R2=0.77, p=0.001, respectively) and during inspiration (R2=0.66 for both, p=0.01 and p=0.014, respectively). PL values calculated using Poes were close to those obtained from the dependent pleural catheter but higher than those obtained from the nondependent pleural catheter both during expiration and inspiration. Conclusions In ventilated lung transplant recipients, oesophageal manometry is well correlated with pleural pressure. The absolute value of Poes is higher than Ppl of nondependent lung regions and could therefore underestimate the highest level of lung stress in those at high risk of overinflation. During controlled ventilation without respiratory muscle activity, absolute oesophageal pressure is higher than the pleural pressure of the nondependent lung regions and could therefore underestimate the highest level of lung stress in that lunghttps://bit.ly/3a95CUh
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Affiliation(s)
- Antoine Tilmont
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Benjamin Coiffard
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Takeshi Yoshida
- Dept of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan.,Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium
| | - Florence Daviet
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Karine Baumstarck
- Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Geoffrey Brioude
- Dept of Thoracic Surgery and Oesophageal Diseases, Hôpital Nord, AP-HM, Marseille, France
| | - Sami Hraiech
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Jean-Marie Forel
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Aix-Marseille Université, Marseille, France
| | - Antoine Roch
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Service des Urgences, Hôpital Nord, AP-HM, Marseille, France
| | - Laurent Brochard
- Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Laurent Papazian
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium
| | - Christophe Guervilly
- Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Marseille, France.,Pleural Pressure Working Group (PLUG) - Acute Respiratory Failure Section of the European Society of Intensive Care Medicine, Brussels, Belgium
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10
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Fiedler MO, Simeliunas E, Deutsch BL, Diktanaite D, Harms A, Brune M, Dietrich M, Uhle F, Weigand MA, Kalenka A. Impact of Different Positive End-Expiratory Pressures on Lung Mechanics in the Setting of Moderately Elevated Intra-Abdominal Pressure and Acute Lung Injury in a Porcine Model. J Clin Med 2021; 10:306. [PMID: 33467666 PMCID: PMC7830768 DOI: 10.3390/jcm10020306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 12/27/2022] Open
Abstract
The effects of a moderately elevated intra-abdominal pressure (IAP) on lung mechanics in acute respiratory distress syndrome (ARDS) have still not been fully analyzed. Moreover, the optimal positive end-expiratory pressure (PEEP) in elevated IAP and ARDS is unclear. In this paper, 18 pigs under general anesthesia received a double hit lung injury. After saline lung lavage and 2 h of injurious mechanical ventilation to induce an acute lung injury (ALI), an intra-abdominal balloon was filled until an IAP of 10 mmHg was generated. Animals were randomly assigned to one of three groups (group A = PEEP 5, B = PEEP 10 and C = PEEP 15 cmH2O) and ventilated for 6 h. We measured end-expiratory lung volume (EELV) per kg bodyweight, driving pressure (ΔP), transpulmonary pressure (ΔPL), static lung compliance (Cstat), oxygenation (P/F ratio) and cardiac index (CI). In group A, we found increases in ΔP (22 ± 1 vs. 28 ± 2 cmH2O; p = 0.006) and ΔPL (16 ± 1 vs. 22 ± 2 cmH2O; p = 0.007), with no change in EELV/kg (15 ± 1 vs. 14 ± 1 mL/kg) when comparing hours 0 and 6. In group B, there was no change in ΔP (26 ± 2 vs. 25 ± 2 cmH2O), ΔPL (19 ± 2 vs. 18 ± 2 cmH2O), Cstat (21 ± 3 vs. 21 ± 2 cmH2O/mL) or EELV/kg (12 ± 2 vs. 13 ± 3 mL/kg). ΔP and ΔPL were significantly lower after 6 h when comparing between group C and A (21 ± 1 vs. 28 ± 2 cmH2O; p = 0.020) and (14 ± 1 vs. 22 ± 2 cmH2O; p = 0.013)). The EELV/kg increased over time in group C (13 ± 1 vs. 19 ± 2 mL/kg; p = 0.034). The P/F ratio increased in all groups over time. CI decreased in groups B and C. The global lung injury score did not significantly differ between groups (A: 0.25 ± 0.05, B: 0.21 ± 0.02, C: 0.22 ± 0.03). In this model of ALI, elevated IAP, ΔP and ΔPL increased further over time in the group with a PEEP of 5 cmH2O applied over 6 h. This was not the case in the groups with a PEEP of 10 and 15 cmH2O. Although ΔP and ΔPL were significantly lower after 6 hours in group C compared to group A, we could not show significant differences in histological lung injury score.
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Affiliation(s)
- Mascha O. Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany;
| | - Emilis Simeliunas
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Department of Anesthesiology, Kantonsspital Lucerne, 6004 Lucerne, Switzerland
| | - B. Luise Deutsch
- Faculty of Medicine, Justus Liebig University, 35392 Giessen, Germany;
| | - Dovile Diktanaite
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Department of Anesthesiology, Kantonsspital Lucerne, 6004 Lucerne, Switzerland
| | - Alexander Harms
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Maik Brune
- Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany;
| | - Armin Kalenka
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany;
- Department of Anesthesiology and Intensive Care Medicine, Hospital Bergstrasse, 64646 Heppenheim, Germany
- Faculty of Medicine, University of Heidelberg, 69120 Heidelberg, Germany
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11
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Tonetti T, Cavalli I, Ranieri VM, Mascia L. Respiratory consequences of intra-abdominal hypertension. Minerva Anestesiol 2020; 86:877-883. [DOI: 10.23736/s0375-9393.20.14325-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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12
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Effects of intra-operative positive end-expiratory pressure setting guided by oesophageal pressure measurement on oxygenation and respiratory mechanics during laparoscopic gynaecological surgery: A randomised controlled trial. Eur J Anaesthesiol 2020; 37:1032-1039. [PMID: 32371830 DOI: 10.1097/eja.0000000000001204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The creation of pneumoperitoneum during laparoscopic surgery can lead to adverse effects on the respiratory system. Positive end-expiratory pressure (PEEP) plays an important role in mechanical ventilation during laparoscopic surgery. OBJECTIVE To evaluate whether PEEP setting guided by oesophageal pressure (Poeso) measurement would affect oxygenation and respiratory mechanics during laparoscopic gynaecological surgery. DESIGN A randomised controlled study. SETTING A single-centre trial from March 2018 to June 2018. PATIENTS Forty-four adult patients undergoing laparoscopic gynaecological surgery with anticipated duration of surgery more than 2 h. INTERVENTION PEEP set according to Poeso measurement (intervention group) versus PEEP constantly set at 5 cmH2O (control group). MAIN OUTCOME MEASURES Gas exchange and respiratory mechanics after induction and intubation (T0) and at 15 and 60 min after initiation of pneumoperitoneum (T1 and T2, respectively). RESULTS PEEP during pneumoperitoneum was significantly higher in the intervention group than in the control group (T1, 12.5 ± 1.9 vs. 5.0 ± 0.0 cmH2O and T2, 12.4 ± 1.9 vs. 5.0 ± 0.0 cmH2O, both P < 0.001). Partial pressures of oxygen decreased significantly from baseline during pneumoperitoneum in the control group but not in the intervention group. Nevertheless, the changes in partial pressures of oxygen did not differ between groups. Compliance of the respiratory system (CRS) significantly decreased and driving pressure significantly increased during pneumoperitoneum in both groups. However, the changes in CRS and driving pressure were significantly less in the intervention group. Transpulmonary pressure during expiration was maintained in the intervention group while it decreased significantly in the control group. CONCLUSION PEEP setting guided by Poeso measurement showed no beneficial effects in terms of oxygenation but respiratory mechanics were better during laparoscopic gynaecological surgery. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03256396.
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13
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Individualized Positive End-expiratory Pressure and Regional Gas Exchange in Porcine Lung Injury. Anesthesiology 2020; 132:808-824. [DOI: 10.1097/aln.0000000000003151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Background
In acute respiratory failure elevated intraabdominal pressure aggravates lung collapse, tidal recruitment, and ventilation inhomogeneity. Low positive end-expiratory pressure (PEEP) may promote lung collapse and intrapulmonary shunting, whereas high PEEP may increase dead space by inspiratory overdistension. The authors hypothesized that an electrical impedance tomography–guided PEEP approach minimizing tidal recruitment improves regional ventilation and perfusion matching when compared to a table-based low PEEP/no recruitment and an oxygenation-guided high PEEP/full recruitment strategy in a hybrid model of lung injury and elevated intraabdominal pressure.
Methods
In 15 pigs with oleic acid–induced lung injury intraabdominal pressure was increased by intraabdominal saline infusion. PEEP was set in randomized order: (1) guided by a PEEP/inspired oxygen fraction table, without recruitment maneuver; (2) minimizing tidal recruitment guided by electrical impedance tomography after a recruitment maneuver; and (3) maximizing oxygenation after a recruitment maneuver. Single photon emission computed tomography was used to analyze regional ventilation, perfusion, and aeration. Primary outcome measures were differences in PEEP levels and regional ventilation/perfusion matching.
Results
Resulting PEEP levels were different (mean ± SD) with (1) table PEEP: 11 ± 3 cm H2O; (2) minimal tidal recruitment PEEP: 22 ± 3 cm H2O; and (3) maximal oxygenation PEEP: 25 ± 4 cm H2O; P < 0.001. Table PEEP without recruitment maneuver caused highest lung collapse (28 ± 11% vs. 5 ± 5% vs. 4 ± 4%; P < 0.001), shunt perfusion (3.2 ± 0.8 l/min vs. 1.0 ± 0.8 l/min vs. 0.7 ± 0.6 l/min; P < 0.001) and dead space ventilation (2.9 ± 1.0 l/min vs. 1.5 ± 0.7 l/min vs. 1.7 ± 0.8 l/min; P < 0.001). Although resulting in different PEEP levels, minimal tidal recruitment and maximal oxygenation PEEP, both following a recruitment maneuver, had similar effects on regional ventilation/perfusion matching.
Conclusions
When compared to table PEEP without a recruitment maneuver, both minimal tidal recruitment PEEP and maximal oxygenation PEEP following a recruitment maneuver decreased shunting and dead space ventilation, and the effects of minimal tidal recruitment PEEP and maximal oxygenation PEEP were comparable.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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14
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Respiratory Mechanics, Lung Recruitability, and Gas Exchange in Pulmonary and Extrapulmonary Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:792-799. [PMID: 30908313 DOI: 10.1097/ccm.0000000000003715] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Acute respiratory distress syndrome is a clinical syndrome characterized by a refractory hypoxemia due to an inflammatory and high permeability pulmonary edema secondary to direct or indirect lung insult (pulmonary and extrapulmonary form). Aim of this study was to evaluate in a large database of acute respiratory distress syndrome patients, the pulmonary versus extrapulmonary form in terms of respiratory mechanics, lung recruitment, gas exchange, and positive end-expiratory pressure response. DESIGN A secondary analysis of previously published data. PATIENTS One-hundred eighty-one sedated and paralyzed acute respiratory distress syndrome patients (age 60 yr [46-72 yr], body mass index 25 kg/m [22-28 kg/m], and PaO2/FIO2 184 ± 66). INTERVENTIONS Lung CT scan performed at 5 and 45 cm H2O. Two levels of positive end-expiratory pressure (5 and 15 cm H2O) were randomly applied. MEASUREMENTS AND MAIN RESULTS Ninety-seven and 84 patients had a pulmonary and extrapulmonary acute respiratory distress syndrome. The median time from intensive care admission to the CT scan and respiratory mechanics analysis was 4 days (interquartile range, 2-6). At both positive end-expiratory pressure levels, pulmonary acute respiratory distress syndrome presented a significantly lower PaO2/FIO2 and higher physiologic dead space compared with extrapulmonary acute respiratory distress syndrome. The lung and chest wall elastance were similar between groups. The intra-abdominal pressure was significantly higher in extrapulmonary compared with pulmonary acute respiratory distress syndrome (10 mm Hg [7-12 mm Hg] vs 7 mm Hg [5-8 mm Hg]). The lung weight and lung recruitability were significantly higher in pulmonary acute respiratory distress syndrome (1,534 g [1,286-1,835 g] vs 1,342 g [1,090-1,507 g] and 16% [9-25%] vs 9% [5-14%]). CONCLUSIONS In the early stage, pulmonary acute respiratory distress syndrome is characterized by a greater impairment of gas exchange and higher lung recruitability. The recognition of the origin of acute respiratory distress syndrome is important for a more customized ventilatory management.
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Regli A, Pelosi P, Malbrain MLNG. Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know. Ann Intensive Care 2019; 9:52. [PMID: 31025221 PMCID: PMC6484068 DOI: 10.1186/s13613-019-0522-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/04/2019] [Indexed: 12/16/2022] Open
Abstract
The incidence of intra-abdominal hypertension (IAH) is high and still underappreciated by critical care physicians throughout the world. One in four to one in three patients will have IAH on admission, while one out of two will develop IAH within the first week of Intensive Care Unit stay. IAH is associated with high morbidity and mortality. Although considerable progress has been made over the past decades, some important questions remain regarding the optimal ventilation management in patients with IAH. An important first step is to measure intra-abdominal pressure (IAP). If IAH (IAP > 12 mmHg) is present, medical therapies should be initiated to reduce IAP as small reductions in intra-abdominal volume can significantly reduce IAP and airway pressures. Protective lung ventilation with low tidal volumes in patients with respiratory failure and IAH is important. Abdominal-thoracic pressure transmission is around 50%. In patients with IAH, higher positive end-expiratory pressure (PEEP) levels are often required to avoid alveolar collapse but the optimal PEEP in these patients is still unknown. During recruitment manoeuvres, higher opening pressures may be required while closely monitoring oxygenation and the haemodynamic response. During lung-protective ventilation, whilst keeping driving pressures within safe limits, higher plateau pressures than normally considered might be acceptable. Monitoring of the respiratory function and adapting the ventilatory settings during anaesthesia and critical care are of great importance. This review will focus on how to deal with the respiratory derangements in critically ill patients with IAH.
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Affiliation(s)
- Adrian Regli
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch Drive, Murdoch, WA 6152 Australia
- Medical School, Division of Emergency Medicine, The University of Western Australia, Sterling Highway, Crawley, Perth, WA 6009 Australia
- Medical School, The Notre Dame University, Henry Road, Fremantle, Perth, WA 6959 Australia
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Manu L. N. G. Malbrain
- Intensive Care Unit, University Hospital Brussels (UZB), Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Papakrivou E, Manoulakas E, Zakynthinos E, Makris D. Is intra-abdominal hypertension a risk factor for ventilator-associated pneumonia? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:419. [PMID: 30581827 DOI: 10.21037/atm.2018.08.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In the last years, there has been a significant amount of research about the impact of intra-abdominal hypertension (IAH) on the outcomes of critical care patients. IAH is increasingly recognized as potential complication in intensive care unit (ICU) patients. IAH affects all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. On the other hand, ICU patients present frequently ventilator- associated respiratory infections. Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection (HAI) in adult critical care units. It is associated with increased ICU stay, patient ventilator days and mortality. This paper reviews the relationship between IAH and VAP. Despite animal experimentation and physiological studies on humans, in favor of the impact of IAH to VAP, there is no definitive clinical data that IAH is associated with VAP. Microaspirations form the gastrointestinal track is a pathophysiological mechanism for VAP. This review provides data suggesting that under IAH conditions bacterial translocation might be an additional responsible mechanism for VAP in those patients that merits further investigation in the future.
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Affiliation(s)
- Eleni Papakrivou
- Department of Critical Care Medicine, University Hospital of Larisa, University of Thessaly School of Medicine, Larisa, Greece
| | - Eustratios Manoulakas
- Department of Critical Care Medicine, University Hospital of Larisa, University of Thessaly School of Medicine, Larisa, Greece
| | - Epaminondas Zakynthinos
- Department of Critical Care Medicine, University Hospital of Larisa, University of Thessaly School of Medicine, Larisa, Greece
| | - Demosthenes Makris
- Department of Critical Care Medicine, University Hospital of Larisa, University of Thessaly School of Medicine, Larisa, Greece
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Papakrivou E, Makris D, Manoulakas E, Karvouniaris M, Zakynthinos E. Intra-Abdominal Hypertension is a Risk Factor for Increased VAP Incidence: A Prospective Cohort Study in the ICU of a Tertiary Hospital. J Intensive Care Med 2018; 35:700-707. [PMID: 29902954 DOI: 10.1177/0885066618779369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) might be increased in cases with intra-abdominal hypertension (IAH). However, despite animal experimentation and physiological studies on humans in favor of this hypothesis, there is no definitive clinical data that IAH is associated with VAP. We therefore aimed to study whether IAH is a risk factor for increased incidence of VAP in critical care patients. This 1-center prospective observational cohort study was conducted in the intensive care unit of the University Hospital of Larissa, Greece, during 2013 to 2015. Consecutive patients were recruited if they presented risk factors for IAH at admission and were evaluated systematically for IAH and VAP for a 28-day period. RESULTS Forty-five (36.6%) of 123 patients presented IAH and 45 (36.6%) presented VAP; 24 patients presented VAP following IAH. Cox regression analysis showed that VAP was independently associated with IAH (1.06 [1.01-1.11]; P = .053), while there was an indication for an independent association between VAP and abdominal surgery (1.62 [0.87-3.03]; P = .11] and chronic obstructive pulmonary disease (1.79 [0.96-3.37]; P = .06). CONCLUSIONS Intra-abdominal hypertension is an independent risk factor for increased VAP incidence in critically ill patients who present risk factors for IAH at admission to the ICU.
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Affiliation(s)
- Eleni Papakrivou
- Department of Critical Care Medicine, University Hospital of Larissa, University of Thessaly, School of Medicine, Larissa, Greece
| | - Demosthenes Makris
- Department of Critical Care Medicine, University Hospital of Larissa, University of Thessaly, School of Medicine, Larissa, Greece
| | - Efstratios Manoulakas
- Department of Critical Care Medicine, University Hospital of Larissa, University of Thessaly, School of Medicine, Larissa, Greece
| | - Marios Karvouniaris
- Department of Critical Care Medicine, University Hospital of Larissa, University of Thessaly, School of Medicine, Larissa, Greece
| | - Epaminondas Zakynthinos
- Department of Critical Care Medicine, University Hospital of Larissa, University of Thessaly, School of Medicine, Larissa, Greece
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Braha B, Mahmutaj D, Maxhuni M, Neziri B, Krasniqi S. Correlation of Procalcitonin and C-Reactive Protein with Intra-Abdominal Hypertension in Intra-Abdominal Infections: Their Predictive Role in the Progress of the Disease. Open Access Maced J Med Sci 2018; 6:479-484. [PMID: 29610604 PMCID: PMC5874369 DOI: 10.3889/oamjms.2018.112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 01/17/2023] Open
Abstract
AIM To analyse the correlation of procalcitonin (PCT) and C-reactive protein (CRP) values with increased intra-abdominal pressure and to evaluate their predictive role in the progression of Intra-abdominal infections. MATERIALS AND METHODS A non-randomized prospective study conducted in the group of 80 patients. We have measured the PCT, CRP and intra-abdominal pressure (IAP). RESULTS According to IAH grades (G), there was a significant difference of PCT values: G I 3.6 ± 5.1 ng/ml, G II 10.9 ± 22.6 ng/ml, G III 15.2 ± 30.2 ng/ml (p = 0.045) until: CRP values were increased in all IAH groups but without distinction between the groups: GI 183 ± 64.5, GII 196 ± 90.2, GIII 224 ± 96.3 (p = 0.17). According to the severity of the infection, we yielded increased values of PCT, IAP and CRP in septic shock, severe sepsis and SIRS/sepsis resulting in significant differences of PCT and IAP. CONCLUSION Based on the results of our research, we conclude that the correlation of PCT values with IAH grades is quite significant while the CRP results remain high in IAH but without significant difference between the different grades of IAH.
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Affiliation(s)
- Bedri Braha
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Dafina Mahmutaj
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Mehmet Maxhuni
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Burim Neziri
- Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
| | - Shaip Krasniqi
- Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
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Regli A, De Keulenaer BL, Palermo A, van Heerden PV. Positive end-expiratory pressure adjusted for intra-abdominal pressure - A pilot study. J Crit Care 2017; 43:390-394. [PMID: 29054769 DOI: 10.1016/j.jcrc.2017.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/29/2017] [Accepted: 10/13/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Intra-abdominal hypertension (IAH) is associated with impaired respiratory function. Animal data suggest that positive end-expiratory pressure (PEEP) levels adjusted to intra-abdominal pressure (IAP) levels may counteract IAH-induced respiratory dysfunction. In this pilot study, our aim was to assess whether PEEP adjusted for IAP can be applied safely in patients with IAH. MATERIALS AND METHODS We included patients on mechanical ventilation and with IAH. Patients were excluded with severe cardiovascular dysfunction or severe hypoxemia or if the patient was in imminent danger of dying. Following a recruitment manoeuvre, the following PEEP levels were randomly applied: PEEP of 5cmH2O (baseline), PEEP=50% of IAP, and PEEP=100% of IAP. After a 30min equilibration period we measured arterial blood gases and cardio-respiratory parameters. RESULTS Fifteen patients were enrolled. Six (41%) patients did not tolerate PEEP=100% IAP due to hypoxemia, hypotension or endotracheal cuff leak. PaO2/FiO2 ratios were 234 (68), 271 (99), and 329 (107) respectively. The differences were significant (p=0.009) only between baseline and PEEP=100% IAP. CONCLUSIONS PEEP=100% of IAP was not well-tolerated and only marginally improved oxygenation in ventilated patients with IAH.
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Affiliation(s)
- Adrian Regli
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia; Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia; School of Medicine and Pharmacology, The University of Western Australia, Sterling Highway, Crawley, (Perth) WA 6009, Australia; Medical School, The Notre Dame University, Henry Road, Fremantle, WA 6160, Australia.
| | - Bart Leon De Keulenaer
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia; Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia; School of Surgery, The University of Western Australia, Sterling Highway, Crawley, (Perth) WA 6009, Australia.
| | - Annamaria Palermo
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia; Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia.
| | - Peter Vernon van Heerden
- School of Medicine and Pharmacology, The University of Western Australia, Sterling Highway, Crawley, (Perth) WA 6009, Australia; General Intensive Care Unit, Hadassah University Hospital, Kiryat Hadassah, Jerusalem 91120, Israel.
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20
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Santos CL, Santos RS, Moraes L, Samary CS, Felix NS, Silva JD, Morales MM, Huhle R, Abreu MG, Schanaider A, Silva PL, Pelosi P, Rocco PRM. Effects of pressure support and pressure-controlled ventilation on lung damage in a model of mild extrapulmonary acute lung injury with intra-abdominal hypertension. PLoS One 2017; 12:e0178207. [PMID: 28542443 PMCID: PMC5444773 DOI: 10.1371/journal.pone.0178207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/08/2017] [Indexed: 12/22/2022] Open
Abstract
Intra-abdominal hypertension (IAH) may co-occur with the acute respiratory distress syndrome (ARDS), with significant impact on morbidity and mortality. Lung-protective controlled mechanical ventilation with low tidal volume and positive end-expiratory pressure (PEEP) has been recommended in ARDS. However, mechanical ventilation with spontaneous breathing activity may be beneficial to lung function and reduce lung damage in mild ARDS. We hypothesized that preserving spontaneous breathing activity during pressure support ventilation (PSV) would improve respiratory function and minimize ventilator-induced lung injury (VILI) compared to pressure-controlled ventilation (PCV) in mild extrapulmonary acute lung injury (ALI) with IAH. Thirty Wistar rats (334±55g) received Escherichia coli lipopolysaccharide intraperitoneally (1000μg) to induce mild extrapulmonary ALI. After 24h, animals were anesthetized and randomized to receive PCV or PSV. They were then further randomized into subgroups without or with IAH (15 mmHg) and ventilated with PCV or PSV (PEEP = 5cmH2O, driving pressure adjusted to achieve tidal volume = 6mL/kg) for 1h. Six of the 30 rats were used for molecular biology analysis and were not mechanically ventilated. The main outcome was the effect of PCV versus PSV on mRNA expression of interleukin (IL)-6 in lung tissue. Regardless of whether IAH was present, PSV resulted in lower mean airway pressure (with no differences in peak airway or peak and mean transpulmonary pressures) and less mRNA expression of biomarkers associated with lung inflammation (IL-6) and fibrogenesis (type III procollagen) than PCV. In the presence of IAH, PSV improved oxygenation; decreased alveolar collapse, interstitial edema, and diffuse alveolar damage; and increased expression of surfactant protein B as compared to PCV. In this experimental model of mild extrapulmonary ALI associated with IAH, PSV compared to PCV improved lung function and morphology and reduced type 2 epithelial cell damage.
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Affiliation(s)
- Cintia L. Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
- Laboratory of Experimental Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Av. Professor Rodolpho Paulo Rocco, 225, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Raquel S. Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Lillian Moraes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Cynthia S. Samary
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Nathane S. Felix
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Johnatas D. Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Marcelo M. Morales
- Laboratory of Cellular and Molecular Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G2-048, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetschertsrasse 74, Dresden, Germany
| | - Marcelo G. Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden University of Technology, Fetschertsrasse 74, Dresden, Germany
| | - Alberto Schanaider
- Laboratory of Experimental Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Av. Professor Rodolpho Paulo Rocco, 225, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Pedro L. Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
| | - Paolo Pelosi
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, Brazil
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Roth CJ, Becher T, Frerichs I, Weiler N, Wall WA. Coupling of EIT with computational lung modeling for predicting patient-specific ventilatory responses. J Appl Physiol (1985) 2017; 122:855-867. [DOI: 10.1152/japplphysiol.00236.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 12/19/2022] Open
Abstract
Providing optimal personalized mechanical ventilation for patients with acute or chronic respiratory failure is still a challenge within a clinical setting for each case anew. In this article, we integrate electrical impedance tomography (EIT) monitoring into a powerful patient-specific computational lung model to create an approach for personalizing protective ventilatory treatment. The underlying computational lung model is based on a single computed tomography scan and able to predict global airflow quantities, as well as local tissue aeration and strains for any ventilation maneuver. For validation, a novel “virtual EIT” module is added to our computational lung model, allowing to simulate EIT images based on the patient's thorax geometry and the results of our numerically predicted tissue aeration. Clinically measured EIT images are not used to calibrate the computational model. Thus they provide an independent method to validate the computational predictions at high temporal resolution. The performance of this coupling approach has been tested in an example patient with acute respiratory distress syndrome. The method shows good agreement between computationally predicted and clinically measured airflow data and EIT images. These results imply that the proposed framework can be used for numerical prediction of patient-specific responses to certain therapeutic measures before applying them to an actual patient. In the long run, definition of patient-specific optimal ventilation protocols might be assisted by computational modeling. NEW & NOTEWORTHY In this work, we present a patient-specific computational lung model that is able to predict global and local ventilatory quantities for a given patient and any selected ventilation protocol. For the first time, such a predictive lung model is equipped with a virtual electrical impedance tomography module allowing real-time validation of the computed results with the patient measurements. First promising results obtained in an acute respiratory distress syndrome patient show the potential of this approach for personalized computationally guided optimization of mechanical ventilation in future.
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Affiliation(s)
- Christian J. Roth
- Institute for Computational Mechanics, Technical University of Munich, Munich, Germany; and
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, Christian Albrechts University, Kiel, Germany
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, Christian Albrechts University, Kiel, Germany
| | - Norbert Weiler
- Department of Anesthesiology and Intensive Care Medicine, Christian Albrechts University, Kiel, Germany
| | - Wolfgang A. Wall
- Institute for Computational Mechanics, Technical University of Munich, Munich, Germany; and
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Wang HY, Yu JW. Liver injury in malignant ascites-induced abdominal compartment syndrome. Shijie Huaren Xiaohua Zazhi 2017; 25:769-774. [DOI: 10.11569/wcjd.v25.i9.769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Liver injury in malignant ascites-induced abdominal compartment syndrome (MAACS) has received little attention. In recent years, due to the gradual clarification of pathogenesis and pathological physiology of abdominal interval syndrome, liver injury in MAACS has become a hot research topic. In this paper, we will review the pathophysiological process, pathological changes, and treatment of liver injury in MAACS.
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Intra-Abdominal Hypertension Causes Bacterial Growth in Lungs: An Animal Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4601348. [PMID: 28357400 PMCID: PMC5357524 DOI: 10.1155/2017/4601348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/25/2016] [Accepted: 01/17/2017] [Indexed: 11/17/2022]
Abstract
To study the effect of intra-abdominal hypertension (IAH) on the frequency of pneumonia with an experimental study, thirteen Sprague-Dawley rats were included. Eight out of thirteen animals were randomly assigned to receive 10 ml of benzalkonium chloride 0.2% (megacolon group) and five animals received 10 ml NaCl 0.9% (controls). Animals were anaesthetized by intramuscular delivery of ketamine. The incidence of positivity for bacteria lung tissue cultures and mesenteric lymph node cultures was assessed at the 21st day after animals' sacrification, or before in case of death. All megacolon group animals presented progressive increase of the abdomen and increased IAP (≥10 mmHg) whereas the frequency of their evacuations was almost eliminated. Controls presented normal evacuations, no sign of abdominal distention, and normal IAP. In megacolon group animals, there was evidence of significant amount of bacteria in lung cultures. In contrast, no bacteria were found in control animals.
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24
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Bian W, Chen W, Chao Y, Wang L, Li L, Guan J, Zang X, Zhen J, Sheng B, Zhu X. Application of dead space fraction to titrate optimal positive end-expiratory pressure in an ARDS swine model. Exp Ther Med 2017; 13:1572-1577. [PMID: 28413511 DOI: 10.3892/etm.2017.4117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/05/2016] [Indexed: 11/05/2022] Open
Abstract
This study aimed to apply the dead space fraction [ratio of dead space to tidal volume (VD/VT)] to titrate the optimal positive end-expiratory pressure (PEEP) in a swine model of acute respiratory distress syndrome (ARDS). Twelve swine models of ARDS were constructed. A lung recruitment maneuver was then conducted and the PEEP was set at 20 cm H2O. The PEEP was reduced by 2 cm H2O every 10 min until 0 cm H2O was reached, and VD/VT was measured after each decrement step. VD/VT was measured using single-breath analysis of CO2, and calculated from arterial CO2 partial pressure (PaCO2) and mixed expired CO2 (PeCO2) using the following formula: VD/VT = (PaCO2 - PeCO2)/PaCO2. The optimal PEEP was identified by the lowest VD/VT method. Respiration and hemodynamic parameters were recorded during the periods of pre-injury and injury, and at 4 and 2 cm H2O below and above the optimal PEEP (Po). The optimal PEEP in this study was found to be 13.25±1.36 cm H2O. During the Po period, VD/VT decreased to a lower value (0.44±0.08) compared with that during the injury period (0.68±0.10) (P<0.05), while the intrapulmonary shunt fraction reached its lowest value. In addition, a significant change of dynamic tidal respiratory compliance and oxygenation index was induced by PEEP titration. These results indicate that minimal VD/VT can be used for PEEP titration in ARDS.
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Affiliation(s)
- Weishuai Bian
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Wei Chen
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Yangong Chao
- Department of Critical Care Medicine, The First Affiliated Hospital, Tsing Hua University, Beijing 100016, P.R. China
| | - Lan Wang
- Department of Critical Care Medicine, Dongzhimen Chinese Medical Hospital, Beijing Chinese-Medical University, Beijing 100700, P.R. China
| | - Liming Li
- Department of Critical Care Medicine, The First Affiliated Hospital, Tsing Hua University, Beijing 100016, P.R. China
| | - Jian Guan
- Department of Critical Care Medicine, The First Affiliated Hospital, Tsing Hua University, Beijing 100016, P.R. China
| | - Xuefeng Zang
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Jie Zhen
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Bo Sheng
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Xi Zhu
- Department of Critical Care Medicine, Third Hospital, Peking University, Beijing 100083, P.R. China
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Vieillard-Baron A, Matthay M, Teboul JL, Bein T, Schultz M, Magder S, Marini JJ. Experts' opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation. Intensive Care Med 2016; 42:739-749. [PMID: 27038480 DOI: 10.1007/s00134-016-4326-3] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/11/2016] [Indexed: 02/06/2023]
Abstract
RATIONALE Acute respiratory distress syndrome (ARDS) is frequently associated with hemodynamic instability which appears as the main factor associated with mortality. Shock is driven by pulmonary hypertension, deleterious effects of mechanical ventilation (MV) on right ventricular (RV) function, and associated-sepsis. Hemodynamic effects of ventilation are due to changes in pleural pressure (Ppl) and changes in transpulmonary pressure (TP). TP affects RV afterload, whereas changes in Ppl affect venous return. Tidal forces and positive end-expiratory pressure (PEEP) increase pulmonary vascular resistance (PVR) in direct proportion to their effects on mean airway pressure (mPaw). The acutely injured lung has a reduced capacity to accommodate flowing blood and increases of blood flow accentuate fluid filtration. The dynamics of vascular pressure may contribute to ventilator-induced injury (VILI). In order to optimize perfusion, improve gas exchange, and minimize VILI risk, monitoring hemodynamics is important. RESULTS During passive ventilation pulse pressure variations are a predictor of fluid responsiveness when conditions to ensure its validity are observed, but may also reflect afterload effects of MV. Central venous pressure can be helpful to monitor the response of RV function to treatment. Echocardiography is suitable to visualize the RV and to detect acute cor pulmonale (ACP), which occurs in 20-25 % of cases. Inserting a pulmonary artery catheter may be useful to measure/calculate pulmonary artery pressure, pulmonary and systemic vascular resistance, and cardiac output. These last two indexes may be misleading, however, in cases of West zones 2 or 1 and tricuspid regurgitation associated with RV dilatation. Transpulmonary thermodilution may be useful to evaluate extravascular lung water and the pulmonary vascular permeability index. To ensure adequate intravascular volume is the first goal of hemodynamic support in patients with shock. The benefit and risk balance of fluid expansion has to be carefully evaluated since it may improve systemic perfusion but also may decrease ventilator-free days, increase pulmonary edema, and promote RV failure. ACP can be prevented or treated by applying RV protective MV (low driving pressure, limited hypercapnia, PEEP adapted to lung recruitability) and by prone positioning. In cases of shock that do not respond to intravascular fluid administration, norepinephrine infusion and vasodilators inhalation may improve RV function. Extracorporeal membrane oxygenation (ECMO) has the potential to be the cause of, as well as a remedy for, hemodynamic problems. Continuous thermodilution-based and pulse contour analysis-based cardiac output monitoring are not recommended in patients treated with ECMO, since the results are frequently inaccurate. Extracorporeal CO2 removal, which could have the capability to reduce hypercapnia/acidosis-induced ACP, cannot currently be recommended because of the lack of sufficient data.
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Affiliation(s)
- A Vieillard-Baron
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Service de Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,University of Versailles Saint-Quentin en Yvelines, Faculty of Medicine Paris Ile-de-France Ouest, 78280, Saint-Quentin en Yvelines, France. .,INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807, Villejuif, France.
| | - M Matthay
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - J L Teboul
- Assistance Publique-Hôpitaux de Paris, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - T Bein
- Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, 93042, Regensburg, Germany
| | - M Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - S Magder
- Department of Critical Care, McGill University Health Centre (Glen Site Campus), Montreal, Canada
| | - J J Marini
- Departments of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, Minneapolis/St. Paul, MN, USA
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Fluid Management, Volume Overload, and Gastrointestinal Tolerance in the Perioperative Period. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0135-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Santos CL, Santos RS, Moraes L, Samary CS, Felix NS, Fiorio Júnior PL, Morales MM, Abreu MG, Pelosi P, Schanaider A, Silva PL, Rocco PRM. Effects of pressure control and pressure support ventilation on ventilator induced lung injury in experimental acute respiratory distress syndrome with intra-abdominal hypertension. Intensive Care Med Exp 2015. [PMCID: PMC4797610 DOI: 10.1186/2197-425x-3-s1-a806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hecker A, Hecker B, Hecker M, Riedel JG, Weigand MA, Padberg W. Acute abdominal compartment syndrome: current diagnostic and therapeutic options. Langenbecks Arch Surg 2015; 401:15-24. [PMID: 26518567 DOI: 10.1007/s00423-015-1353-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/22/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND If untreated, the abdominal compartment syndrome (ACS) has a mortality of nearly 100 %. Thus, its early recognition is of major importance for daily rounds on surgical intensive care units. Intraabdominal hypertension (IAH) is a poorly recognized entity, which occurs if intraabdominal pressure arises >12 mmHg. Measurement of the intravesical pressure is the gold standard to diagnose IAH, which can be detected in about one fourth of surgical intensive care patients. PURPOSE The aim of this manuscript is to outline the current diagnostic and therapeutic options for IAH and ACS. While diagnosis of IAH and ACS strongly depends on clinical experience, new diagnostic markers could play an important role in the future. Therapy of IAH/ACS consists of five treatment "columns": intraluminal evacuation, intraabdominal evacuation, improvement of abdominal wall compliance, fluid management, and improved organ perfusion. If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. Thereafter, patients with an open abdomen require intensive care and are permanently threatened by the quadrangle of fluid loss, muscle proteolysis, heat loss, and an impaired immune function. As a consequence, complication rate dramatically increases after 8 days of open abdomen therapy. CONCLUSION Despite many efforts, the mortality of patients with ACS remains unacceptably high. Permanent clinical education and surgical trials will be necessary to improve the outcome of our critically ill surgical patients.
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Affiliation(s)
- A Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.
| | - B Hecker
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Hecker
- Medical Clinic II, Pulmonary and Critical Care Medicine, University Hospital of Giessen, Giessen, Germany
| | - J G Riedel
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - M A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - W Padberg
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
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Chadi SA, Abdo H, Bihari A, Parry N, Lawendy AR. Hepatic microvascular changes in rat abdominal compartment syndrome. J Surg Res 2015; 197:398-404. [DOI: 10.1016/j.jss.2015.04.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/24/2014] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
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Abstract
Abdominal compliance (AC) is an important determinant and predictor of available workspace during laparoscopic surgery. Furthermore, critically ill patients with a reduced AC are at an increased risk of developing intra-abdominal hypertension and abdominal compartment syndrome, both of which are associated with high morbidity and mortality. Despite this, AC is a concept that has been neglected in the past.AC is defined as a measure of the ease of abdominal expansion, expressed as a change in intra-abdominal volume (IAV) per change in intra-abdominal pressure (IAP):AC = ΔIAV / ΔIAPAC is a dynamic variable dependent on baseline IAV and IAP as well as abdominal reshaping and stretching capacity. Whereas AC itself can only rarely be measured, it always needs to be considered an important component of IAP. Patients with decreased AC are prone to fulminant development of abdominal compartment syndrome when concomitant risk factors for intra-abdominal hypertension are present.This review aims to clarify the pressure-volume relationship within the abdominal cavity. It highlights how different conditions and pathologies can affect AC and which management strategies could be applied to avoid serious consequences of decreased AC.We have pooled all available human data to calculate AC values in patients acutely and chronically exposed to intra-abdominal hypertension and demonstrated an exponential abdominal pressure-volume relationship. Most importantly, patients with high level of IAP have a reduced AC. In these patients, only small reduction in IAV can significantly increase AC and reduce IAPs.A greater knowledge on AC may help in selecting a better surgical approach and in reducing complications related to intra-abdominal hypertension.
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Almeida CP, Ponce D, de Marchi AC, Balbi AL. Effect of peritoneal dialysis on respiratory mechanics in acute kidney injury patients. Perit Dial Int 2015; 34:544-9. [PMID: 25074997 DOI: 10.3747/pdi.2013.00092] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Cibele Puato Almeida
- Internal Medicine, Botucatu School of Medicine - UNESP Distrito de Rubiao Junior, Botucatu, Sao Paulo, Brazil
| | - Daniela Ponce
- Internal Medicine, Botucatu School of Medicine - UNESP Distrito de Rubiao Junior, Botucatu, Sao Paulo, Brazil
| | - Ana Carolina de Marchi
- Internal Medicine, Botucatu School of Medicine - UNESP Distrito de Rubiao Junior, Botucatu, Sao Paulo, Brazil
| | - Andre Luis Balbi
- Internal Medicine, Botucatu School of Medicine - UNESP Distrito de Rubiao Junior, Botucatu, Sao Paulo, Brazil
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Ferrando C, Suárez-Sipmann F, Gutierrez A, Tusman G, Carbonell J, García M, Piqueras L, Compañ D, Flores S, Soro M, Llombart A, Belda FJ. Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:9. [PMID: 25583125 PMCID: PMC4352239 DOI: 10.1186/s13054-014-0726-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 12/18/2014] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The stress index (SI), a parameter derived from the shape of the pressure-time curve, can identify injurious mechanical ventilation. We tested the hypothesis that adjusting tidal volume (VT) to a non-injurious SI in an open lung condition avoids hypoventilation while preventing overdistension in an experimental model of combined lung injury and low chest-wall compliance (Ccw). METHODS Lung injury was induced by repeated lung lavages using warm saline solution, and Ccw was reduced by controlled intra-abdominal air-insufflation in 22 anesthetized, paralyzed and mechanically ventilated pigs. After injury animals were recruited and submitted to a positive end-expiratory pressure (PEEP) titration trial to find the PEEP level resulting in maximum compliance. During a subsequent four hours of mechanical ventilation, VT was adjusted to keep a plateau pressure (Pplat) of 30 cmH2O (Pplat-group, n = 11) or to a SI between 0.95 and 1.05 (SI-group, n = 11). Respiratory rate was adjusted to maintain a 'normal' PaCO2 (35 to 65 mmHg). SI, lung mechanics, arterial-blood gases haemodynamics pro-inflammatory cytokines and histopathology were analyzed. In addition Computed Tomography (CT) data were acquired at end expiration and end inspiration in six animals. RESULTS PaCO2 was significantly higher in the Pplat-group (82 versus 53 mmHg, P = 0.01), with a resulting lower pH (7.19 versus 7.34, P = 0.01). We observed significant differences in VT (7.3 versus 5.4 mlKg(-1), P = 0.002) and Pplat values (30 versus 35 cmH2O, P = 0.001) between the Pplat-group and SI-group respectively. SI (1.03 versus 0.99, P = 0.42) and end-inspiratory transpulmonary pressure (PTP) (17 versus 18 cmH2O, P = 0.42) were similar in the Pplat- and SI-groups respectively, without differences in overinflated lung areas at end- inspiration in both groups. Cytokines and histopathology showed no differences. CONCLUSIONS Setting tidal volume to a non-injurious stress index in an open lung condition improves alveolar ventilation and prevents overdistension without increasing lung injury. This is in comparison with limited Pplat protective ventilation in a model of lung injury with low chest-wall compliance.
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Affiliation(s)
- Carlos Ferrando
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Fernando Suárez-Sipmann
- Section of Anesthesiology and Critical Care, Uppsala University Hospital Uppsala, Uppsala, Sweden. .,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Andrea Gutierrez
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata, Argentina.
| | - Jose Carbonell
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Marisa García
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Laura Piqueras
- Clinical Research Foundation, Hospital Clínico Universitario of Valencia, Valencia, Spain.
| | - Desamparados Compañ
- Pathological Anatomy Department, Hospital Clínico Universitario of Valencia, Valencia, Spain.
| | - Susanie Flores
- Radiology Department, Hospital Clinico Universitario of Valencia, Valencia, Spain.
| | - Marina Soro
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Alicia Llombart
- Clinical Research Foundation, Hospital Clínico Universitario of Valencia, Valencia, Spain.
| | - Francisco Javier Belda
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
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Santos CL, Moraes L, Santos RS, dos Santos Samary C, Silva JD, Morales MM, Capelozzi VL, de Abreu MG, Schanaider A, Silva PL, Garcia CSNB, Pelosi P, Rocco PRM. The biological effects of higher and lower positive end-expiratory pressure in pulmonary and extrapulmonary acute lung injury with intra-abdominal hypertension. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R121. [PMID: 24928415 PMCID: PMC4095606 DOI: 10.1186/cc13920] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/27/2014] [Indexed: 01/01/2023]
Abstract
Introduction Mechanical ventilation with high positive end-expiratory pressure (PEEP) has been used in patients with acute respiratory distress syndrome (ARDS) and intra-abdominal hypertension (IAH), but the role of PEEP in minimizing lung injury remains controversial. We hypothesized that in the presence of acute lung injury (ALI) with IAH: 1) higher PEEP levels improve pulmonary morphofunction and minimize lung injury; and 2) the biological effects of higher PEEP are more effective in extrapulmonary (exp) than pulmonary (p) ALI. Methods In 48 adult male Wistar rats, ALIp and ALIexp were induced by Escherichia coli lipopolysaccharide intratracheally and intraperitoneally, respectively. After 24 hours, animals were anesthetized and mechanically ventilated (tidal volume of 6 mL/kg). IAH (15 mmHg) was induced and rats randomly assigned to PEEP of 5 (PEEP5), 7 (PEEP7) or 10 (PEEP10) cmH2O for 1 hour. Results In both ALIp and ALIexp, higher PEEP levels improved oxygenation. PEEP10 increased alveolar hyperinflation and epithelial cell damage compared to PEEP5, independent of ALI etiology. In ALIp, PEEP7 and PEEP10 increased lung elastance compared to PEEP5 (4.3 ± 0.7 and 4.3 ± 0.9 versus 3.1 ± 0.3 cmH2O/mL, respectively, P <0.01), without changes in alveolar collapse, interleukin-6, caspase-3, type III procollagen, receptor for advanced glycation end-products, and vascular cell adhesion molecule-1 expressions. Moreover, PEEP10 increased diaphragmatic injury compared to PEEP5. In ALIexp, PEEP7 decreased lung elastance and alveolar collapse compared to PEEP5 (2.3 ± 0.5 versus 3.6 ± 0.7 cmH2O/mL, P <0.02, and 27.2 (24.7 to 36.8) versus 44.2 (39.7 to 56.9)%, P <0.05, respectively), while PEEP7 and PEEP10 increased interleukin-6 and type III procollagen expressions, as well as type II epithelial cell damage compared to PEEP5. Conclusions In the current models of ALI with IAH, in contrast to our primary hypothesis, higher PEEP is more effective in ALIp than ALIexp as demonstrated by the activation of biological markers. Therefore, higher PEEP should be used cautiously in the presence of IAH and ALI, mainly in ALIexp.
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Malbrain MLNG, Pelosi P, De Laet I, Lattuada M, Hedenstierna G. Lymphatic drainage between thorax and abdomen: please take good care of this well-performing machinery…. Acta Clin Belg 2014; 62 Suppl 1:152-61. [PMID: 24881713 DOI: 10.1179/acb.2007.62.s1.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Patients with sepsis often receive large amounts of fluids and the presence of capillary leak, trauma or bleeding results in ongoing fluid resuscitation. This increases interstitial and intestinal edema and finally leads to intra-abdominal hypertension (IAH), which in turn impedes lymphatic drainage. Patients with IAH often develop secondary respiratory failure needing mechanical ventilation with high intrathoracic pressure or PEEP that might further alter lymphatic drainage. This review will try to convince the reader of the importance of the lymphatics in septic patients with IAH. METHODS A Medline and PubMed literature search was performed using the terms "abdominal pressure", "lymphatic drainage" and "ascites formation". The references from these studies were searched for relevant articles that may have been missed in the primary search. These articles served as the basis for the recommendations below. RESULTS Induction of sepsis with lesion of the capillary alveolar barrier results in an increased water gradient between the capillaries and the interstitium in the lungs. The drainage flow to the thoracic duct is initially increased in order to protect the lung and maintain the pulmonary interstitium as dry as possible, however this results in increased intrathoracic pressure. Sepsis also increases the permeability of the capillaries in the splanchnic beds. In analogy to the lungs the lymphatic flow in the splanchnic areas increases together with the pressure inside as a physiological response in order to limit the increase in IAP. At a critical IAP level (around 20 cmH2O) the lymph flow starts to decrease and the splanchnic water content progressively increases. The lymph flow from the abdomen to the thorax is progressively decreased resulting in increased splanchnic water content and ascites formation. The presence of mechanical ventilation with high PEEP reduces the lymph drainage further which together with the increase in IAP decreases the lymphatic pressure gradient in the splanchnic regions, with a further increase in water content and IAP triggering a vicious cycle. CONCLUSION Although often overlooked the role of lymphatic flow is complex but very important to determine not only the fluid balance in the lung but also in the peripheral organs. Different pathologies and treatments can markedly influence the pathophysiology of the lymphatics with dramatic effects on endorgan function.
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Pelosi P, Quintel M, Malbrain MLNG. Effect of intra-abdominal pressure on respiratory mechanics. Acta Clin Belg 2014; 62 Suppl 1:78-88. [PMID: 24881704 DOI: 10.1179/acb.2007.62.s1.011] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION There has been an exponentially increasing interest in intra-abdominal hypertension (IAH). The intra-abdominal pressure (IAP) markedly affects the function of the respiratory system. METHODS This review will focus on the available literature from the past few years. A Medline and Pubmed search was performed in order to find an answer to the question "What is the impact of increased IAP on respiratory function in the critically ill?". RESULTS In particular, increased IAP increases chest wall elastance (or decreases compliance) and promotes cranial shift of the diaphragm, with consequent reduction in lung volume and atelectasis formation. Compression of the lung parenchyma also triggers pulmonary infection. During general anaesthesia, in normal subjects, IAP does not affect the chest wall mechanics, but plays a relevant role in the caudal-cranial displacement of the abdominal content, the diaphragm and consequent changes in lung mechanics and function. In obese patients, the increased IAP is the major determinant of the reduction in lung volume, atelectasis formation and alterations in chest wall mechanics. In ARDS patients the measurement of IAP and chest wall mechanics is important for a better interpretation of respiratory mechanics, hemodynamics and appropriate setting of the ventilator. Furthermore, increased IAP promotes lung oedema, ventilator induced lung injury and reduced lymphatic flow in normal and diseased lungs. CONCLUSION Increased IAP markedly affects respiratory function in such a way that it has an impact on daily clinical practise.
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De Laet I, Malbrain MLNG. ICU management of the patient with intra-abdominal hypertension: what to do, when and to whom? Acta Clin Belg 2014; 62 Suppl 1:190-9. [PMID: 24881718 DOI: 10.1179/acb.2007.62.s1.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are increasingly recognised to be a contributing cause of organ dysfunction and mortality in critically ill patients. The number of publications describing and researching this phenomenon is increasing exponentially but there are still very limited data about treatment and outcome. METHODS This review will focus on the available literature from the last years. A Medline and PubMed search was performed using the search terms "abdominal compartment syndrome" and "treatment". RESULTS This search yielded 437 references, most of which were not relevant to the subject of this paper. The remaining abstracts were screened and selected on the basis of relevance, methodology and number of cases. Full text articles of the selected abstracts were used to supplement the authors' expert opinion and experience. The abdomino-thoracic transmission of pressure has direct clinical consequences on the cardiovascular, respiratory and central nervous systems in terms of monitoring and management. These interactions are discussed and treatment recommendations are made. IAH-induced renal dysfunction is addressed as a separate issue. Finally, an overview of non-invasive measures to decrease IAP is given. CONCLUSION This paper describes current insights on management of IAP induced organ dysfunction and lists the most widely used and published non-invasive techniques to decrease IAP with their limitations and pitfalls.
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Severgnini P, Inzigneri G, Olvera C, Fugazzola C, Mangini M, Padalino P, Pelosi P. New and old tools for abdominal imaging in critically ill patients. Acta Clin Belg 2014; 62 Suppl 1:173-82. [PMID: 24881716 DOI: 10.1179/acb.2007.62.s1.023] [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: 01/17/2023]
Abstract
Diagnostic imaging technology has advanced considerably during the past two decades. Different imaging techniques have been proposed for abdominal imaging in critically ill patients like plain radiography, sonography, computed tomography (CT), magnetic resonance and positron emission tomography. Sonography has been proven to be effective to detect free intra-peritoneal fluid and it is considered one of the primary diagnostic modalities for abdominal evaluation for trauma assessment. In our opinion sonography should replace other invasive techniques to rapidly triage blunt trauma patients with unstable vital signs and examine the peritoneal cavity as a site of major haemorrhage to expedite exploratory laparotomy. On the other hand, CT has become the imaging modality of choice in hemodynamically stable patients with multisystem blunt and penetrating trauma. New developments in the quantitative analysis of the CT images will improve our knowledge of pathophysiology, diagnostic and therapeutic management of abdominal pathologies in critically ill patients.
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Abstract
INTRODUCTION Since the second World Congress on the Abdominal Compartment Syndrome (WCACS) in Noosa 2 years ago, interest and publications on intra-abdominal hypertension (IAH) and ACS have increased exponentially. This paper aimed to critically review recent publications and put this new data into the context of already acquired knowledge concerning IAH/ACS. METHODS A Medline and PubMed search was performed from January 2005 up to now using "intra-abdominal pressure (IAP)", "intra-abdominal hypertension (IAH)", "abdominal compartment syndrome (ACS)" and "decompressive laparotomy" as search items. RESULTS Although consensus definitions of IAH/ACS have been formulated recently, data on awareness are still disconcerting. Several groups refined current IAP measurement techniques and tested new direct IAP measurement devices for use in selected subpopulations. A series of recent publications identified specific patient subpopulations in IAH/ACS, like patients with burns or severe acute pancreatitis, with their specific pathophysiology and therapy. Although many studies already assessed the effect of elevated IAP on regional and micro-circulatory organ perfusion, a number of new publications attempted to unravel the link between elevated IAP and more "downstream" organ function or histology. Finally, therapy for IAH/ACS still reveals more questions than it answers. Global resuscitation does not necessarily equate with organ resuscitation. In fact, fluid-resuscitation may even induce IAH/ACS. CONCLUSIONS After publication of consensus guidelines on IAH/ACS, there is an urgent need for human intervention studies and, in parallel, clinically relevant animal models. Given moderately low incidence of ACS and the complex and interrelated pathologies of the critically ill patient with IAH/ACS, large animal models of pathology-induced IAH/ACS might create the opportunity to gain clinically relevant knowledge on the treatment of IAH/ACS.
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Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, Pelosi P, Talmor D, Grasso S, Chiumello D, Guérin C, Patroniti N, Ranieri VM, Gattinoni L, Nava S, Terragni PP, Pesenti A, Tobin M, Mancebo J, Brochard L. The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 2014; 189:520-31. [PMID: 24467647 DOI: 10.1164/rccm.201312-2193ci] [Citation(s) in RCA: 333] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This report summarizes current physiological and technical knowledge on esophageal pressure (Pes) measurements in patients receiving mechanical ventilation. The respiratory changes in Pes are representative of changes in pleural pressure. The difference between airway pressure (Paw) and Pes is a valid estimate of transpulmonary pressure. Pes helps determine what fraction of Paw is applied to overcome lung and chest wall elastance. Pes is usually measured via a catheter with an air-filled thin-walled latex balloon inserted nasally or orally. To validate Pes measurement, a dynamic occlusion test measures the ratio of change in Pes to change in Paw during inspiratory efforts against a closed airway. A ratio close to unity indicates that the system provides a valid measurement. Provided transpulmonary pressure is the lung-distending pressure, and that chest wall elastance may vary among individuals, a physiologically based ventilator strategy should take the transpulmonary pressure into account. For monitoring purposes, clinicians rely mostly on Paw and flow waveforms. However, these measurements may mask profound patient-ventilator asynchrony and do not allow respiratory muscle effort assessment. Pes also permits the measurement of transmural vascular pressures during both passive and active breathing. Pes measurements have enhanced our understanding of the pathophysiology of acute lung injury, patient-ventilator interaction, and weaning failure. The use of Pes for positive end-expiratory pressure titration may help improve oxygenation and compliance. Pes measurements make it feasible to individualize the level of muscle effort during mechanical ventilation and weaning. The time is now right to apply the knowledge obtained with Pes to improve the management of critically ill and ventilator-dependent patients.
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Affiliation(s)
- Evangelia Akoumianaki
- 1 Department of Intensive Care Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
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Struck MF, Reske AW, Schmidt T, Hilbert P, Steen M, Wrigge H. Respiratory functions of burn patients undergoing decompressive laparotomy due to secondary abdominal compartment syndrome. Burns 2013; 40:120-6. [PMID: 23790395 DOI: 10.1016/j.burns.2013.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 04/23/2013] [Accepted: 05/21/2013] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The development of secondary abdominal compartment syndrome (ACS) is associated with multiple organ dysfunction. There is little information about the effects of decompressive laparotomy (DL) on respiratory function (RF) in burn patients developing ACS. PATIENTS AND METHODS We retrospectively obtained data characterising RF from the database of an adult burn intensive care unit (BICU). Peak inspiratory pressure (Pip), PaO2/FiO2-ratio (P/F), static compliance (Cstat) and airway resistance (Raw) were analysed over the course of 60 h at 8 time points relative to DL. RESULTS Thirty-five patients with ACS underwent DL with a mean percentage of total burned body surface area (TBSA) 39 ± 23% and mean intra-abdominal pressure 33 ± 7 mmHg. All patients presented with significantly deteriorating RF within 12h of DL (Pip 33 ± 4 to 39 ± 7 cm/H2O, p=0.003; P/F 232 ± 59 to 160 ± 55 mmHg, p<0.001, Cstat 34 ± 5 to 26 ± 6 mL/cmH2O, p<0.001; Raw 18 ± 3 to 24 ± 9 cm H2O/L/s, p=0.02). All these parameters improved significantly (p<0.001) after DL, regardless of the presence of inhalation injury or torso burns. Mortality was 71.4%. CONCLUSIONS Variables characterising RF demonstrated a rapid deterioration before and a significant and sustained improvement after DL in burn patients developing ACS. Despite these respiratory improvements, DL was associated with low survival rates. Secondary ACS remains a challenge in burn patients and thus warrants particular attention during intensive care treatment.
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Affiliation(s)
- Manuel F Struck
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Leipzig, Germany; Department of Plastic and Hand Surgery, Burn Trauma Centre, Bergmannstrost Hospital, Halle/Saale, Germany.
| | - Andreas W Reske
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Leipzig, Germany
| | - Thomas Schmidt
- Department of Medical Psychology, Bergmannstrost Hospital, Halle/Saale, Germany
| | - Peter Hilbert
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Bergmannstrost Hospital, Halle/Saale, Germany
| | - Michael Steen
- Department of Plastic and Hand Surgery, Burn Trauma Centre, Bergmannstrost Hospital, Halle/Saale, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Leipzig, Germany
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Malbrain ML, De laet IE, De Waele JJ, Kirkpatrick AW. Intra-abdominal hypertension: Definitions, monitoring, interpretation and management. Best Pract Res Clin Anaesthesiol 2013; 27:249-70. [DOI: 10.1016/j.bpa.2013.06.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 06/28/2013] [Indexed: 02/01/2023]
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Gaidukov KM, Raibuzhis EN, Hussain A, Teterin AY, Smetkin AA, Kuzkov VV, Malbrain MLNG, Kirov MY. Effect of intra-abdominal pressure on respiratory function in patients undergoing ventral hernia repair. World J Crit Care Med 2013; 2:9-16. [PMID: 24701411 PMCID: PMC3953861 DOI: 10.5492/wjccm.v2.i2.9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 03/20/2013] [Accepted: 04/27/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the influence of intra-abdominal pressure (IAP) on respiratory function after surgical repair of ventral hernia and to compare two different methods of IAP measurement during the perioperative period. METHODS Thirty adult patients after elective repair of ventral hernia were enrolled into this prospective study. IAP monitoring was performed via both a balloon-tipped nasogastric probe [intragastric pressure (IGP), CiMON, Pulsion Medical Systems, Munich, Germany] and a urinary catheter [intrabladder pressure (IBP), UnoMeterAbdo-Pressure Kit, UnoMedical, Denmark] on five consecutive stages: (1) after tracheal intubation (AI); (2) after ventral hernia repair; (3) at the end of surgery; (4) during spontaneous breathing trial through the endotracheal tube; and (5) at 1 h after tracheal extubation. The patients were in the complete supine position during all study stages. RESULTS The IAP (measured via both techniques) increased on average by 12% during surgery compared to AI (P < 0.02) and by 43% during spontaneous breathing through the endotracheal tube (P < 0.01). In parallel, the gradient between РаСО2 and EtCO2 [Р(а-et)CO2] rose significantly, reaching a maximum during the spontaneous breathing trial. The PаO2/FiO2 decreased by 30% one hour after tracheal extubation (P = 0.02). The dynamic compliance of respiratory system reduced intraoperatively by 15%-20% (P < 0.025). At all stages, we observed a significant correlation between IGP and IBP (r = 0.65-0.81, P < 0.01) with a mean bias varying from -0.19 mmHg (2SD 7.25 mmHg) to -1.06 mm Hg (2SD 8.04 mmHg) depending on the study stage. Taking all paired measurements together (n = 133), the median IGP was 8.0 (5.5-11.0) mmHg and the median IBP was 8.8 (5.8-13.1) mmHg. The overall r (2) value (n = 30) was 0.76 (P < 0.0001). Bland and Altman analysis showed an overall bias for the mean values per patient of 0.6 mmHg (2SD 4.2 mmHg) with percentage error of 45.6%. Looking at changes in IAP between the different study stages, we found an excellent concordance coefficient of 94.9% comparing ΔIBP and ΔIGP (n = 117). CONCLUSION During ventral hernia repair, the IAP rise is accompanied by changes in Р(а-et)CO2 and PаO2/FiO2-ratio. Estimation of IAP via IGP or IBP demonstrated excellent concordance.
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Pelosi P, Vargas M. Mechanical ventilation and intra-abdominal hypertension: 'Beyond Good and Evil'. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:187. [PMID: 23256904 PMCID: PMC3672607 DOI: 10.1186/cc11874] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Intra-abdominal hypertension is frequent in surgical and medical critically ill patients. Intra-abdominal hypertension has a serious impact on the function of respiratory as well as peripheral organs. In the presence of alveolar capillary damage, which occurs in acute respiratory distress syndrome (ARDS), intra-abdominal hypertension promotes lung injury as well as edema, impedes the pulmonary lymphatic drainage, and increases intra-thoracic pressures, leading to atelectasis, airway closure, and deterioration of respiratory mechanics and gas exchange. The optimal setting of mechanical ventilation and its impact on respiratory function and hemodynamics in ARDS associated with intra-abdominal hypertension are far from being assessed. We suggest that the optimal ventilator management of patients with ARDS and intra-abdominal hypertension would include the following: (a) intra-abdominal, esophageal pressure, and hemodynamic monitoring; (b) ventilation setting with protective tidal volume, recruitment maneuver, and level of positive end-expiratory pressure set according to the 'best' compliance of the respiratory system or the lung; (c) deep sedation with or without neuromuscular paralysis in severe ARDS; and (d) open abdomen in selected patients with severe abdominal compartment syndrome.
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Raymondos K, Molitoris U, Capewell M, Sander B, Dieck T, Ahrens J, Weilbach C, Knitsch W, Corrado A. Negative- versus positive-pressure ventilation in intubated patients with acute respiratory distress syndrome. Crit Care 2012; 16:R37. [PMID: 22386062 PMCID: PMC3681349 DOI: 10.1186/cc11216] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 12/27/2011] [Accepted: 03/02/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction Recent experimental data suggest that continuous external negative-pressure ventilation (CENPV) results in better oxygenation and less lung injury than continuous positive-pressure ventilation (CPPV). The effects of CENPV on patients with acute respiratory distress syndrome (ARDS) remain unknown. Methods We compared 2 h CENPV in a tankrespirator ("iron lung") with 2 h CPPV. The six intubated patients developed ARDS after pulmonary thrombectomy (n = 1), aspiration (n = 3), sepsis (n = 1) or both (n = 1). We used a tidal volume of 6 ml/kg predicted body weight and matched lung volumes at end expiration. Haemodynamics were assessed using the pulse contour cardiac output (PiCCO) system, and pressure measurements were referenced to atmospheric pressure. Results CENPV resulted in better oxygenation compared to CPPV (median ratio of arterial oxygen pressure to fraction of inspired oxygen of 345 mmHg (minimum-maximum 183 to 438 mmHg) vs 256 mmHg (minimum-maximum 123 to 419 mmHg) (P < 0.05). Tank pressures were -32.5 cmH2O (minimum-maximum -30 to -43) at end inspiration and -15 cmH2O (minimum-maximum -15 to -19 cmH2O) at end expiration. NO Inspiratory transpulmonary pressures decreased (P = 0.04) and airway pressures were considerably lower at inspiration (-1.5 cmH2O (minimum-maximum -3 to 0 cmH2O) vs 34.5 cmH2O (minimum-maximum 30 to 47 cmH2O), P = 0.03) and expiration (4.5 cmH2O (minimum-maximum 2 to 5) vs 16 cmH2O (minimum-maximum 16 to 23), P =0.03). During CENPV, intraabdominal pressures decreased from 20.5 mmHg (12 to 30 mmHg) to 1 mmHg (minimum-maximum -7 to 5 mmHg) (P = 0.03). Arterial pressures decreased by approximately 10 mmHg and central venous pressures by 18 mmHg. Intrathoracic blood volume indices and cardiac indices increased at the initiation of CENPV by 15% and 20% (P < 0.05), respectively. Heart rate and extravascular lung water indices remained unchanged. Conclusions CENPV with a tank respirator improved gas exchange in patients with ARDS at lower transpulmonary, airway and intraabdominal pressures and, at least initially improving haemodynamics. Our observations encourage the consideration of further studies on the physiological effects and the clinical effectiveness of CENPV in patients with ARDS.
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Affiliation(s)
- Konstantinos Raymondos
- Anaesthesiology and Intensive Care Medicine, Medical School Hanover, Carl-Neuberg-Strasse 1, D-30625 Hanover, Germany.
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Regli A, Mahendran R, Fysh ET, Roberts B, Noffsinger B, De Keulenaer BL, Singh B, van Heerden PV. Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension. Crit Care 2012; 16:R208. [PMID: 23098278 PMCID: PMC3682312 DOI: 10.1186/cc11840] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/05/2012] [Accepted: 10/18/2012] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Intra-abdominal hypertension (IAH) causes atelectasis, reduces lung volumes and increases respiratory system elastance. Positive end-expiratory pressure (PEEP) in the setting of IAH and healthy lungs improves lung volumes but not oxygenation. However, critically ill patients with IAH often suffer from acute lung injury (ALI). This study, therefore, examined the respiratory and cardiac effects of positive end-expiratory pressure in an animal model of IAH, with sick lungs. METHODS Nine pigs were anesthetized and ventilated (48 +/- 6 kg). Lung injury was induced with oleic acid. Three levels of intra-abdominal pressure (baseline, 18, and 22 mmHg) were randomly generated. At each level of intra-abdominal pressure, three levels of PEEP were randomly applied: baseline (5 cmH2O), moderate (0.5 × intra-abdominal pressure), and high (1.0 × intra-abdominal pressure). We measured end-expiratory lung volumes, arterial oxygen levels, respiratory mechanics, and cardiac output 10 minutes after each new IAP and PEEP setting. RESULTS At baseline PEEP, IAH (22 mmHg) decreased oxygen levels (-55%, P <0.001) and end-expiratory lung volumes (-45%, P = 0.007). At IAP of 22 mmHg, moderate and high PEEP increased oxygen levels (+60%, P = 0.04 and +162%, P <0.001) and end-expiratory lung volume (+44%, P = 0.02 and +279%, P <0.001) and high PEEP reduced cardiac output (-30%, P = 0.04). Shunt and dead-space fraction inversely correlated with oxygen levels and end-expiratory lung volumes. In the presence of IAH, lung, chest wall and respiratory system elastance increased. Subsequently, PEEP decreased respiratory system elastance by decreasing chest wall elastance. CONCLUSIONS In a porcine sick lung model of IAH, PEEP matched to intra-abdominal pressure led to increased lung volumes and oxygenation and decreased chest wall elastance shunt and dead-space fraction. High PEEP decreased cardiac output. The study shows that lung injury influences the effects of IAH and PEEP on oxygenation and respiratory mechanics. Our findings support the application of PEEP in the setting of acute lung injury and IAH.
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Affiliation(s)
- Adrian Regli
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle 6160, Australia
- School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, 6009 Crawley, Australia
- Medical School, The University of Notre Dame Australia, 19 Mouat Street, 6959 Fremantle, Australia
| | - Rohan Mahendran
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle 6160, Australia
| | - Edward T Fysh
- School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, 6009 Crawley, Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Brigit Roberts
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Bill Noffsinger
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Bart L De Keulenaer
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle 6160, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Peter V van Heerden
- School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, 6009 Crawley, Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
- Medical Intensive Care Unit, Hadassah University Hospital, Ein Kerem, 91120 Jerusalem, Israel
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Abdominal compartment syndrome: a decade of progress. J Am Coll Surg 2012; 216:135-46. [PMID: 23062520 DOI: 10.1016/j.jamcollsurg.2012.09.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 08/26/2012] [Accepted: 09/10/2012] [Indexed: 12/22/2022]
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Malbrain MLNG, De Laet IE. Intra-abdominal hypertension: evolving concepts. Crit Care Nurs Clin North Am 2012; 24:275-309. [PMID: 22548864 DOI: 10.1016/j.ccell.2012.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Manu L N G Malbrain
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, Campus Stuivenberg, Antwerpen, Belgium.
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Matching positive end-expiratory pressure to intra-abdominal pressure prevents end-expiratory lung volume decline in a pig model of intra-abdominal hypertension. Crit Care Med 2012; 40:1879-86. [PMID: 22488004 DOI: 10.1097/ccm.0b013e31824e0e80] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Intra-abdominal hypertension is common in critically ill patients and is associated with increased morbidity and mortality. In a previous experimental study, positive end-expiratory pressures of up to 15 cm H2O did not prevent end-expiratory lung volume decline caused by intra-abdominal hypertension. Therefore, we examined the effect of matching positive end-expiratory pressure to the intra-abdominal pressure on cardio-respiratory parameters. DESIGN Experimental pig model of intra-abdominal hypertension. SETTING Large animal facility, University of Western Australia. SUBJECTS Nine anesthetized, nonparalyzed, and ventilated pigs (48 ± 7 kg). INTERVENTIONS Four levels of intra-abdominal pressure (baseline, 12, 18, and 22 mm Hg) were generated in a randomized order by inflating an intra-abdominal balloon. At each level of intra-abdominal pressure, three levels of positive end-expiratory pressure were randomly applied with varying degrees of matching the corresponding intra-abdominal pressure: baseline positive end-expiratory pressure (= 5 cm H2O), moderate positive end-expiratory pressure (= half intra-abdominal pressure in cm H2O + 5 cm H2O), and high positive end-expiratory pressure (= intra-abdominal pressure in cm H2O). MEASUREMENTS We measured end-expiratory lung volume, arterial oxygen levels, respiratory mechanics, and cardiac output 5 mins after each new intra-abdominal pressure and positive end-expiratory pressure setting. MAIN RESULTS Intra-abdominal hypertension decreased end-expiratory lung volume and PaO2 (-49% [p < .001] and -8% [p < .05], respectively, at 22 mm Hg intra-abdominal pressure compared with baseline intra-abdominal pressure) but did not change cardiac output (p = .5). At each level of intra-abdominal pressure, moderate positive end-expiratory pressure increased end-expiratory lung volume (+119% [p < .001] at 22 mm Hg intra-abdominal pressure compared with 5 cm H2O positive end-expiratory pressure) while minimally decreasing cardiac output (-8%, p < .05). High positive end-expiratory pressure further increased end-expiratory lung volume (+233% [p < .001] at 22 mm Hg intra-abdominal pressure compared with 5 cm H2O positive end-expiratory pressure) but led to a greater decrease in cardiac output (-26%, p < .05). Neither moderate nor high positive end-expiratory pressure improved PaO2 (p = .7). Intra-abdominal hypertension decreased end-expiratory transpulmonary pressure but did not alter end-inspiratory transpulmonary pressure. Intra-abdominal hypertension decreased total respiratory compliance through a decrease in chest wall compliance. Positive end-expiratory pressure decreased the respiratory compliance by reducing lung compliance. CONCLUSIONS In a pig model of intra-abdominal hypertension, positive end-expiratory pressure matched to intra-abdominal pressure led to a preservation of end-expiratory lung volume, but did not improve arterial oxygen tension and caused a reduction in cardiac output. Therefore, we do not recommend routine application of positive end-expiratory pressure matched to intra-abdominal pressure to prevent intra-abdominal pressure-induced end-expiratory lung volume decline in healthy lungs.
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Physiological effects of an open lung ventilatory strategy titrated on elastance-derived end-inspiratory transpulmonary pressure. Crit Care Med 2012; 40:2124-31. [DOI: 10.1097/ccm.0b013e31824e1b65] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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