1
|
Le Marec J, Hajage D, Decavèle M, Schmidt M, Laurent I, Ricard JD, Jaber S, Azoulay E, Fartoukh M, Hraiech S, Mercat A, Similowski T, Demoule A. High Airway Occlusion Pressure Is Associated with Dyspnea and Increased Mortality in Critically Ill Mechanically Ventilated Patients. Am J Respir Crit Care Med 2024; 210:201-210. [PMID: 38319128 DOI: 10.1164/rccm.202308-1358oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/05/2024] [Indexed: 02/07/2024] Open
Abstract
Rationale: Airway occlusion pressure at 100 ms (P0.1) reflects central respiratory drive. Objectives: We aimed to assess factors associated with P0.1 and whether an abnormally low or high P0.1 value is associated with higher mortality and longer duration of mechanical ventilation (MV). Methods: We performed a secondary analysis of a prospective cohort study conducted in 10 ICUs in France to evaluate dyspnea in communicative MV patients. In patients intubated for more than 24 hours, P0.1 was measured with dyspnea as soon as patients could communicate and the next day. Measurements and Main Results: Among 260 patients assessed after a median time of ventilation of 4 days, P0.1 was 1.9 (1-3.5) cm H2O at enrollment, 24% had P0.1 values >3.5 cm H2O, 37% had P0.1 values between 1.5 and 3.5 cm H2O, and 39% had P0.1 values <1.5 cm H2O. In multivariable linear regression, independent factors associated with P0.1 were the presence of dyspnea (P = 0.037), respiratory rate (P < 0.001), and PaO2 (P = 0.008). Ninety-day mortality was 33% in patients with P0.1 > 3.5 cm H2O versus 19% in those with P0.1 between 1.5 and 3.5 cm H2O and 17% in those with P0.1 < 1.5 cm H2O (P = 0.046). After adjustment for the main risk factors, P0.1 was associated with 90-day mortality (hazard ratio per 1 cm H2O, 1.19 [95% confidence interval, 1.04-1.37]; P = 0.011). P0.1 was also independently associated with a longer duration of MV (hazard ratio per 1 cm H2O, 1.10 [95% confidence interval, 1.02-1.19]; P = 0.016). Conclusions: In patients receiving invasive MV, abnormally high P0.1 values may suggest dyspnea and are associated with higher mortality and prolonged duration of MV.
Collapse
Affiliation(s)
- Julien Le Marec
- Assistance Publique-Hôpitaux de Paris, 26930, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, Paris, France
| | - Maxens Decavèle
- Assistance Publique-Hôpitaux de Paris, 26930, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Sorbonne Université, GRC 30, Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aiguë, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aiguë, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, Research Unit on Cardiovascular Diseases, Metabolism and Nutrition, ICAN, Paris, France
| | - Isaura Laurent
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, Paris, France
| | - Jean-Damien Ricard
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
- Université Paris Cité, UMR1137 IAME, INSERM, Paris, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Elie Azoulay
- Service de Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Université de Paris, Paris, France
| | - Muriel Fartoukh
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Service de Médecine Intensive Réanimation, Hôpital Tenon, Paris, France
- Sorbonne Université, UFR Médecine, Paris, France
- Groupe de Recherche Clinique CARMAS, Université Paris Est Créteil, Créteil, France
| | - Sami Hraiech
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, Marseille, France
- Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Marseille, France
| | - Alain Mercat
- Service de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France; and
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Alexandre Demoule
- Assistance Publique-Hôpitaux de Paris, 26930, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Sorbonne Université, GRC 30, Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aiguë, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
| |
Collapse
|
2
|
Marongiu I, Slobod D, Leali M, Spinelli E, Mauri T. Clinical and Experimental Evidence for Patient Self-Inflicted Lung Injury (P-SILI) and Bedside Monitoring. J Clin Med 2024; 13:4018. [PMID: 39064059 PMCID: PMC11278124 DOI: 10.3390/jcm13144018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/01/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Patient self-inflicted lung injury (P-SILI) is a major challenge for the ICU physician: although spontaneous breathing is associated with physiological benefits, in patients with acute respiratory distress syndrome (ARDS), the risk of uncontrolled inspiratory effort leading to additional injury needs to be assessed to avoid delayed intubation and increased mortality. In the present review, we analyze the available clinical and experimental evidence supporting the existence of lung injury caused by uncontrolled high inspiratory effort, we discuss the pathophysiological mechanisms by which increased effort causes P-SILI, and, finally, we consider the measurements and interpretation of bedside physiological measures of increased drive that should alert the clinician. The data presented in this review could help to recognize injurious respiratory patterns that may trigger P-SILI and to prevent it.
Collapse
Affiliation(s)
- Ines Marongiu
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, QC H4A 3J1, Canada
| | - Marco Leali
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| |
Collapse
|
3
|
Torsani V, Cardoso PFG, Borges JB, Gomes S, Moriya HT, Cruz AFD, Santiago RRDS, Nagao CK, Fitipaldi MF, Beraldo MDA, Junior MHV, Mlček M, Pego-Fernandes PM, Amato MBP. First real-time imaging of bronchoscopic lung volume reduction by electrical impedance tomography. Respir Res 2024; 25:264. [PMID: 38965590 PMCID: PMC11225379 DOI: 10.1186/s12931-024-02877-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/11/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Bronchoscopic lung volume reduction (BLVR) with one-way endobronchial valves (EBV) has better outcomes when the target lobe has poor collateral ventilation, resulting in complete lobe atelectasis. High-inspired oxygen fraction (FIO2) promotes atelectasis through faster gas absorption after airway occlusion, but its application during BLVR with EBV has been poorly understood. We aimed to investigate the real-time effects of FIO2 on regional lung volumes and regional ventilation/perfusion by electrical impedance tomography (EIT) during BLVR with EBV. METHODS Six piglets were submitted to left lower lobe occlusion by a balloon-catheter and EBV valves with FIO2 0.5 and 1.0. Regional end-expiratory lung impedances (EELI) and regional ventilation/perfusion were monitored. Local pocket pressure measurements were obtained (balloon occlusion method). One animal underwent simultaneous acquisitions of computed tomography (CT) and EIT. Regions-of-interest (ROIs) were right and left hemithoraces. RESULTS Following balloon occlusion, a steep decrease in left ROI-EELI with FIO2 1.0 occurred, 3-fold greater than with 0.5 (p < 0.001). Higher FIO2 also enhanced the final volume reduction (ROI-EELI) achieved by each valve (p < 0.01). CT analysis confirmed the denser atelectasis and greater volume reduction achieved by higher FIO2 (1.0) during balloon occlusion or during valve placement. CT and pocket pressure data agreed well with EIT findings, indicating greater strain redistribution with higher FIO2. CONCLUSIONS EIT demonstrated in real-time a faster and more complete volume reduction in the occluded lung regions under high FIO2 (1.0), as compared to 0.5. Immediate changes in the ventilation and perfusion of ipsilateral non-target lung regions were also detected, providing better estimates of the full impact of each valve in place. TRIAL REGISTRATION Not applicable.
Collapse
Affiliation(s)
- Vinicius Torsani
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Paulo Francisco Guerreiro Cardoso
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - João Batista Borges
- Institute of Physiology, First Faculty of Medicine, Charles University, Albertov 5, Prague, 128 00, Czech Republic.
| | - Susimeire Gomes
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Henrique Takachi Moriya
- Biomedical Engineering Laboratory, Escola Politecnica da Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Andrea Fonseca da Cruz
- Biomedical Engineering Laboratory, Escola Politecnica da Universidade de Sao Paulo, Sao Paulo, Brasil
| | | | - Cristopher Kengo Nagao
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Mariana Fernandes Fitipaldi
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Marcelo do Amaral Beraldo
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Marcus Henrique Victor Junior
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Mikuláš Mlček
- Institute of Physiology, First Faculty of Medicine, Charles University, Albertov 5, Prague, 128 00, Czech Republic
| | - Paulo Manuel Pego-Fernandes
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Marcelo Britto Passos Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| |
Collapse
|
4
|
Arriagada R, Bachmann MC, San Martin C, Rauseo M, Battaglini D. Electrical impedance tomography: Usefulness for respiratory physiotherapy in critical illnesses. Med Intensiva 2024; 48:403-410. [PMID: 38538496 DOI: 10.1016/j.medine.2024.03.006] [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: 02/03/2024] [Accepted: 02/26/2024] [Indexed: 07/05/2024]
Abstract
Respiratory physiotherapy, including the management of invasive mechanical ventilation (MV) and noninvasive mechanical ventilation (NIV), is a key supportive intervention for critically ill patients. MV has potential for inducing ventilator-induced lung injury (VILI) as well as long-term complications related to prolonged bed rest, such as post-intensive care syndrome and intensive care unit acquired weakness. Physical and respiratory therapy, developed by the critical care team, in a timely manner, has been shown to prevent these complications. In this pathway, real-time bedside monitoring of changes in pulmonary aeration and alveolar gas distribution associated with postural positioning, respiratory physiotherapy techniques and changes in MV strategies can be crucial in guiding these procedures, providing safe therapy and prevention of potential harm to the patient. Along this path, electrical impedance tomography (EIT) has emerged as a new key non-invasive bedside strategy free of radiation, to allow visualization of lung recruitment. This review article presents the main and potential applications of EIT in relation to physiotherapy techniques in the ICU setting.
Collapse
Affiliation(s)
- Ricardo Arriagada
- Unidad de Paciente Crítico Adulto, Hospital Las Higueras de Talcahuano, Chile; Escuela de Kinesiología Universidad San Sebastián, Sede Tres Pascualas, Concepción, Chile; Unidad de Paciente Crìtico, Clìnica Biobìo, Hualpén, Chile
| | - María Consuelo Bachmann
- Unidad de Paciente Crítico Adulto, Hospital Clínico Pontificia Universidad Católica de Chile, Escuela de Kinesiología, Universidad de Los Andes, Santiago, Chile
| | - Constanza San Martin
- Unidad de Paciente Crítico Adulto, Hospital Las Higueras de Talcahuano, Chile; Escuela de Kinesiología Universidad San Sebastián, Sede Tres Pascualas, Concepción, Chile
| | - Michela Rauseo
- Anesthesia and Intensive Care Medicine, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| |
Collapse
|
5
|
Liu W, Chi Y, Zhao Y, He H, Long Y, Zhao Z. Occurrence of pendelluft during ventilator weaning with T piece correlated with increased mortality in difficult-to-wean patients. J Intensive Care 2024; 12:23. [PMID: 38915067 PMCID: PMC11194869 DOI: 10.1186/s40560-024-00737-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/14/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Difficult-to-wean patients, typically identified as those failing the initial spontaneous breathing trial (SBT), face elevated mortality rates. Pendelluft, frequently observed in patients experiencing SBT failure, can be conveniently detected through bedside monitoring with electrical impedance tomography (EIT). This study aimed to explore the impact of pendelluft during SBT on difficult-to-wean patients. METHODS This retrospective observational study included difficult-to-wean patients undergoing spontaneous T piece breathing, during which EIT data were collected. Pendelluft occurrence was defined when its amplitude exceeded 2.5% of global tidal impedance variation. Physiological parameters during SBT were retrospectively retrieved from the EIT Examination Report Form. Other clinical data including mechanical ventilation duration, length of ICU stay, length of hospital stay, and 28-day mortality were retrieved from patient records in the hospital information system for each subject. RESULTS Pendelluft was observed in 72 (70.4%) of the 108 included patients, with 16 (14.8%) experiencing mortality by day 28. The pendelluft group exhibited significantly higher mortality (19.7% vs. 3.1%, p = 0.035), longer median mechanical ventilation duration [9 (5-15) vs. 7 (5-11) days, p = 0.041] and shorter ventilator-free days at day 28 [18 (4-22) vs. 20 (16-23) days, p = 0.043]. The presence of pendellfut was independently associated with increased mortality at day 28 (OR = 10.50, 95% confidence interval 1.21-90.99, p = 0.033). CONCLUSIONS Pendelluft occurred in 70.4% of difficult-to-wean patients undergoing T piece spontaneous breathing. Pendelluft was associated with worse clinical outcomes, including prolonged mechanical ventilation and increased mortality in this population. Our findings underscore the significance of monitoring pendelluft using EIT during SBT for difficult-to-wean patients.
Collapse
Affiliation(s)
- Wanglin Liu
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yi Chi
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yutong Zhao
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
- Department of Critical Care Medicine, The First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Huaiwu He
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Yun Long
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Zhanqi Zhao
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
- School of Biomedical Engineering, Guangzhou Medical University, No. 1 Xinzao Rd. Panyu District, Guangzhou, China.
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany.
| |
Collapse
|
6
|
Costa ELV, Alcala GC, Tucci MR, Goligher E, Morais CC, Dianti J, Nakamura MAP, Oliveira LB, Pereira SM, Toufen C, Barbas CSV, Carvalho CRR, Amato MBP. Impact of extended lung protection during mechanical ventilation on lung recovery in patients with COVID-19 ARDS: a phase II randomized controlled trial. Ann Intensive Care 2024; 14:85. [PMID: 38849605 PMCID: PMC11161454 DOI: 10.1186/s13613-024-01297-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/15/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Protective ventilation seems crucial during early Acute Respiratory Distress Syndrome (ARDS), but the optimal duration of lung protection remains undefined. High driving pressures (ΔP) and excessive patient ventilatory drive may hinder lung recovery, resulting in self-inflicted lung injury. The hidden nature of the ΔP generated by patient effort complicates the situation further. Our study aimed to assess the feasibility of an extended lung protection strategy that includes a stepwise protocol to control the patient ventilatory drive, assessing its impact on lung recovery. METHODS We conducted a single-center randomized study on patients with moderate/severe COVID-19-ARDS with low respiratory system compliance (CRS < 0.6 (mL/Kg)/cmH2O). The intervention group received a ventilation strategy guided by Electrical Impedance Tomography aimed at minimizing ΔP and patient ventilatory drive. The control group received the ARDSNet low-PEEP strategy. The primary outcome was the modified lung injury score (mLIS), a composite measure that integrated daily measurements of CRS, along with oxygen requirements, oxygenation, and X-rays up to day 28. The mLIS score was also hierarchically adjusted for survival and extubation rates. RESULTS The study ended prematurely after three consecutive months without patient enrollment, attributed to the pandemic subsiding. The intention-to-treat analysis included 76 patients, with 37 randomized to the intervention group. The average mLIS score up to 28 days was not different between groups (P = 0.95, primary outcome). However, the intervention group showed a faster improvement in the mLIS (1.4 vs. 7.2 days to reach 63% of maximum improvement; P < 0.001), driven by oxygenation and sustained improvement of X-ray (P = 0.001). The intervention group demonstrated a sustained increase in CRS up to day 28 (P = 0.009) and also experienced a shorter time from randomization to room-air breathing (P = 0.02). Survival at 28 days and time until liberation from the ventilator were not different between groups. CONCLUSIONS The implementation of an individualized PEEP strategy alongside extended lung protection appears viable. Promising secondary outcomes suggested a faster lung recovery, endorsing further examination of this strategy in a larger trial. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT04497454) on August 04, 2020.
Collapse
Affiliation(s)
- Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Glasiele C Alcala
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Mauro R Tucci
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Ewan Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
| | - Caio C Morais
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
| | - Miyuki A P Nakamura
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
| | - Larissa B Oliveira
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Sérgio M Pereira
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Carlos Toufen
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Carmen S V Barbas
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
- Adult ICU Albert Einstein Hospital, São Paulo, Brazil
| | - Carlos R R Carvalho
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, 455 Dr Arnaldo Ave, Room 2144, São Paulo, SP, Brazil.
- Divisao de Pneumologia, Faculdade de Medicina, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, São Paulo, SP, Brasil.
| |
Collapse
|
7
|
Bello G, Giammatteo V, Bisanti A, Delle Cese L, Rosà T, Menga LS, Montini L, Michi T, Spinazzola G, De Pascale G, Pennisi MA, Ribeiro De Santis Santiago R, Berra L, Antonelli M, Grieco DL. High vs Low PEEP in Patients With ARDS Exhibiting Intense Inspiratory Effort During Assisted Ventilation: A Randomized Crossover Trial. Chest 2024; 165:1392-1405. [PMID: 38295949 DOI: 10.1016/j.chest.2024.01.040] [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: 10/01/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) can potentially modulate inspiratory effort (ΔPes), which is the major determinant of self-inflicted lung injury. RESEARCH QUESTION Does high PEEP reduce ΔPes in patients with moderate-to-severe ARDS on assisted ventilation? STUDY DESIGN AND METHODS Sixteen patients with Pao2/Fio2 ≤ 200 mm Hg and ΔPes ≥ 10 cm H2O underwent a randomized sequence of four ventilator settings: PEEP = 5 cm H2O or PEEP = 15 cm H2O + synchronous (pressure support ventilation [PSV]) or asynchronous (pressure-controlled intermittent mandatory ventilation [PC-IMV]) inspiratory assistance. ΔPes and respiratory system, lung, and chest wall mechanics were assessed with esophageal manometry and occlusions. PEEP-induced alveolar recruitment and overinflation, lung dynamic strain, and tidal volume distribution were assessed with electrical impedance tomography. RESULTS ΔPes was not systematically different at high vs low PEEP (pressure support ventilation: median, 20 cm H2O; interquartile range (IQR), 15-24 cm H2O vs median, 15 cm H2O; IQR, 13-23 cm H2O; P = .24; pressure-controlled intermittent mandatory ventilation: median, 20; IQR, 18-23 vs median, 19; IQR, 17-25; P = .67, respectively). Similarly, respiratory system and transpulmonary driving pressures, tidal volume, lung/chest wall mechanics, and pendelluft extent were not different between study phases. High PEEP resulted in lower or higher ΔPes, respiratory system driving pressure, and transpulmonary driving pressure according to whether this increased or decreased respiratory system compliance (r = -0.85, P < .001; r = -0.75, P < .001; r = -0.80, P < .001, respectively). PEEP-induced changes in respiratory system compliance were driven by its lung component and were dependent on the extent of PEEP-induced alveolar overinflation (r = -0.66, P = .006). High PEEP caused variable recruitment and systematic redistribution of tidal volume toward dorsal lung regions, thereby reducing dynamic strain in ventral areas (pressure support ventilation: median, 0.49; IQR, 0.37-0.83 vs median, 0.96; IQR, 0.62-1.56; P = .003; pressure-controlled intermittent mandatory ventilation: median, 0.65; IQR, 0.42-1.31 vs median, 1.14; IQR, 0.79-1.52; P = .002). All results were consistent during synchronous and asynchronous inspiratory assistance. INTERPRETATION The impact of high PEEP on ΔPes and lung stress is interindividually variable according to different effects on the respiratory system and lung compliance resulting from alveolar overinflation. High PEEP may help mitigate the risk of self-inflicted lung injury solely if it increases lung/respiratory system compliance. TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04241874; URL: www. CLINICALTRIALS gov.
Collapse
Affiliation(s)
- Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Alessandra Bisanti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Montini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Giorgia Spinazzola
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Roberta Ribeiro De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy.
| |
Collapse
|
8
|
Baedorf-Kassis E, Murn M, Dzierba AL, Serra AL, Garcia I, Minus E, Padilla C, Sarge T, Goodspeed VM, Matthay MA, Gong MN, Cook D, Loring SH, Talmor D, Beitler JR. Respiratory drive heterogeneity associated with systemic inflammation and vascular permeability in acute respiratory distress syndrome. Crit Care 2024; 28:136. [PMID: 38654391 PMCID: PMC11036740 DOI: 10.1186/s13054-024-04920-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 04/17/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND In acute respiratory distress syndrome (ARDS), respiratory drive often differs among patients with similar clinical characteristics. Readily observable factors like acid-base state, oxygenation, mechanics, and sedation depth do not fully explain drive heterogeneity. This study evaluated the relationship of systemic inflammation and vascular permeability markers with respiratory drive and clinical outcomes in ARDS. METHODS ARDS patients enrolled in the multicenter EPVent-2 trial with requisite data and plasma biomarkers were included. Neuromuscular blockade recipients were excluded. Respiratory drive was measured as PES0.1, the change in esophageal pressure during the first 0.1 s of inspiratory effort. Plasma angiopoietin-2, interleukin-6, and interleukin-8 were measured concomitantly, and 60-day clinical outcomes evaluated. RESULTS 54.8% of 124 included patients had detectable respiratory drive (PES0.1 range of 0-5.1 cm H2O). Angiopoietin-2 and interleukin-8, but not interleukin-6, were associated with respiratory drive independently of acid-base, oxygenation, respiratory mechanics, and sedation depth. Sedation depth was not significantly associated with PES0.1 in an unadjusted model, or after adjusting for mechanics and chemoreceptor input. However, upon adding angiopoietin-2, interleukin-6, or interleukin-8 to models, lighter sedation was significantly associated with higher PES0.1. Risk of death was less with moderate drive (PES0.1 of 0.5-2.9 cm H2O) compared to either lower drive (hazard ratio 1.58, 95% CI 0.82-3.05) or higher drive (2.63, 95% CI 1.21-5.70) (p = 0.049). CONCLUSIONS Among patients with ARDS, systemic inflammatory and vascular permeability markers were independently associated with higher respiratory drive. The heterogeneous response of respiratory drive to varying sedation depth may be explained in part by differences in inflammation and vascular permeability.
Collapse
Affiliation(s)
- Elias Baedorf-Kassis
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Murn
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, 622 West 168th Street, New York, NY, 10032, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Amy L Dzierba
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, 622 West 168th Street, New York, NY, 10032, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY, USA
| | - Alexis L Serra
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, 622 West 168th Street, New York, NY, 10032, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Ivan Garcia
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, 622 West 168th Street, New York, NY, 10032, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Emily Minus
- Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Clarissa Padilla
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, 622 West 168th Street, New York, NY, 10032, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Todd Sarge
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Valerie M Goodspeed
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Michelle N Gong
- Department of Critical Care Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deborah Cook
- St. Joseph's Hospital and McMaster University, Hamilton, ON, Canada
| | - Stephen H Loring
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, 622 West 168th Street, New York, NY, 10032, USA.
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.
| |
Collapse
|
9
|
Georgopoulos D, Bolaki M, Stamatopoulou V, Akoumianaki E. Respiratory drive: a journey from health to disease. J Intensive Care 2024; 12:15. [PMID: 38650047 DOI: 10.1186/s40560-024-00731-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024] Open
Abstract
Respiratory drive is defined as the intensity of respiratory centers output during the breath and is primarily affected by cortical and chemical feedback mechanisms. During the involuntary act of breathing, chemical feedback, primarily mediated through CO2, is the main determinant of respiratory drive. Respiratory drive travels through neural pathways to respiratory muscles, which execute the breathing process and generate inspiratory flow (inspiratory flow-generation pathway). In a healthy state, inspiratory flow-generation pathway is intact, and thus respiratory drive is satisfied by the rate of volume increase, expressed by mean inspiratory flow, which in turn determines tidal volume. In this review, we will explain the pathophysiology of altered respiratory drive by analyzing the respiratory centers response to arterial partial pressure of CO2 (PaCO2) changes. Both high and low respiratory drive have been associated with several adverse effects in critically ill patients. Hence, it is crucial to understand what alters the respiratory drive. Changes in respiratory drive can be explained by simultaneously considering the (1) ventilatory demands, as dictated by respiratory centers activity to CO2 (brain curve); (2) actual ventilatory response to CO2 (ventilation curve); and (3) metabolic hyperbola. During critical illness, multiple mechanisms affect the brain and ventilation curves, as well as metabolic hyperbola, leading to considerable alterations in respiratory drive. In critically ill patients the inspiratory flow-generation pathway is invariably compromised at various levels. Consequently, mean inspiratory flow and tidal volume do not correspond to respiratory drive, and at a given PaCO2, the actual ventilation is less than ventilatory demands, creating a dissociation between brain and ventilation curves. Since the metabolic hyperbola is one of the two variables that determine PaCO2 (the other being the ventilation curve), its upward or downward movements increase or decrease respiratory drive, respectively. Mechanical ventilation indirectly influences respiratory drive by modifying PaCO2 levels through alterations in various parameters of the ventilation curve and metabolic hyperbola. Understanding the diverse factors that modulate respiratory drive at the bedside could enhance clinical assessment and the management of both the patient and the ventilator.
Collapse
Affiliation(s)
| | - Maria Bolaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Vaia Stamatopoulou
- Department of Pulmonary Medicine, University Hospital of Heraklion, Heraklion , Crete, Greece
| | - Evangelia Akoumianaki
- Medical School, University of Crete, Heraklion, Crete, Greece
- Department of Intensive Care Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| |
Collapse
|
10
|
Mosier JM, Tidswell M, Wang HE. Noninvasive respiratory support in the emergency department: Controversies and state-of-the-art recommendations. J Am Coll Emerg Physicians Open 2024; 5:e13118. [PMID: 38464331 PMCID: PMC10920951 DOI: 10.1002/emp2.13118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 03/12/2024] Open
Abstract
Acute respiratory failure is a common reason for emergency department visits and hospital admissions. Diverse underlying physiologic abnormalities lead to unique aspects about the most common causes of acute respiratory failure: acute decompensated heart failure, acute exacerbation of chronic obstructive pulmonary disease, and acute de novo hypoxemic respiratory failure. Noninvasive respiratory support strategies are increasingly used methods to support work of breathing and improve gas exchange abnormalities to improve outcomes relative to conventional oxygen therapy or invasive mechanical ventilation. Noninvasive respiratory support includes noninvasive positive pressure ventilation and nasal high flow, each with unique physiologic mechanisms. This paper will review the physiology of respiratory failure and noninvasive respiratory support modalities and offer data and guideline-driven recommendations in the context of key clinical controversies.
Collapse
Affiliation(s)
- Jarrod M. Mosier
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
| | - Mark Tidswell
- Division of Pulmonary and Critical Care, Department of MedicineUniversity of Massachusetts Chan Medical School – Baystate Medical CenterSpringfieldMassachusettsUSA
| | - Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| |
Collapse
|
11
|
Franchineau G, Jonkman AH, Piquilloud L, Yoshida T, Costa E, Rozé H, Camporota L, Piraino T, Spinelli E, Combes A, Alcala GC, Amato M, Mauri T, Frerichs I, Brochard LJ, Schmidt M. Electrical Impedance Tomography to Monitor Hypoxemic Respiratory Failure. Am J Respir Crit Care Med 2024; 209:670-682. [PMID: 38127779 DOI: 10.1164/rccm.202306-1118ci] [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: 07/01/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023] Open
Abstract
Hypoxemic respiratory failure is one of the leading causes of mortality in intensive care. Frequent assessment of individual physiological characteristics and delivery of personalized mechanical ventilation (MV) settings is a constant challenge for clinicians caring for these patients. Electrical impedance tomography (EIT) is a radiation-free bedside monitoring device that is able to assess regional lung ventilation and changes in aeration. With real-time tomographic functional images of the lungs obtained through a thoracic belt, clinicians can visualize and estimate the distribution of ventilation at different ventilation settings or following procedures such as prone positioning. Several studies have evaluated the performance of EIT to monitor the effects of different MV settings in patients with acute respiratory distress syndrome, allowing more personalized MV. For instance, EIT could help clinicians find the positive end-expiratory pressure that represents a compromise between recruitment and overdistension and assess the effect of prone positioning on ventilation distribution. The clinical impact of the personalization of MV remains to be explored. Despite inherent limitations such as limited spatial resolution, EIT also offers a unique noninvasive bedside assessment of regional ventilation changes in the ICU. This technology offers the possibility of a continuous, operator-free diagnosis and real-time detection of common problems during MV. This review provides an overview of the functioning of EIT, its main indices, and its performance in monitoring patients with acute respiratory failure. Future perspectives for use in intensive care are also addressed.
Collapse
Affiliation(s)
- Guillaume Franchineau
- Service de Medecine Intensive Reanimation, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lise Piquilloud
- Adult Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eduardo Costa
- Pulmonary Division, Cardiopulmonary Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Hadrien Rozé
- Department of Thoraco-Abdominal Anesthesiology and Intensive Care, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
- Réanimation Polyvalente, Centre Hospitalier Côte Basque, Bayonne, France
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Thomas Piraino
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alain Combes
- Sorbonne Université, Groupe de Recherche Clinique 30, Réanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigüe, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive - Réanimation, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Glasiele C Alcala
- Pulmonary Division, Cardiopulmonary Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Marcelo Amato
- Pulmonary Division, Cardiopulmonary Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Centre of Schleswig-Holstein Campus Kiel, Kiel, Germany; and
| | - Laurent J Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Matthieu Schmidt
- Sorbonne Université, Groupe de Recherche Clinique 30, Réanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aigüe, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive - Réanimation, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| |
Collapse
|
12
|
Wu H, Chasteen B. Rapid review of ventilator-induced diaphragm dysfunction. Respir Med 2024; 223:107541. [PMID: 38290603 DOI: 10.1016/j.rmed.2024.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/01/2024]
Abstract
Ventilator-induced diaphragm dysfunction is gaining increased recognition. Evidence of diaphragm weakness can manifest within 12 h to a few days after the initiation of mechanical ventilation. Various noninvasive and invasive methods have been developed to assess diaphragm function. The implementation of diaphragm-protective ventilation strategies is crucial for preventing diaphragm injuries. Furthermore, diaphragm neurostimulation emerges as a promising and novel treatment option. In this rapid review, our objective is to discuss the current understanding of ventilator-induced diaphragm dysfunction, diagnostic approaches, and updates on strategies for prevention and management.
Collapse
Affiliation(s)
- Huimin Wu
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States; Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
| | - Bobby Chasteen
- Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
| |
Collapse
|
13
|
Plens GM, Droghi MT, Alcala GC, Pereira SM, Wawrzeniak IC, Victorino JA, Crivellari C, Grassi A, Rezoagli E, Foti G, Costa ELV, Amato MBP, Bellani G. Expiratory Muscle Activity Counteracts Positive End-Expiratory Pressure and Is Associated with Fentanyl Dose in Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:563-572. [PMID: 38190718 DOI: 10.1164/rccm.202308-1376oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024] Open
Abstract
Rationale: Hypoxemia during mechanical ventilation might be worsened by expiratory muscle activity, which reduces end-expiratory lung volume through lung collapse. A proposed mechanism of benefit of neuromuscular blockade in acute respiratory distress syndrome (ARDS) is the abolition of expiratory efforts. This may contribute to the restoration of lung volumes. The prevalence of this phenomenon, however, is unknown. Objectives: To investigate the incidence and amount of end-expiratory lung impedance (EELI) increase after the administration of neuromuscular blocking agents (NMBAs), clinical factors associated with this phenomenon, its impact on regional lung ventilation, and any association with changes in pleural pressure. Methods: We included mechanically ventilated patients with ARDS monitored with electrical impedance tomography (EIT) who received NMBAs in one of two centers. We measured changes in EELI, a surrogate for end-expiratory lung volume, before and after NMBA administration. In an additional 10 patients, we investigated the characteristic signatures of expiratory muscle activity depicted by EIT and esophageal catheters simultaneously. Clinical factors associated with EELI changes were assessed. Measurements and Main Results: We included 46 patients, half of whom showed an increase in EELI of >10% of the corresponding Vt (46.2%; IQR, 23.9-60.9%). The degree of EELI increase correlated positively with fentanyl dosage and negatively with changes in end-expiratory pleural pressures. This suggests that expiratory muscle activity might exert strong counter-effects against positive end-expiratory pressure that are possibly aggravated by fentanyl. Conclusions: Administration of NMBAs during EIT monitoring revealed activity of expiratory muscles in half of patients with ARDS. The resultant increase in EELI had a dose-response relationship with fentanyl dosage. This suggests a potential side effect of fentanyl during protective ventilation.
Collapse
Affiliation(s)
- Glauco M Plens
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Maddalena T Droghi
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Glasiele C Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Sérgio M Pereira
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Iuri C Wawrzeniak
- Programa de Pós-Graduação em Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Josué A Victorino
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Internal Medicine Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Chiara Crivellari
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alice Grassi
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy; and
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, Azienda Provinciale per i Servizi Sanitari Trento, Trento, Italy
| |
Collapse
|
14
|
Parfait M, Rohrs E, Joussellin V, Mayaux J, Decavèle M, Reynolds S, Similowski T, Demoule A, Dres M. An Initial Investigation of Diaphragm Neurostimulation in Patients with Acute Respiratory Distress Syndrome. Anesthesiology 2024; 140:483-494. [PMID: 38088791 DOI: 10.1097/aln.0000000000004873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Lung protective ventilation aims at limiting lung stress and strain. By reducing the amount of pressure transmitted by the ventilator into the lungs, diaphragm neurostimulation offers a promising approach to minimize ventilator-induced lung injury. This study investigates the physiologic effects of diaphragm neurostimulation in acute respiratory distress syndrome (ARDS) patients. The hypothesis was that diaphragm neurostimulation would improve oxygenation, would limit the distending pressures of the lungs, and would improve cardiac output. METHODS Patients with moderate ARDS were included after 48 h of invasive mechanical ventilation and had a left subclavian catheter placed to deliver bilateral transvenous phrenic nerve stimulation. Two 60-min volume-controlled mechanical ventilation (control) sessions were interspersed by two 60-min diaphragm neurostimulation sessions delivered continually, in synchrony with the ventilator. Gas exchange, lung mechanics, chest electrical impedance tomography, and cardiac index were continuously monitored and compared across four sessions. The primary endpoint was the Pao2/fraction of inspired oxygen (Fio2) ratio at the end of each session, and the secondary endpoints were lung mechanics and hemodynamics. RESULTS Thirteen patients were enrolled but the catheter could not be inserted in one, leaving 12 patients for analysis. All sessions were conducted without interruption and well tolerated. The Pao2/Fio2 ratio did not change during the four sessions. Median (interquartile range) plateau pressure was 23 (20 to 31) cm H2O and 21 (17 to 25) cm H2O, driving pressure was 14 (12 to 18) cm H2O and 11 (10 to 13) cm H2O, and end-inspiratory transpulmonary pressure was 9 (5 to 11) cm H2O and 7 (4 to 11) cm H2O during mechanical ventilation alone and during mechanical ventilation + neurostimulation session, respectively. The dorsal/ventral ventilation surface ratio was 0.70 (0.54 to 0.91) when on mechanical ventilation and 1.20 (0.76 to 1.33) during the mechanical ventilation + neurostimulation session. The cardiac index was 2.7 (2.3 to 3.5) l · min-1 · m-2 on mechanical ventilation and 3.0 (2.4 to 3.9) l · min-1 · m-2 on mechanical ventilation + neurostimulation. CONCLUSIONS This proof-of-concept study showed the feasibility of short-term diaphragm neurostimulation in conjunction with mechanical ventilation in ARDS patients. Diaphragm neurostimulation was associated with positive effects on lung mechanics and on hemodynamics. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Mélodie Parfait
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Elizabeth Rohrs
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Vincent Joussellin
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Julien Mayaux
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Steven Reynolds
- Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Département "R3S," Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France
| |
Collapse
|
15
|
Chow JWY, Al-Bassam W, Yanase F, O'Brien Z, Bassam A, Hadzakis S, Chaba A, Maeda A, Bellomo R, Serpa Neto A. P0.1 During Pressure Support Ventilation. Am J Respir Crit Care Med 2024; 209:590-592. [PMID: 37991405 DOI: 10.1164/rccm.202307-1314le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023] Open
Affiliation(s)
- Joanna W Y Chow
- Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Wisam Al-Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | | | - Zachary O'Brien
- Austin Health and
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Ahmad Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Stefanos Hadzakis
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | | | | | - Rinaldo Bellomo
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; and
| | - Ary Serpa Neto
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| |
Collapse
|
16
|
Widing H, Pellegrini M, Chiodaroli E, Persson P, Hallén K, Perchiazzi G. Positive end-expiratory pressure limits inspiratory effort through modulation of the effort-to-drive ratio: an experimental crossover study. Intensive Care Med Exp 2024; 12:10. [PMID: 38311676 PMCID: PMC10838888 DOI: 10.1186/s40635-024-00597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/11/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND How assisted spontaneous breathing should be used during acute respiratory distress syndrome is questioned. Recent evidence suggests that high positive end-expiratory pressure (PEEP) may limit the risk of patient self-inflicted lung injury (P-SILI). The aim of this study was to assess the effects of PEEP on esophageal pressure swings, inspiratory drive, and the neuromuscular efficiency of ventilation. We hypothesized that high PEEP would reduce esophageal pressure swings, regardless of inspiratory drive changes, by modulating the effort-to-drive ratio (EDR). This was tested retrospectively in an experimental animal crossover study. Anesthetized pigs (n = 15) were subjected to mild to moderate lung injury and different PEEP levels were applied, changing PEEP from 0 to 15 cmH2O and back to 0 cmH2O in steps of 3 cmH2O. Airway pressure, esophageal pressure (Pes), and electric activity of the diaphragm (Edi) were collected. The EDR was calculated as the tidal change in Pes divided by the tidal change in Edi. Statistical differences were tested using the Wilcoxon signed-rank test. RESULTS Inspiratory esophageal pressure swings decreased from - 4.2 ± 3.1 cmH2O to - 1.9 ± 1.5 cmH2O (p < 0.01), and the mean EDR fell from - 1.12 ± 1.05 cmH2O/µV to - 0.24 ± 0.20 (p < 0.01) as PEEP was increased from 0 to 15 cmH2O. The EDR was significantly correlated to the PEEP level (rs = 0.35, p < 0.01). CONCLUSIONS Higher PEEP limits inspiratory effort by modulating the EDR of the respiratory system. These findings indicate that PEEP may be used in titration of the spontaneous impact on ventilation and in P-SILI risk reduction, potentially facilitating safe assisted spontaneous breathing. Similarly, ventilation may be shifted from highly spontaneous to predominantly controlled ventilation using PEEP. These findings need to be confirmed in clinical settings.
Collapse
Affiliation(s)
- Hannes Widing
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden.
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.
| | - Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Department of Anesthesia, Operation, and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Elena Chiodaroli
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Anesthesia and Intensive Care Medicine, Polo Universitario San Paolo, University of Milan, Milan, Italy
| | - Per Persson
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Hallén
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Department of Anesthesia, Operation, and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|
17
|
Collins PD, Giosa L, Camporota L, Barrett NA. State of the art: Monitoring of the respiratory system during veno-venous extracorporeal membrane oxygenation. Perfusion 2024; 39:7-30. [PMID: 38131204 DOI: 10.1177/02676591231210461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Monitoring the patient receiving veno-venous extracorporeal membrane oxygenation (VV ECMO) is challenging due to the complex physiological interplay between native and membrane lung. Understanding these interactions is essential to understand the utility and limitations of different approaches to respiratory monitoring during ECMO. We present a summary of the underlying physiology of native and membrane lung gas exchange and describe different tools for titrating and monitoring gas exchange during ECMO. However, the most important role of VV ECMO in severe respiratory failure is as a means of avoiding further ergotrauma. Although optimal respiratory management during ECMO has not been defined, over the last decade there have been advances in multimodal respiratory assessment which have the potential to guide care. We describe a combination of imaging, ventilator-derived or invasive lung mechanic assessments as a means to individualise management during ECMO.
Collapse
Affiliation(s)
- Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| |
Collapse
|
18
|
Arellano DH, Brito R, Morais CCA, Ruiz-Rudolph P, Gajardo AIJ, Guiñez DV, Lazo MT, Ramirez I, Rojas VA, Cerda MA, Medel JN, Illanes V, Estuardo NR, Bruhn AR, Brochard LJ, Amato MBP, Cornejo RA. Pendelluft in hypoxemic patients resuming spontaneous breathing: proportional modes versus pressure support ventilation. Ann Intensive Care 2023; 13:131. [PMID: 38117367 PMCID: PMC10733241 DOI: 10.1186/s13613-023-01230-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Internal redistribution of gas, referred to as pendelluft, is a new potential mechanism of effort-dependent lung injury. Neurally-adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV +) follow the patient's respiratory effort and improve synchrony compared with pressure support ventilation (PSV). Whether these modes could prevent the development of pendelluft compared with PSV is unknown. We aimed to compare pendelluft magnitude during PAV + and NAVA versus PSV in patients with resolving acute respiratory distress syndrome (ARDS). METHODS Patients received either NAVA, PAV + , or PSV in a crossover trial for 20-min using comparable assistance levels after controlled ventilation (> 72 h). We assessed pendelluft (the percentage of lost volume from the non-dependent lung region displaced to the dependent region during inspiration), drive (as the delta esophageal swing of the first 100 ms [ΔPes 100 ms]) and inspiratory effort (as the esophageal pressure-time product per minute [PTPmin]). We performed repeated measures analysis with post-hoc tests and mixed-effects models. RESULTS Twenty patients mechanically ventilated for 9 [5-14] days were monitored. Despite matching for a similar tidal volume, respiratory drive and inspiratory effort were slightly higher with NAVA and PAV + compared with PSV (ΔPes 100 ms of -2.8 [-3.8--1.9] cm H2O, -3.6 [-3.9--2.4] cm H2O and -2.1 [-2.5--1.1] cm H2O, respectively, p < 0.001 for both comparisons; PTPmin of 155 [118-209] cm H2O s/min, 197 [145-269] cm H2O s/min, and 134 [93-169] cm H2O s/min, respectively, p < 0.001 for both comparisons). Pendelluft magnitude was higher in NAVA (12 ± 7%) and PAV + (13 ± 7%) compared with PSV (8 ± 6%), p < 0.001. Pendelluft magnitude was strongly associated with respiratory drive (β = -2.771, p-value < 0.001) and inspiratory effort (β = 0.026, p < 0.001), independent of the ventilatory mode. A higher magnitude of pendelluft in proportional modes compared with PSV existed after adjusting for PTPmin (β = 2.606, p = 0.010 for NAVA, and β = 3.360, p = 0.004 for PAV +), and only for PAV + when adjusted for respiratory drive (β = 2.643, p = 0.009 for PAV +). CONCLUSIONS Pendelluft magnitude is associated with respiratory drive and inspiratory effort. Proportional modes do not prevent its occurrence in resolving ARDS compared with PSV.
Collapse
Affiliation(s)
- Daniel H Arellano
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Roberto Brito
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - Caio C A Morais
- Divisao de Pneumologia, Faculdade de Medicina, Instituto Do Coração, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
- Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, Brazil
| | - Pablo Ruiz-Rudolph
- Programa de Epidemiología, Facultad de Medicina, Instituto de Salud Poblacional, Universidad de Chile, Santiago, Chile
| | - Abraham I J Gajardo
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
- Programa de Fisiopatología, Facultad de Medicina, Instituto de Ciencias Biomédicas, Universidad de Chile, Santiago, Chile
| | - Dannette V Guiñez
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - Marioli T Lazo
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - Ivan Ramirez
- Escuela de Kinesiología, Universidad Diego Portales, Santiago, Chile
| | - Verónica A Rojas
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - María A Cerda
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - Juan N Medel
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - Victor Illanes
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - Nivia R Estuardo
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile
| | - Alejandro R Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Center of Acute Respiratory Critical Illness (ARCI), Santiago, Chile
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Marcelo B P Amato
- Divisao de Pneumologia, Faculdade de Medicina, Instituto Do Coração, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Rodrigo A Cornejo
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Dr. Carlos Lorca Tobar 999, 8380456, Santiago, Chile.
- Center of Acute Respiratory Critical Illness (ARCI), Santiago, Chile.
| |
Collapse
|
19
|
Docci M, Rezoagli E, Teggia-Droghi M, Coppadoro A, Pozzi M, Grassi A, Bianchi I, Foti G, Bellani G. Individual response in patient's effort and driving pressure to variations in assistance during pressure support ventilation. Ann Intensive Care 2023; 13:132. [PMID: 38123757 PMCID: PMC10733248 DOI: 10.1186/s13613-023-01231-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND During Pressure Support Ventilation (PSV) an inspiratory hold allows to measure plateau pressure (Pplat), driving pressure (∆P), respiratory system compliance (Crs) and pressure-muscle-index (PMI), an index of inspiratory effort. This study aims [1] to assess systematically how patient's effort (estimated with PMI), ∆P and tidal volume (Vt) change in response to variations in PSV and [2] to confirm the robustness of Crs measurement during PSV. METHODS 18 patients recovering from acute respiratory failure and ventilated by PSV were cross-randomized to four steps of assistance above (+ 3 and + 6 cmH2O) and below (-3 and -6 cmH2O) clinically set PS. Inspiratory and expiratory holds were performed to measure Pplat, PMI, ∆P, Vt, Crs, P0.1 and occluded inspiratory airway pressure (Pocc). Electromyography of respiratory muscles was monitored noninvasively from body surface (sEMG). RESULTS As PSV was decreased, Pplat (from 20.5 ± 3.3 cmH2O to 16.7 ± 2.9, P < 0.001) and ∆P (from 12.5 ± 2.3 to 8.6 ± 2.3 cmH2O, P < 0.001) decreased much less than peak airway pressure did (from 21.7 ± 3.8 to 9.7 ± 3.8 cmH2O, P < 0.001), given the progressive increase of patient's effort (PMI from -1.2 ± 2.3 to 6.4 ± 3.2 cmH2O) in line with sEMG of the diaphragm (r = 0.614; P < 0.001). As ∆P increased linearly with Vt, Crs did not change through steps (P = 0.119). CONCLUSION Patients react to a decrease in PSV by increasing inspiratory effort-as estimated by PMI-keeping Vt and ∆P on a desired value, therefore, limiting the clinician's ability to modulate them. PMI appears a valuable index to assess the point of ventilatory overassistance when patients lose control over Vt like in a pressure-control mode. The measurement of Crs in PSV is constant-likely suggesting reliability-independently from the level of assistance and patient's effort.
Collapse
Affiliation(s)
- Mattia Docci
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Maddalena Teggia-Droghi
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Andrea Coppadoro
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Alice Grassi
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Isabella Bianchi
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy.
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento Largo Medaglie d'Oro Trento, Trento, Italy.
| |
Collapse
|
20
|
Panelli A, Verfuß MA, Dres M, Brochard L, Schaller SJ. Phrenic nerve stimulation to prevent diaphragmatic dysfunction and ventilator-induced lung injury. Intensive Care Med Exp 2023; 11:94. [PMID: 38109016 PMCID: PMC10728426 DOI: 10.1186/s40635-023-00577-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Side effects of mechanical ventilation, such as ventilator-induced diaphragmatic dysfunction (VIDD) and ventilator-induced lung injury (VILI), occur frequently in critically ill patients. Phrenic nerve stimulation (PNS) has been a valuable tool for diagnosing VIDD by assessing respiratory muscle strength in response to magnetic PNS. The detection of pathophysiologically reduced respiratory muscle strength is correlated with weaning failure, longer mechanical ventilation time, and mortality. Non-invasive electromagnetic PNS designed for diagnostic use is a reference technique that allows clinicians to measure transdiaphragm pressure as a surrogate parameter for diaphragm strength and functionality. This helps to identify diaphragm-related issues that may impact weaning readiness and respiratory support requirements, although lack of lung volume measurement poses a challenge to interpretation. In recent years, therapeutic PNS has been demonstrated as feasible and safe in lung-healthy and critically ill patients. Effects on critically ill patients' VIDD or diaphragm atrophy outcomes are the subject of ongoing research. The currently investigated application forms are diverse and vary from invasive to non-invasive and from electrical to (electro)magnetic PNS, with most data available for electrical stimulation. Increased inspiratory muscle strength and improved diaphragm activity (e.g., excursion, thickening fraction, and thickness) indicate the potential of the technique for beneficial effects on clinical outcomes as it has been successfully used in spinal cord injured patients. Concerning the potential for electrophrenic respiration, the data obtained with non-invasive electromagnetic PNS suggest that the induced diaphragmatic contractions result in airway pressure swings and tidal volumes remaining within the thresholds of lung-protective mechanical ventilation. PNS holds significant promise as a therapeutic intervention in the critical care setting, with potential applications for ameliorating VIDD and the ability for diaphragm training in a safe lung-protective spectrum, thereby possibly reducing the risk of VILI indirectly. Outcomes of such diaphragm training have not been sufficiently explored to date but offer the perspective for enhanced patient care and reducing weaning failure. Future research might focus on using PNS in combination with invasive and non-invasive assisted ventilation with automatic synchronisation and the modulation of PNS with spontaneous breathing efforts. Explorative approaches may investigate the feasibility of long-term electrophrenic ventilation as an alternative to positive pressure-based ventilation.
Collapse
Affiliation(s)
- Alessandro Panelli
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Michael A Verfuß
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Martin Dres
- Sorbonne Université, INSERM UMRS 1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation, Département R3S, APHP, Sorbonne Université, Hôpital Pitie Salpêtrière, Paris, France
| | - Laurent Brochard
- Unity Health Toronto, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany.
- Technical University of Munich, School of Medicine and Health, Klinikum Rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany.
| |
Collapse
|
21
|
Lin WC, Su PF, Chen CW. Pendelluft in patients with acute respiratory distress syndrome during trigger and reverse triggering breaths. Sci Rep 2023; 13:22143. [PMID: 38092775 PMCID: PMC10719360 DOI: 10.1038/s41598-023-49038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023] Open
Abstract
Pendelluft, the shift of air from non-dependent to dependent lung regions, is known to occur during active breathing in ventilated patients. However, information about pendelluft in ARDS patients under assisted mechanical ventilation is limited. In this prospectively collected and retrospectively analyzed study, we combined electrical impedance tomography and respiratory mechanics monitoring to quantitatively examine pendelluft in trigger and reverse triggering breaths in 20 mechanically ventilated patients with ARDS during the transition from controlled to active breaths under volume-cycled ventilation. Besides the 10 resting breaths in each patient, 20% of the counted active breaths were selected based on three levels of esophageal pressure swing (∆Pes): low (< 5 cm H2O, breaths = 471), moderate (≥ 5, < 10 cm H2O, breaths = 906), and high effort (≥ 10 cm H2O, breaths = 565). The pendelluft response to breathing efforts was significantly greater in trigger breaths than in reverse triggering breaths (p < 0.0001). Based on the pendelluft-∆Pes slope (ml/cmH2O), there were two distinct patterns of effort-related pendelluft (high vs. low pendelluft group). For trigger breaths, the high pendelluft group (n = 9, slope 0.7-2.4 ml/cmH2O) was significantly associated with lower peak airway/plateau pressure and lower respiratory system/lung elastance than the low pendelluft group (n = 11, slope - 0.1 to 0.3 ml/cmH2O). However, there was no difference in respiratory mechanics between high and low pendelluft groups for reverse triggering breathes. The use of ∆Pes to predict pendelluft was found to have a low positive predictive value.
Collapse
Affiliation(s)
- Wei-Chieh Lin
- Section of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, Taiwan
| | - Pei-Fang Su
- Department of Statistics, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Wen Chen
- Section of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, Taiwan.
| |
Collapse
|
22
|
Ito Y, Herrera MG, Hotz JC, Kyogoku M, Newth CJL, Bhalla AK, Takeuchi M, Khemani RG. Estimation of inspiratory effort using airway occlusion maneuvers in ventilated children: a secondary analysis of an ongoing randomized trial testing a lung and diaphragm protective ventilation strategy. Crit Care 2023; 27:466. [PMID: 38031116 PMCID: PMC10685539 DOI: 10.1186/s13054-023-04754-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Monitoring respiratory effort in ventilated patients is important to balance lung and diaphragm protection. Esophageal manometry remains the gold standard for monitoring respiratory effort but is invasive and requires expertise for its measurement and interpretation. Airway pressures during occlusion maneuvers may provide an alternative, although pediatric data are limited. We sought to determine the correlation between change in esophageal pressure during tidal breathing (∆Pes) and airway pressure measured during three airway occlusion maneuvers: (1) expiratory occlusion pressure (Pocc), (2) airway occlusion pressure (P0.1), and (3) respiratory muscle pressure index (PMI) in children. We also sought to explore pediatric threshold values for these pressures to detect excessive or insufficient respiratory effort. METHODS Secondary analysis of physiologic data from children between 1 month and 18 years of age with acute respiratory distress syndrome enrolled in an ongoing randomized clinical trial testing a lung and diaphragm protective ventilation strategy (REDvent, R01HL124666). ∆Pes, Pocc, P0.1, and PMI were measured. Repeated measure correlations were used to investigate correlation coefficients between ∆Pes and the three measures, and linear regression equations were generated to identify potential therapeutic thresholds. RESULTS There were 653 inspiratory and 713 expiratory holds from 97 patients. Pocc had the strongest correlation with ∆Pes (r = 0.68), followed by PMI (r = 0.60) and P0.1 (r = 0.42). ∆Pes could be reliably estimated using the regression equation ∆Pes = 0.66 [Formula: see text] Pocc (R2 = 0.82), with Pocc cut-points having high specificity and moderate sensitivity to detect respective ∆Pes thresholds for high and low respiratory effort. There were minimal differences in the relationship between Pocc and ∆Pes based on age (infant, child, adolescent) or mode of ventilation (SIMV versus Pressure Support), although these differences were more apparent with P0.1 and PMI. CONCLUSIONS Airway occlusion maneuvers may be appropriate alternatives to esophageal pressure measurement to estimate the inspiratory effort in children, and Pocc represents the most promising target. TRIAL REGISTRATION NCT03266016; August 23, 2017.
Collapse
Affiliation(s)
- Yukie Ito
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Matías G Herrera
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Intensive Care, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Miyako Kyogoku
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Muneyuki Takeuchi
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA.
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA.
| |
Collapse
|
23
|
Katayama S, Tonai K, Atsuko S. Intercostal Recession and Bulging during Pendelluft Detected in Four-Dimensional Computed Tomography. Am J Respir Crit Care Med 2023; 208:e41-e43. [PMID: 37672024 DOI: 10.1164/rccm.202303-0413im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Affiliation(s)
- Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Ken Tonai
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Shono Atsuko
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| |
Collapse
|
24
|
Menga LS, Delle Cese L, Grieco DL, Antonelli M. Reply to Wang et al.. Am J Respir Crit Care Med 2023; 208:1002-1004. [PMID: 37586080 PMCID: PMC10870867 DOI: 10.1164/rccm.202307-1173le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/18/2023] Open
Affiliation(s)
- Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico L. Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
25
|
Wang Y, Li J, Zhong M, Zhao Z. The Proper Assessment of Pendelluft and Absolute End-Expiratory Lung Volume. Am J Respir Crit Care Med 2023; 208:1001-1002. [PMID: 37586081 PMCID: PMC10870860 DOI: 10.1164/rccm.202306-1058le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/16/2023] [Indexed: 08/18/2023] Open
Affiliation(s)
- Yuxian Wang
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois; and
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Zhanqi Zhao
- Institute of Technical Medicine, Furtwangen University, Schwarzwald, Germany
| |
Collapse
|
26
|
Núñez Silveira JM, Gallardo A, García-Valdés P, Ríos F, Rodriguez PO, Felipe Damiani L. Reverse triggering during mechanical ventilation: Diagnosis and clinical implications. Med Intensiva 2023; 47:648-657. [PMID: 37867118 DOI: 10.1016/j.medine.2023.10.009] [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: 08/11/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 10/24/2023]
Abstract
This review addresses the phenomenon of "reverse triggering", an asynchrony that occurs in deeply sedated patients or patients in transition from deep to light sedation. Reverse triggering has been reported to occur in 30-90% of all ventilated patients. The underlying pathophysiological mechanisms remain unclear, but "entrainment" is proposed as one of them. Detecting this asynchrony is crucial, and methods such as visual inspection, esophageal pressure, diaphragmatic ultrasound and automated methods have been used. Reverse triggering may have effects on lung and diaphragm function, probably mediated by the level of breathing effort and eccentric activation of the diaphragm. The optimal management of reverse triggering has not been established, but may include the adjustment of ventilatory parameters as well as of sedation level, and in extreme cases, neuromuscular block. It is important to understand the significance of this condition and its detection, but also to conduct dedicated research to improve its clinical management and potential effects in critically ill patients.
Collapse
Affiliation(s)
- Juan M Núñez Silveira
- Servicio de Kinesiología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Adrián Gallardo
- Servicio de Kinesiología, Sanatorio Clínica Modelo de Morón, Morón, Buenos Aires, Argentina
| | - Patricio García-Valdés
- Departamento de Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; CardioREspirAtory Research Laboratory (CREAR), Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Fernando Ríos
- Casa Hospital San Juan De Dios, Ramos Mejía, Buenos Aires, Argentina
| | - Pablo O Rodriguez
- Unidad de Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina; Instituto Universitario CEMIC (IUC), Buenos Aires, Argentina
| | - L Felipe Damiani
- Departamento de Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; CardioREspirAtory Research Laboratory (CREAR), Pontificia Universidad Católica de Chile, Santiago, Chile.
| |
Collapse
|
27
|
Giosa L, Collins PD, Sciolla M, Cerrone F, Di Blasi S, Macrì MM, Davicco L, Laguzzi A, Gorgonzola F, Penso R, Steinberg I, Muraccini M, Perboni A, Russotto V, Camporota L, Bellani G, Caironi P. Effects of CPAP and FiO 2 on respiratory effort and lung stress in early COVID-19 pneumonia: a randomized, crossover study. Ann Intensive Care 2023; 13:103. [PMID: 37847454 PMCID: PMC10581975 DOI: 10.1186/s13613-023-01202-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/06/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND in COVID-19 acute respiratory failure, the effects of CPAP and FiO2 on respiratory effort and lung stress are unclear. We hypothesize that, in the compliant lungs of early Sars-CoV-2 pneumonia, the application of positive pressure through Helmet-CPAP may not decrease respiratory effort, and rather worsen lung stress and oxygenation when compared to higher FiO2 delivered via oxygen masks. METHODS In this single-center (S.Luigi Gonzaga University-Hospital, Turin, Italy), randomized, crossover study, we included patients receiving Helmet-CPAP for early (< 48 h) COVID-19 pneumonia without additional cardiac or respiratory disease. Healthy subjects were included as controls. Participants were equipped with an esophageal catheter, a non-invasive cardiac output monitor, and an arterial catheter. The protocol consisted of a random sequence of non-rebreather mask (NRB), Helmet-CPAP (with variable positive pressure and FiO2) and Venturi mask (FiO2 0.5), each delivered for 20 min. Study outcomes were changes in respiratory effort (esophageal swing), total lung stress (dynamic + static transpulmonary pressure), gas-exchange and hemodynamics. RESULTS We enrolled 28 COVID-19 patients and 7 healthy controls. In all patients, respiratory effort increased from NRB to Helmet-CPAP (5.0 ± 3.7 vs 8.3 ± 3.9 cmH2O, p < 0.01). However, Helmet's pressure decreased by a comparable amount during inspiration (- 3.1 ± 1.0 cmH2O, p = 0.16), therefore dynamic stress remained stable (p = 0.97). Changes in static and total lung stress from NRB to Helmet-CPAP were overall not significant (p = 0.07 and p = 0.09, respectively), but showed high interpatient variability, ranging from - 4.5 to + 6.1 cmH2O, and from - 5.8 to + 5.7 cmH2O, respectively. All findings were confirmed in healthy subjects, except for an increase in dynamic stress (p < 0.01). PaO2 decreased from NRB to Helmet-CPAP with FiO2 0.5 (107 ± 55 vs 86 ± 30 mmHg, p < 0.01), irrespective of positive pressure levels (p = 0.64). Conversely, with Helmet's FiO2 0.9, PaO2 increased (p < 0.01), but oxygen delivery remained stable (p = 0.48) as cardiac output decreased (p = 0.02). When PaO2 fell below 60 mmHg with VM, respiratory effort increased proportionally (p < 0.01, r = 0.81). CONCLUSIONS In early COVID-19 pneumonia, Helmet-CPAP increases respiratory effort without altering dynamic stress, while the effects upon static and total stress are variable, requiring individual assessment. Oxygen masks with higher FiO2 provide better oxygenation with lower respiratory effort. Trial registration Retrospectively registered (13-May-2021): clinicaltrials.gov (NCT04885517), https://clinicaltrials.gov/ct2/show/NCT04885517 .
Collapse
Affiliation(s)
- Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, St. Thomas' Hospital, Westminster Bridge Road, London, SE17EH, UK.
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.
| | - Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, St. Thomas' Hospital, Westminster Bridge Road, London, SE17EH, UK
| | - Martina Sciolla
- Department of Pulmonary Medicine, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | | | - Salvatore Di Blasi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Matteo Maria Macrì
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Luca Davicco
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Andrea Laguzzi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Fabiana Gorgonzola
- Department of Pulmonary Medicine, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Roberto Penso
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Irene Steinberg
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anaesthesia, Intensive Care and Emergency, Città della Salute e della Scienza University Hospital, Turin, Italy
| | | | - Alberto Perboni
- Department of Pulmonary Medicine, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
| | - Vincenzo Russotto
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, St. Thomas' Hospital, Westminster Bridge Road, London, SE17EH, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
| |
Collapse
|
28
|
Takahashi K, Toyama H, Ejima Y, Yang J, Kikuchi K, Ishikawa T, Yamauchi M. Endotracheal tube, by the venturi effect, reduces the efficacy of increasing inlet pressure in improving pendelluft. PLoS One 2023; 18:e0291319. [PMID: 37708106 PMCID: PMC10501657 DOI: 10.1371/journal.pone.0291319] [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: 03/16/2023] [Accepted: 08/27/2023] [Indexed: 09/16/2023] Open
Abstract
In mechanically ventilated severe acute respiratory distress syndrome patients, spontaneous inspiratory effort generates more negative pressure in the dorsal lung than in the ventral lung. The airflow caused by this pressure difference is called pendelluft, which is a possible mechanisms of patient self-inflicted lung injury. This study aimed to use computer simulation to understand how the endotracheal tube and insufficient ventilatory support contribute to pendelluft. We established two models. In the invasive model, an endotracheal tube was connected to the tracheobronchial tree with 34 outlets grouped into six locations: the right and left upper, lower, and middle lobes. In the non-invasive model, the upper airway, including the glottis, was connected to the tracheobronchial tree. To recreate the inspiratory effort of acute respiratory distress syndrome patients, the lower lobe pressure was set at -13 cmH2O, while the upper and middle lobe pressure was set at -6.4 cmH2O. The inlet pressure was set from 10 to 30 cmH2O to recreate ventilatory support. Using the finite volume method, the total flow rates through each model and toward each lobe were calculated. The invasive model had half the total flow rate of the non-invasive model (1.92 L/s versus 3.73 L/s under 10 cmH2O, respectively). More pendelluft (gas flow into the model from the outlets) was observed in the invasive model than in the non-invasive model. The inlet pressure increase from 10 to 30 cmH2O decreased pendelluft by 11% and 29% in the invasive and non-invasive models, respectively. In the invasive model, a faster jet flowed from the tip of the endotracheal tube toward the lower lobes, consequently entraining gas from the upper and middle lobes. Increasing ventilatory support intensifies the jet from the endotracheal tube, causing a venturi effect at the bifurcation in the tracheobronchial tree. Clinically acceptable ventilatory support cannot completely prevent pendelluft.
Collapse
Affiliation(s)
- Kazuhiro Takahashi
- Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Toyama
- Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yutaka Ejima
- Division of Surgical Center and Supply, Sterilization, Tohoku University Hospital, Sendai, Japan
| | - Jinyou Yang
- Department of Biophysics, School of Intelligent Medicine, China Medical University, Shenyang, China
| | - Kenji Kikuchi
- Department of Finemechanics, Graduate School of Engineering, Tohoku University, Sendai, Japan
| | - Takuji Ishikawa
- Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan
| | - Masanori Yamauchi
- Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
29
|
Gao Y, Yin H, Wang MH, Gao YH. Accuracy of lung and diaphragm ultrasound in predicting infant weaning outcomes: a systematic review and meta-analysis. Front Pediatr 2023; 11:1211306. [PMID: 37744441 PMCID: PMC10511769 DOI: 10.3389/fped.2023.1211306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background Although lung and diaphragm ultrasound are valuable tools for predicting weaning results in adults with MV, their relevance in children is debatable. The goal of this meta-analysis was to determine the predictive value of lung and diaphragm ultrasound in newborn weaning outcomes. Methods For eligible studies, the databases MEDLINE, Web of Science, Cochrane Library, PubMed, and Embase were thoroughly searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) method was used to evaluate the study's quality. Results were gathered for sensitivity, specificity, diagnostic odds ratio (DOR), and the area under the curve of summary receiver operating characteristic curves (AUSROC). To investigate the causes of heterogeneity, subgroup analyses and meta-regression were conducted. Results A total of 11 studies were suitable for inclusion in the meta-analysis, which included 828 patients. The pooled sensitivity and specificity of lung ultrasound (LUS) were 0.88 (95%CI, 0.85-0.90) and 0.81 (95%CI, 0.75-0.87), respectively. The DOR for diaphragmatic excursion (DE) is 13.17 (95%CI, 5.65-30.71). The AUSROC for diaphragm thickening fraction (DTF) is 0.86 (95%CI, 0.82-0.89). The most sensitive and specific method is LUS. The DE and DTF were the key areas where study heterogeneity was evident. Conclusions Lung ultrasonography is an extremely accurate method for predicting weaning results in MV infants. DTF outperforms DE in terms of diaphragm ultrasound predictive power.
Collapse
Affiliation(s)
- Yang Gao
- Department of Ultrasound, Shandong Provincial Maternal and Child Health Care Hospital, Jinan, China
| | - Hong Yin
- Department of Ultrasound, Shandong Provincial Maternal and Child Health Care Hospital, Jinan, China
| | - Mei-Huan Wang
- Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yue-Hua Gao
- Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| |
Collapse
|
30
|
Ribeiro De Santis Santiago R, Xin Y, Gaulton TG, Alcala G, León Bueno de Camargo ED, Cereda M, Britto Passos Amato M, Berra L. Lung Imaging Acquisition with Electrical Impedance Tomography: Tackling Common Pitfalls. Anesthesiology 2023; 139:329-341. [PMID: 37402247 DOI: 10.1097/aln.0000000000004613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Electrical impedance tomography is a powerful tool for lung imaging that can be employed at the bedside in multiple clinical scenarios. Diagnosing and preventing interpretation pitfalls will ensure reliable data and allow for appropriate clinical decision-making.
Collapse
Affiliation(s)
- Roberta Ribeiro De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yi Xin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy G Gaulton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Glasiele Alcala
- Pulmonary Division, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Erick Dario León Bueno de Camargo
- Federal University of ABC/Engineering, Modeling and Applied Social Sciences Centre, Biomedical Engineering, São Bernardo do Campo, Brazil
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
31
|
Grieco DL, Delle Cese L, Menga LS, Rosà T, Michi T, Lombardi G, Cesarano M, Giammatteo V, Bello G, Carelli S, Cutuli SL, Sandroni C, De Pascale G, Pesenti A, Maggiore SM, Antonelli M. Physiological effects of awake prone position in acute hypoxemic respiratory failure. Crit Care 2023; 27:315. [PMID: 37592288 PMCID: PMC10433569 DOI: 10.1186/s13054-023-04600-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The effects of awake prone position on the breathing pattern of hypoxemic patients need to be better understood. We conducted a crossover trial to assess the physiological effects of awake prone position in patients with acute hypoxemic respiratory failure. METHODS Fifteen patients with acute hypoxemic respiratory failure and PaO2/FiO2 < 200 mmHg underwent high-flow nasal oxygen for 1 h in supine position and 2 h in prone position, followed by a final 1-h supine phase. At the end of each study phase, the following parameters were measured: arterial blood gases, inspiratory effort (ΔPES), transpulmonary driving pressure (ΔPL), respiratory rate and esophageal pressure simplified pressure-time product per minute (sPTPES) by esophageal manometry, tidal volume (VT), end-expiratory lung impedance (EELI), lung compliance, airway resistance, time constant, dynamic strain (VT/EELI) and pendelluft extent through electrical impedance tomography. RESULTS Compared to supine position, prone position increased PaO2/FiO2 (median [Interquartile range] 104 mmHg [76-129] vs. 74 [69-93], p < 0.001), reduced respiratory rate (24 breaths/min [22-26] vs. 27 [26-30], p = 0.05) and increased ΔPES (12 cmH2O [11-13] vs. 9 [8-12], p = 0.04) with similar sPTPES (131 [75-154] cmH2O s min-1 vs. 105 [81-129], p > 0.99) and ΔPL (9 [7-11] cmH2O vs. 8 [5-9], p = 0.17). Airway resistance and time constant were higher in prone vs. supine position (9 cmH2O s arbitrary units-3 [4-11] vs. 6 [4-9], p = 0.05; 0.53 s [0.32-61] vs. 0.40 [0.37-0.44], p = 0.03). Prone position increased EELI (3887 arbitrary units [3414-8547] vs. 1456 [959-2420], p = 0.002) and promoted VT distribution towards dorsal lung regions without affecting VT size and lung compliance: this generated lower dynamic strain (0.21 [0.16-0.24] vs. 0.38 [0.30-0.49], p = 0.004). The magnitude of pendelluft phenomenon was not different between study phases (55% [7-57] of VT in prone vs. 31% [14-55] in supine position, p > 0.99). CONCLUSIONS Prone position improves oxygenation, increases EELI and promotes VT distribution towards dependent lung regions without affecting VT size, ΔPL, lung compliance and pendelluft magnitude. Prone position reduces respiratory rate and increases ΔPES because of positional increases in airway resistance and prolonged expiratory time. Because high ΔPES is the main mechanistic determinant of self-inflicted lung injury, caution may be needed in using awake prone position in patients exhibiting intense ΔPES. Clinical trail registeration: The study was registered on clinicaltrials.gov (NCT03095300) on March 29, 2017.
Collapse
Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Gianmarco Lombardi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Simone Carelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Salvatore L. Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Claudio Sandroni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Salvatore M. Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS, L.go F. Vito, 00168 Rome, Italy
| |
Collapse
|
32
|
Khorsand S, Chin J, Rice J, Bughrara N, Myatra SN, Karamchandani K. Role of Point-of-Care Ultrasound in Emergency Airway Management Outside the Operating Room. Anesth Analg 2023; 137:124-136. [PMID: 36693019 DOI: 10.1213/ane.0000000000006371] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.
Collapse
Affiliation(s)
- Sarah Khorsand
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeanette Chin
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jake Rice
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nibras Bughrara
- Department of Anesthesiology and Critical Care Medicine, Albany Medical College, Albany, New York
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi-Bhabha National Institute, Mumbai, India
| | - Kunal Karamchandani
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
33
|
Jonkman AH, Telias I, Spinelli E, Akoumianaki E, Piquilloud L. The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects. Eur Respir Rev 2023; 32:220186. [PMID: 37197768 PMCID: PMC10189643 DOI: 10.1183/16000617.0186-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/22/2023] [Indexed: 05/19/2023] Open
Abstract
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure (P oes) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, P oes monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using P oes measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of P oes-guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
Collapse
Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital-Unity Health Toronto, Toronto, ON, Canada
| | - Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evangelia Akoumianaki
- Adult Intensive Care Unit, University Hospital of Heraklion, Heraklion, Greece
- Medical School, University of Crete, Heraklion, Greece
| | - Lise Piquilloud
- Adult Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| |
Collapse
|
34
|
Cutuli SL, Grieco DL, Michi T, Cesarano M, Rosà T, Pintaudi G, Menga LS, Ruggiero E, Giammatteo V, Bello G, De Pascale G, Antonelli M. Personalized Respiratory Support in ARDS: A Physiology-to-Bedside Review. J Clin Med 2023; 12:4176. [PMID: 37445211 DOI: 10.3390/jcm12134176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a leading cause of disability and mortality worldwide, and while no specific etiologic interventions have been shown to improve outcomes, noninvasive and invasive respiratory support strategies are life-saving interventions that allow time for lung recovery. However, the inappropriate management of these strategies, which neglects the unique features of respiratory, lung, and chest wall mechanics may result in disease progression, such as patient self-inflicted lung injury during spontaneous breathing or by ventilator-induced lung injury during invasive mechanical ventilation. ARDS characteristics are highly heterogeneous; therefore, a physiology-based approach is strongly advocated to titrate the delivery and management of respiratory support strategies to match patient characteristics and needs to limit ARDS progression. Several tools have been implemented in clinical practice to aid the clinician in identifying the ARDS sub-phenotypes based on physiological peculiarities (inspiratory effort, respiratory mechanics, and recruitability), thus allowing for the appropriate application of personalized supportive care. In this narrative review, we provide an overview of noninvasive and invasive respiratory support strategies, as well as discuss how identifying ARDS sub-phenotypes in daily practice can help clinicians to deliver personalized respiratory support and potentially improve patient outcomes.
Collapse
Affiliation(s)
- Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luca Salvatore Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
35
|
Dianti J, Morris IS, Urner M, Schmidt M, Tomlinson G, Amato MBP, Blanch L, Rubenfeld G, Goligher EC. Linking Acute Physiology to Outcomes in the ICU: Challenges and Solutions for Research. Am J Respir Crit Care Med 2023; 207:1441-1450. [PMID: 36705985 DOI: 10.1164/rccm.202206-1216ci] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
ICU clinicians rely on bedside physiological measurements to inform many routine clinical decisions. Because deranged physiology is usually associated with poor clinical outcomes, it is tempting to hypothesize that manipulating and intervening on physiological parameters might improve outcomes for patients. However, testing these hypotheses through mathematical models of the relationship between physiology and outcomes presents a number of important methodological challenges. These models reflect the theories of the researcher and can therefore be heavily influenced by one's assumptions and background beliefs. Model building must therefore be approached with great care and forethought, because failure to consider relevant sources of measurement error, confounding, coupling, and time dependency or failure to assess the direction of causality for associations of interest before modeling may give rise to spurious results. This paper outlines the main challenges in analyzing and interpreting these models and offers potential solutions to address these challenges.
Collapse
Affiliation(s)
- Jose Dianti
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
| | - Idunn S Morris
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine
- Department of Anesthesiology and Pain Medicine
| | | | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Lluis Blanch
- Critical Care Center, Institut d'Investigacio i Innovacio Parc Taulí I3PT-CERCA, Parc Taulí Hospital Universitari, Universitat Autonoma de Barcelona, Sabadell, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Universitat Autonoma de Barcelona, Parc Taulí 1, Sabadell, Spain
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| |
Collapse
|
36
|
Michi T, Mattana C, Menga LS, Bocci MG, Cesarano M, Rosà T, Gualano MR, Montomoli J, Spadaro S, Tosato M, Rota E, Landi F, Cutuli SL, Tanzarella ES, Pintaudi G, Piervincenzi E, Bello G, Tonetti T, Rucci P, De Pascale G, Maggiore SM, Grieco DL, Conti G, Antonelli M. Long-term outcome of COVID-19 patients treated with helmet noninvasive ventilation vs. high-flow nasal oxygen: a randomized trial. J Intensive Care 2023; 11:21. [PMID: 37208787 DOI: 10.1186/s40560-023-00669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Long-term outcomes of patients treated with helmet noninvasive ventilation (NIV) are unknown: safety concerns regarding the risk of patient self-inflicted lung injury and delayed intubation exist when NIV is applied in hypoxemic patients. We assessed the 6-month outcome of patients who received helmet NIV or high-flow nasal oxygen for COVID-19 hypoxemic respiratory failure. METHODS In this prespecified analysis of a randomized trial of helmet NIV versus high-flow nasal oxygen (HENIVOT), clinical status, physical performance (6-min-walking-test and 30-s chair stand test), respiratory function and quality of life (EuroQoL five dimensions five levels questionnaire, EuroQoL VAS, SF36 and Post-Traumatic Stress Disorder Checklist for the DSM) were evaluated 6 months after the enrollment. RESULTS Among 80 patients who were alive, 71 (89%) completed the follow-up: 35 had received helmet NIV, 36 high-flow oxygen. There was no inter-group difference in any item concerning vital signs (N = 4), physical performance (N = 18), respiratory function (N = 27), quality of life (N = 21) and laboratory tests (N = 15). Arthralgia was significantly lower in the helmet group (16% vs. 55%, p = 0.002). Fifty-two percent of patients in helmet group vs. 63% of patients in high-flow group had diffusing capacity of the lungs for carbon monoxide < 80% of predicted (p = 0.44); 13% vs. 22% had forced vital capacity < 80% of predicted (p = 0.51). Both groups reported similar degree of pain (p = 0.81) and anxiety (p = 0.81) at the EQ-5D-5L test; the EQ-VAS score was similar in the two groups (p = 0.27). Compared to patients who successfully avoided invasive mechanical ventilation (54/71, 76%), intubated patients (17/71, 24%) had significantly worse pulmonary function (median diffusing capacity of the lungs for carbon monoxide 66% [Interquartile range: 47-77] of predicted vs. 80% [71-88], p = 0.005) and decreased quality of life (EQ-VAS: 70 [53-70] vs. 80 [70-83], p = 0.01). CONCLUSIONS In patients with COVID-19 hypoxemic respiratory failure, treatment with helmet NIV or high-flow oxygen yielded similar quality of life and functional outcome at 6 months. The need for invasive mechanical ventilation was associated with worse outcomes. These data indicate that helmet NIV, as applied in the HENIVOT trial, can be safely used in hypoxemic patients. Trial registration Registered on clinicaltrials.gov NCT04502576 on August 6, 2020.
Collapse
Affiliation(s)
- Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Chiara Mattana
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Maria Grazia Bocci
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Maria Rosaria Gualano
- Department of Hygiene and Public Health, UniCamillus University, Rome, Italy
- Leadership in Medicine Research Center, Catholic University of The Sacred Heart, Rome , Italy
| | - Jonathan Montomoli
- Department of Anaesthesia and Intensive Care, Infermi Hospital, Rimini, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Matteo Tosato
- Geriatrics Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elisabetta Rota
- Geriatrics Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Landi
- Geriatrics Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore L Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Eloisa S Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Edoardo Piervincenzi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Medicine, Alma Mater Studiorum, Policlinico Di Sant'Orsola, Università Di Bologna, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Science, Alma Mater Studiorum-Università Di Bologna, Bologna, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Salvatore M Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy.
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy.
| | - Giorgio Conti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
- Istituto Di Anestesiologia E Rianimazione, Catholic University of The Sacred Heart, Rome, Italy
| |
Collapse
|
37
|
Etienne H, Morris IS, Hermans G, Heunks L, Goligher EC, Jaber S, Morelot-Panzini C, Assouad J, Gonzalez-Bermejo J, Papazian L, Similowski T, Demoule A, Dres M. Diaphragm Neurostimulation Assisted Ventilation in Critically Ill Patients. Am J Respir Crit Care Med 2023; 207:1275-1282. [PMID: 36917765 PMCID: PMC10595441 DOI: 10.1164/rccm.202212-2252cp] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/14/2023] [Indexed: 03/15/2023] Open
Abstract
Diaphragm neurostimulation consists of placing electrodes directly on or in proximity to the phrenic nerve(s) to elicit diaphragmatic contractions. Since its initial description in the 18th century, indications have shifted from cardiopulmonary resuscitation to long-term ventilatory support. Recently, the technical development of devices for temporary diaphragm neurostimulation has opened up the possibility of a new era for the management of mechanically ventilated patients. Combining positive pressure ventilation with diaphragm neurostimulation offers a potentially promising new approach to the delivery of mechanical ventilation which may benefit multiple organ systems. Maintaining diaphragm contractions during ventilation may attenuate diaphragm atrophy and accelerate weaning from mechanical ventilation. Preventing atelectasis and preserving lung volume can reduce lung stress and strain and improve homogeneity of ventilation, potentially mitigating ventilator-induced lung injury. Furthermore, restoring the thoracoabdominal pressure gradient generated by diaphragm contractions may attenuate the drop in cardiac output induced by positive pressure ventilation. Experimental evidence suggests diaphragm neurostimulation may prevent neuroinflammation associated with mechanical ventilation. This review describes the historical development and evolving approaches to diaphragm neurostimulation during mechanical ventilation and surveys the potential mechanisms of benefit. The review proposes a research agenda and offers perspectives for the future of diaphragm neurostimulation assisted mechanical ventilation for critically ill patients.
Collapse
Affiliation(s)
- Harry Etienne
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Department of Thoracic Surgery, Tenon University Hospital, Paris, France
| | - Idunn S. Morris
- Interdepartmental Division of Critical Care Medicine and
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospital Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine and
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Samir Jaber
- Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Capucine Morelot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Pneumologie
| | - Jalal Assouad
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Department of Thoracic Surgery, Tenon University Hospital, Paris, France
| | - Jésus Gonzalez-Bermejo
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Soins de Suite Réadaptation
| | - Laurent Papazian
- Service de Médecine Intensive Reanimation, Centre Hospitalier de Bastia, Bastia, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Département R3S, and
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive – Réanimation, Hopital Pitie Salpetriere, APHP, Sorbonne Universite, Paris, France; and
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive – Réanimation, Hopital Pitie Salpetriere, APHP, Sorbonne Universite, Paris, France; and
| |
Collapse
|
38
|
Menga LS, Delle Cese L, Rosà T, Cesarano M, Scarascia R, Michi T, Biasucci DG, Ruggiero E, Dell’Anna AM, Cutuli SL, Tanzarella ES, Pintaudi G, De Pascale G, Sandroni C, Maggiore SM, Grieco DL, Antonelli M. Respective Effects of Helmet Pressure Support, Continuous Positive Airway Pressure, and Nasal High-Flow in Hypoxemic Respiratory Failure: A Randomized Crossover Clinical Trial. Am J Respir Crit Care Med 2023; 207:1310-1323. [PMID: 36378814 PMCID: PMC10595442 DOI: 10.1164/rccm.202204-0629oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 11/15/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: The respective effects of positive end-expiratory pressure (PEEP) and pressure support delivered through the helmet interface in patients with hypoxemia need to be better understood. Objectives: To assess the respective effects of helmet pressure support (noninvasive ventilation [NIV]) and continuous positive airway pressure (CPAP) compared with high-flow nasal oxygen (HFNO) on effort to breathe, lung inflation, and gas exchange in patients with hypoxemia (PaO2/FiO2 ⩽ 200). Methods: Fifteen patients underwent 1-hour phases (constant FiO2) of HFNO (60 L/min), helmet NIV (PEEP = 14 cm H2O, pressure support = 12 cm H2O), and CPAP (PEEP = 14 cm H2O) in randomized sequence. Measurements and Main Results: Inspiratory esophageal (ΔPES) and transpulmonary pressure (ΔPL) swings were used as surrogates for inspiratory effort and lung distension, respectively. Tidal Volume (Vt) and end-expiratory lung volume were assessed with electrical impedance tomography. ΔPES was lower during NIV versus CPAP and HFNO (median [interquartile range], 5 [3-9] cm H2O vs. 13 [10-19] cm H2O vs. 10 [8-13] cm H2O; P = 0.001 and P = 0.01). ΔPL was not statistically different between treatments. PaO2/FiO2 ratio was significantly higher during NIV and CPAP versus HFNO (166 [136-215] and 175 [158-281] vs. 120 [107-149]; P = 0.002 and P = 0.001). NIV and CPAP similarly increased Vt versus HFNO (mean change, 70% [95% confidence interval (CI), 17-122%], P = 0.02; 93% [95% CI, 30-155%], P = 0.002) and end-expiratory lung volume (mean change, 198% [95% CI, 67-330%], P = 0.001; 263% [95% CI, 121-407%], P = 0.001), mostly due to increased aeration/ventilation in dorsal lung regions. During HFNO, 14 of 15 patients had pendelluft involving >10% of Vt; pendelluft was mitigated by CPAP and further by NIV. Conclusions: Compared with HFNO, helmet NIV, but not CPAP, reduced ΔPES. CPAP and NIV similarly increased oxygenation, end-expiratory lung volume, and Vt, without affecting ΔPL. NIV, and to a lesser extent CPAP, mitigated pendelluft. Clinical trial registered with clinicaltrials.gov (NCT04241861).
Collapse
Affiliation(s)
- Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Roberta Scarascia
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Daniele G. Biasucci
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Antonio M. Dell’Anna
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Salvatore L. Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Eloisa S. Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Claudio Sandroni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Salvatore Maurizio Maggiore
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy; and
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Domenico L. Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| |
Collapse
|
39
|
Wang D, Ning Y, He L, Pan K, Xiong X, Jing S, Hu J, Luo J, Ye D, Mei Z, Zhang W. Pendelluft as a predictor of weaning in critically ill patients: An observational cohort study. Front Physiol 2023; 14:1113379. [PMID: 37064916 PMCID: PMC10102394 DOI: 10.3389/fphys.2023.1113379] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/03/2023] Open
Abstract
Objective: Weaning failure is associated with adverse clinical outcomes. This study aimed to evaluate the accuracy of pendelluft during the spontaneous breathing trials (SBT) as a predictor of weaning outcome of patients with mechanical ventilation.Methods: An observational cohort study included 60 critically ill patients who were eligible for extubation. Pendelluft and electrical activity of the diaphragm (Edi) were monitored at baseline and every 10 minutes for the first 30 min of SBT denoted as T0, T1, T2, and T3. The pendelluft was measured using electrical impedance tomography (EIT), and Edi parameters were collected by Edi catheter. Patients were followed up after extubation and were divided into success group and failure group. Pendelluft, Edi parameters, respiratory parameters, and clinical outcomes such as intensive care units (ICU) stay, mortality, and 28-day ventilator-free days were compared between the two groups. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of pendelluft to predict weaning outcome.Results: Fifty patients (50/60) were successfully weaned from the machine and 10 (10/60) failed, with weaning failure rate of 16.7%. Respiratory parameters such as rapid shallow breathing index (RSBI), respiratory rate (RR) and Edi parameters such as maximum value of Edi (Edimax), Edi variation between a maximum and minimum(ΔEdi) in the failure group were higher than those in the success group. The ICU stay and the 28-day ventilator-free days in the failure group were significantly longer than those in the success group. The 28-day mortality rate was higher in the failure group. The pendelluft mainly occurred in the early stage of SBT. Ventral pendelluft and total pendelluft in the failure group were higher than those in the success group at T1. Edimax and ΔEdi were positively correlated with pendelluft. The area under ROC curve (AUC) showed moderate predictive ability for ventral pendelluft in predicting weaning failure at T1 (AUC 0.76, 95% CI 0.58–0.94, cut-off value > 3% global tidal variation).Conclusion: Pendelluft is one of the factors leading to weaning failure, which may be related to diaphragm function. Measuring pendelluft volume maybe helpful to predict weaning.
Collapse
Affiliation(s)
- Danqiong Wang
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yaxin Ning
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Linya He
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Keqi Pan
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
- School of Medicine, Shaoxing University, Shaoxing, China
| | - Xiaohua Xiong
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
| | - Shanshan Jing
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
| | - Jianhua Hu
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
| | - Jian Luo
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
| | - Dehua Ye
- Institute of Teacher Education, Department of Mathematics and Physics, Quzhou University, Quzhou, China
| | - Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
- *Correspondence: Zubing Mei, ; Weiwen Zhang,
| | - Weiwen Zhang
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
- *Correspondence: Zubing Mei, ; Weiwen Zhang,
| |
Collapse
|
40
|
Sklienka P, Frelich M, Burša F. Patient Self-Inflicted Lung Injury-A Narrative Review of Pathophysiology, Early Recognition, and Management Options. J Pers Med 2023; 13:593. [PMID: 37108979 PMCID: PMC10146629 DOI: 10.3390/jpm13040593] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Patient self-inflicted lung injury (P-SILI) is a life-threatening condition arising from excessive respiratory effort and work of breathing in patients with lung injury. The pathophysiology of P-SILI involves factors related to the underlying lung pathology and vigorous respiratory effort. P-SILI might develop both during spontaneous breathing and mechanical ventilation with preserved spontaneous respiratory activity. In spontaneously breathing patients, clinical signs of increased work of breathing and scales developed for early detection of potentially harmful effort might help clinicians prevent unnecessary intubation, while, on the contrary, identifying patients who would benefit from early intubation. In mechanically ventilated patients, several simple non-invasive methods for assessing the inspiratory effort exerted by the respiratory muscles were correlated with respiratory muscle pressure. In patients with signs of injurious respiratory effort, therapy aimed to minimize this problem has been demonstrated to prevent aggravation of lung injury and, therefore, improve the outcome of such patients. In this narrative review, we accumulated the current information on pathophysiology and early detection of vigorous respiratory effort. In addition, we proposed a simple algorithm for prevention and treatment of P-SILI that is easily applicable in clinical practice.
Collapse
Affiliation(s)
- Peter Sklienka
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, 17. listopadu 1790, 70800 Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
- Institute of Physiology and Pathophysiology, Department of Intensive Care Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
| | - Michal Frelich
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, 17. listopadu 1790, 70800 Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
| | - Filip Burša
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, 17. listopadu 1790, 70800 Ostrava, Czech Republic
- Department of Intensive Medicine, Emergency Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
- Institute of Physiology and Pathophysiology, Department of Intensive Care Medicine and Forensic Studies, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
| |
Collapse
|
41
|
Acute Respiratory Distress Syndrome, Mechanical Ventilation, and Inhalation Injury in Burn Patients. Surg Clin North Am 2023; 103:439-451. [PMID: 37149380 PMCID: PMC10028407 DOI: 10.1016/j.suc.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Respiratory failure occurs with some frequency in seriously burned patients, driven by a combination of inflammatory and infection factors. Inhalation injury contributes to respiratory failure in some burn patients via direct mucosal injury and indirect inflammation. In burn patients, respiratory failure leading to acute respiratory distress syndrome, with or without inhalation injury, is effectively managed using principles evolved for non-burn critically ill patients.
Collapse
|
42
|
Mlček M, Borges JB, Otáhal M, Alcala GC, Hladík D, Kuriščák E, Tejkl L, Amato M, Kittnar O. Real-time effects of lateral positioning on regional ventilation and perfusion in an experimental model of acute respiratory distress syndrome. Front Physiol 2023; 14:1113568. [PMID: 37020459 PMCID: PMC10067565 DOI: 10.3389/fphys.2023.1113568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/01/2023] [Indexed: 03/22/2023] Open
Abstract
Low-volume lung injury encompasses local concentration of stresses in the vicinity of collapsed regions in heterogeneously ventilated lungs. We aimed to study the effects on ventilation and perfusion distributions of a sequential lateral positioning (30°) strategy using electrical impedance tomography imaging in a porcine experimental model of early acute respiratory distress syndrome (ARDS). We hypothesized that such strategy, including a real-time individualization of positive end-expiratory pressure (PEEP) whenever in lateral positioning, would provide attenuation of collapse in the dependent lung regions. A two-hit injury acute respiratory distress syndrome experimental model was established by lung lavages followed by injurious mechanical ventilation. Then, all animals were studied in five body positions in a sequential order, 15 min each: Supine 1; Lateral Left; Supine 2; Lateral Right; Supine 3. The following functional images were analyzed by electrical impedance tomography: ventilation distributions and regional lung volumes, and perfusion distributions. The induction of the acute respiratory distress syndrome model resulted in a marked fall in oxygenation along with low regional ventilation and compliance of the dorsal half of the lung (gravitational-dependent in supine position). Both the regional ventilation and compliance of the dorsal half of the lung greatly increased along of the sequential lateral positioning strategy, and maximally at its end. In addition, a corresponding improvement of oxygenation occurred. In conclusion, our sequential lateral positioning strategy, with sufficient positive end-expiratory pressure to prevent collapse of the dependent lung units during lateral positioning, provided a relevant diminution of collapse in the dorsal lung in a porcine experimental model of early acute respiratory distress syndrome.
Collapse
Affiliation(s)
- Mikuláš Mlček
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - João Batista Borges
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
- *Correspondence: João Batista Borges,
| | - Michal Otáhal
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Glasiele Cristina Alcala
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Dominik Hladík
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Eduard Kuriščák
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - Leoš Tejkl
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - Marcelo Amato
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Otomar Kittnar
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| |
Collapse
|
43
|
Performance of Noninvasive Airway Occlusion Maneuvers to Assess Lung Stress and Diaphragm Effort in Mechanically Ventilated Critically Ill Patients. Anesthesiology 2023; 138:274-288. [PMID: 36520507 DOI: 10.1097/aln.0000000000004467] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Monitoring and controlling lung stress and diaphragm effort has been hypothesized to limit lung injury and diaphragm injury. The occluded inspiratory airway pressure (Pocc) and the airway occlusion pressure at 100 ms (P0.1) have been used as noninvasive methods to assess lung stress and respiratory muscle effort, but comparative performance of these measures and their correlation to diaphragm effort is unknown. The authors hypothesized that Pocc and P0.1 correlate with diaphragm effort and lung stress and would have strong discriminative performance in identifying extremes of lung stress and diaphragm effort. METHODS Change in transdiaphragmatic pressure and transpulmonary pressure was obtained with double-balloon nasogastric catheters in critically ill patients (n = 38). Pocc and P0.1 were measured every 1 to 3 h. Correlations between Pocc and P0.1 with change in transdiaphragmatic pressure and transpulmonary pressure were computed from patients from the first cohort. Accuracy of Pocc and P0.1 to identify patients with extremes of lung stress (change in transpulmonary pressure > 20 cm H2O) and diaphragm effort (change in transdiaphragmatic pressure < 3 cm H2O and >12 cm H2O) in the preceding hour was assessed with area under receiver operating characteristic curves. Cutoffs were validated in patients from the second cohort (n = 13). RESULTS Pocc and P0.1 correlate with change in transpulmonary pressure (R2 = 0.62 and 0.51, respectively) and change in transdiaphragmatic pressure (R2 = 0.53 and 0.22, respectively). Area under receiver operating characteristic curves to detect high lung stress is 0.90 (0.86 to 0.94) for Pocc and 0.88 (0.84 to 0.92) for P0.1. Area under receiver operating characteristic curves to detect low diaphragm effort is 0.97 (0.87 to 1.00) for Pocc and 0.93 (0.81 to 0.99) for P0.1. Area under receiver operating characteristic curves to detect high diaphragm effort is 0.86 (0.81 to 0.91) for Pocc and 0.73 (0.66 to 0.79) for P0.1. Performance was similar in the external dataset. CONCLUSIONS Pocc and P0.1 correlate with lung stress and diaphragm effort in the preceding hour. Diagnostic performance of Pocc and P0.1 to detect extremes in these parameters is reasonable to excellent. Pocc is more accurate in detecting high diaphragm effort. EDITOR’S PERSPECTIVE
Collapse
|
44
|
Sattari S, Mariano CA, Kuschner WG, Taheri H, Bates JHT, Eskandari M. Positive- and Negative-Pressure Ventilation Characterized by Local and Global Pulmonary Mechanics. Am J Respir Crit Care Med 2023; 207:577-586. [PMID: 36194677 PMCID: PMC10870900 DOI: 10.1164/rccm.202111-2480oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 10/04/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: There is continued debate regarding the equivalency of positive-pressure ventilation (PPV) and negative-pressure ventilation (NPV). Resolving this question is important because of the different practical ramifications of the two paradigms. Objectives: We sought to investigate the parallel between PPV and NPV and determine whether or not these two paradigms cause identical ventilation profiles by analyzing the local strain mechanics when the global tidal volume (Vt) and inflation pressure was matched. Methods: A custom-designed electromechanical apparatus was used to impose equal global loads and displacements on the same ex vivo healthy porcine lung using PPV and NPV. High-speed high-resolution cameras recorded local lung surface deformations and strains in real time, and differences between PPV and NPV global energetics, viscoelasticity, as well as local tissue distortion were assessed. Measurements and Main Results: During initial inflation, NPV exhibited significantly more bulk pressure-volume compliance than PPV, suggestive of earlier lung recruitment. NPV settings also showed reduced relaxation, hysteresis, and energy loss compared with PPV. Local strain trends were also decreased in NPV, with reduced tissue distortion trends compared with PPV, as revealed through analysis of tissue anisotropy. Conclusions: Apparently, contradictory previous studies are not mutually exclusive. Equivalent changes in transpulmonary pressures in PPV and NPV lead to the same changes in lung volume and pressures, yet local tissue strains differ between PPV and NPV. Although limited to healthy specimens and ex vivo experiments in the absence of a chest cavity, these results may explain previous reports of better oxygenation and less lung injury in NPV.
Collapse
Affiliation(s)
| | | | - Ware G. Kuschner
- Medical Service, Veterans Affairs Palo Alto Health Care System, Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University, Stanford, California; and
| | | | - Jason H. T. Bates
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Mona Eskandari
- Department of Mechanical Engineering
- BREATHE Center, School of Medicine, and
- Department of Bioengineering, University of California Riverside, Riverside, California
| |
Collapse
|
45
|
Liu Y, Liang L, Yang H. Airway management in "tubeless" spontaneous-ventilation video-assisted thoracoscopic tracheal surgery: a retrospective observational case series study. J Cardiothorac Surg 2023; 18:59. [PMID: 36737801 PMCID: PMC9898933 DOI: 10.1186/s13019-023-02157-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Surgeon and anesthetist share the airway in a simpler way in the resection and reconstruction phase of tracheal surgery in tubeless spontaneous-ventilation video-assisted thoracoscopic surgery (SV-VATS). Tubeless SV-VATS means stable spontaneous ventilation in the resection and reconstruction phase to anesthesiologist, and unobstructed surgical field to surgeon. What's the ideal airway management strategy during "Visual Field tubeless" SV-VATS for tracheal surgery is still an open question in the field. METHODS We retrospectively reviewed 33 patients without sleeve and carina resections during the study period (2018-2020) in our hospital. The initial management strategy for these patients was spontaneous ventilation for intrathoracic tracheal resection and reconstruction. We obtained and reviewed medical records from our institution's clinical medical records system to evaluate the airway management strategy and device failure rate for tracheal resection in Tubeless SV-VATS. RESULTS Between 2018 and 2020, SV-VATS was first attempted in the 33 patients who had intrathoracic tracheal surgery but without sleeve and carina resections. All patients underwent bronchoscopy (33/33) and 8 patients (8/33) received partial resection before surgery. During the surgery, the airway device comprised either a ProSeal laryngeal mask airway (ProSeal LMA) (n = 27) or single lumen endotracheal tube (n = 6). During the resection and reconstruction phase, Visual Field tubeless SV-VATS failed in 9 patients, and breathing support switched to plan B which is traditional ventilation of a single lumen endotracheal tube for cross field intubation (n = 4) and ProSeal LMA alongside a high-frequency catheter (high-frequency jet ventilation, HFJV) (n = 5) into the distal trachea ventilation. Preoperative respiratory failure or other ventilation-related complications were not observed in this cohort. CONCLUSION Base on current analysis either ProSeal LMA or endotracheal tube is an effective airway management strategy for tubeless SV-VATS with appropriate patient selection. It also provides breathing support conversion option when there's inadequate ventilation.
Collapse
Affiliation(s)
- Yuying Liu
- grid.470124.4Department of Anesthesia, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120 China
| | - Lixia Liang
- grid.470124.4Department of Anesthesia, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120 China
| | - Hanyu Yang
- Department of Anesthesia, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120, China.
| |
Collapse
|
46
|
Roshdy A. Respiratory Monitoring During Mechanical Ventilation: The Present and the Future. J Intensive Care Med 2023; 38:407-417. [PMID: 36734248 DOI: 10.1177/08850666231153371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increased application of mechanical ventilation, the recognition of its harms and the interest in individualization raised the need for an effective monitoring. An increasing number of monitoring tools and modalities were introduced over the past 2 decades with growing insight into asynchrony, lung and chest wall mechanics, respiratory effort and drive. They should be used in a complementary rather than a standalone way. A sound strategy can guide a reduction in adverse effects like ventilator-induced lung injury, ventilator-induced diaphragm dysfunction, patient-ventilator asynchrony and helps early weaning from the ventilator. However, the diversity, complexity, lack of expertise, and associated cost make formulating the appropriate monitoring strategy a challenge for clinicians. Most often, a big amount of data is fed to the clinicians making interpretation difficult. Therefore, it is fundamental for intensivists to be aware of the principle, advantages, and limits of each tool. This analytic review includes a simplified narrative of the commonly used basic and advanced respiratory monitors along with their limits and future prospective.
Collapse
Affiliation(s)
- Ashraf Roshdy
- Critical Care Medicine Department, Faculty of Medicine, 54562Alexandria University, Alexandria, Egypt.,Critical Care Unit, North Middlesex University Hospital, London, UK
| |
Collapse
|
47
|
Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2023; 11:197-212. [PMID: 36566767 PMCID: PMC10880453 DOI: 10.1016/s2213-2600(22)00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.
Collapse
Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine, University of Groningen, Groningen, Netherlands.
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mary K Dahmer
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montreal, QC, Canada
| | - Jocelyn Grunwell
- Department of Pediatrics, Division of Critical Care, Emory University, Atlanta, GA, USA
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Bhushan H Katira
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics (Critical Care), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| |
Collapse
|
48
|
Bongiovanni F, Michi T, Natalini D, Grieco DL, Antonelli M. Advantages and drawbacks of helmet noninvasive support in acute respiratory failure. Expert Rev Respir Med 2023; 17:27-39. [PMID: 36710082 DOI: 10.1080/17476348.2023.2174974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Non-invasive ventilation (NIV) represents an effective strategy for managing acute respiratory failure. Facemask NIV is strongly recommended in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnia and acute cardiogenic pulmonary edema (ACPE). Its role in managing acute hypoxemic respiratory failure (AHRF) remains a debated issue. NIV and continuous positive airway pressure (CPAP) delivered through the helmet are recently receiving growing interest for AHRF management. AREAS COVERED In this narrative review, we discuss the clinical applications of helmet support compared to the other available noninvasive strategies in the different phenotypes of acute respiratory failure. EXPERT OPINION Helmets enable the use of high positive end-expiratory pressure, which may protect from self-inflicted lung injury: in AHRF, the possible superiority of helmet support over other noninvasive strategies in terms of clinical outcome has been hypothesized in a network metanalysis and a randomized trial, but has not been confirmed by other investigations and warrants confirmation. In AECOPD patients, helmet efficacy may be inferior to that of face masks, and its use prompts caution due to the risk of CO2 rebreathing. Helmet support can be safely applied in hypoxemic patients with ACPE, with no advantages over facemasks.
Collapse
Affiliation(s)
- Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Daniele Natalini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Domenico L Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| |
Collapse
|
49
|
Wittenstein J, Huhle R, Leiderman M, Möbius M, Braune A, Tauer S, Herzog P, Barana G, de Ferrari A, Corona A, Bluth T, Kiss T, Güldner A, Schultz MJ, Rocco PRM, Pelosi P, Gama de Abreu M, Scharffenberg M. Effect of patient-ventilator asynchrony on lung and diaphragmatic injury in experimental acute respiratory distress syndrome in a porcine model. Br J Anaesth 2023; 130:e169-e178. [PMID: 34895719 DOI: 10.1016/j.bja.2021.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patient-ventilator asynchrony during mechanical ventilation may exacerbate lung and diaphragm injury in spontaneously breathing subjects. We investigated whether subject-ventilator asynchrony increases lung or diaphragmatic injury in a porcine model of acute respiratory distress syndrome (ARDS). METHODS ARDS was induced in adult female pigs by lung lavage and injurious ventilation before mechanical ventilation by pressure assist-control for 12 h. Mechanically ventilated pigs were randomised to breathe spontaneously with or without induced subject-ventilator asynchrony or neuromuscular block (n=7 per group). Subject-ventilator asynchrony was produced by ineffective, auto-, or double-triggering of spontaneous breaths. The primary outcome was mean alveolar septal thickness (where thickening of the alveolar wall indicates worse lung injury). Secondary outcomes included distribution of ventilation (electrical impedance tomography), lung morphometric analysis, inflammatory biomarkers (gene expression), lung wet-to-dry weight ratio, and diaphragmatic muscle fibre thickness. RESULTS Subject-ventilator asynchrony (median [interquartile range] 28.8% [10.4] asynchronous breaths of total breaths; n=7) did not increase mean alveolar septal thickness compared with synchronous spontaneous breathing (asynchronous breaths 1.0% [1.6] of total breaths; n=7). There was no difference in mean alveolar septal thickness throughout upper and lower lung lobes between pigs randomised to subject-ventilator asynchrony vs synchronous spontaneous breathing (87.3-92.2 μm after subject-ventilator asynchrony, compared with 84.1-95.0 μm in synchronised spontaneous breathing;). There were also no differences between groups in wet-to-dry weight ratio, diaphragmatic muscle fibre thickness, atelectasis, lung aeration, or mRNA expression levels for inflammatory cytokines pivotal in ARDS pathogenesis. CONCLUSIONS Subject-ventilator asynchrony during spontaneous breathing did not exacerbate lung injury and dysfunction in experimental porcine ARDS.
Collapse
Affiliation(s)
- Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Mark Leiderman
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Marius Möbius
- Neonatology and Pediatric Critical Care Medicine, Department of Pediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Anja Braune
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Nuclear Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Tauer
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Paul Herzog
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Giulio Barana
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology, Hospital Thurgau AG, Frauenfeld, Switzerland
| | - Alessandra de Ferrari
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesia and Intensive Care, IRCCS AOU San Martino IST, Genoa, Italy
| | - Andrea Corona
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology and Intensive Care, Mater Olbia Hospital, Olbia, Italy
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Andreas Güldner
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| |
Collapse
|
50
|
Chelly J, Coupry LM, van Phach Vong L, Kamel T, Marzouk M, Terzi N, Bruel C, Autret A, Garnero A, Arnal JM. Comparison of high-flow nasal therapy, noninvasive ventilation, and continuous positive airway pressure on outcomes in critically ill patients admitted for COVID-19 with acute respiratory failure. Minerva Anestesiol 2023; 89:66-73. [PMID: 36448989 DOI: 10.23736/s0375-9393.22.16918-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND The optimal first-line noninvasive respiratory support (NIRS) to improve outcome in patients affected by COVID-19 pneumonia admitted to ICU is still debated. METHODS We conducted a retrospective study in seven French ICUs, including all adults admitted between July and December 2020 with documented SARS-CoV-2 acute respiratory failure (PaO2/FiO2<300 mmHg), and treated with either high-flow nasal therapy (HFNT) alone, noninvasive ventilation alone or in combination with HFNT (NIV), or continuous positive airway pressure alone or in combination with HFNT (CPAP). The primary outcome was NIRS failure at day 28, defined as the need for endotracheal intubation (ETI) or death without ETI. RESULTS Among the 355 patients included, 160 (45%) were treated with HFNT alone, 115 (32%) with NIV and 80 (23%) with CPAP. The primary outcome occurred in 65 (41%), 69 (60%), and 25 (31%) patients among those treated with HFNT alone, NIV, and CPAP, respectively (P<0.001). After univariate analysis, patients treated with CPAP had a trend for a lower incidence of the primary outcome, whereas patients treated with NIV had a significant higher incidence of the primary outcome, both compared to those treated with HFNT alone (unadjusted Hazard ratio 0.67; 95% CI [0.42-1.06], and 1.58; 95% CI [1.12-2.22]; P=0.09 and 0.008, respectively). CONCLUSIONS Among ICU patients admitted for severe COVID-19 pneumonia and managed with NIRS, the outcome seems to differ according to the initial chosen strategy. Prospective randomized controlled studies are warranted to identify the optimal strategy.
Collapse
Affiliation(s)
- Jonathan Chelly
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France -
| | - Louis-Marie Coupry
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Ly van Phach Vong
- Intensive Care Unit, Grand Hôpital de l'Est Francilien (GHEF), Jossigny, France
| | - Toufik Kamel
- Intensive Care Unit, Centre Hospitalier Régional (CHR) d'Orléans, Orléans, France
| | - Mehdi Marzouk
- Intensive Care Unit, Hospital of Béthune, Béthune, France
| | - Nicolas Terzi
- Intensive Care Unit, Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, France
| | - Cedric Bruel
- Intensive Care Unit, Saint Joseph Hospital, Paris, France
| | - Aurélie Autret
- Clinical Research Department, Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer - Sainte Musse Hospital, Toulon, France
| | - Aude Garnero
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France
| | - Jean-Michel Arnal
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Sainte Musse Hospital, Toulon, France
| |
Collapse
|