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Post-Spenkelink R, Flim M, van Iperen ID, Kuindersma M, Spronk PE. Driving pressure during routine ventilation in the ICU: Is the ICU-team as driven as they should be? J Crit Care 2024; 83:154841. [PMID: 38875915 DOI: 10.1016/j.jcrc.2024.154841] [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: 09/26/2023] [Revised: 05/07/2024] [Accepted: 05/28/2024] [Indexed: 06/16/2024]
Abstract
PURPOSE To evaluate the effect of structured staff training on the respiratory support provided. MATERIALS AND METHODS Staff training with emphasis on the applied DP in mechanical ventilation was provided during one year. After completion of staff training, the effect was prospectively evaluated in patients who were continuously mechanically ventilated in a controlled mode for at least 6 h starting from admission. Pressure difference (Pdiff = Ppeak - PEEPtot) in the baseline period, as a derivative of the driving pressure, was compared with two evaluation periods from 0 to 6 months and 6-12 months (i.e. follow-up) after completion of the training. RESULTS At analysis 248 patients met the inclusion criteria. In the baseline period Pdiff was not lung protective (> 15 cm H2O) in 39% of cases. In the first follow-up period this decreased to 25% of cases and further dropped to 17% in the second follow-up period. This was a relative decrease of 56% compared to the training period. At the end of evaluation the proportion of patients with a safe Pdiff had gradually increased from 58% during training to 82% (χ2 = p 0.005). CONCLUSIONS These results suggest that ICU staff training could lead to more adequate respiratory support provided during controlled mechanical ventilation.
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Affiliation(s)
- Renee Post-Spenkelink
- Gelre Hospitals, Department of Intensive Care Medicine, Albert Schweiterlaan 31, 7334 DZ Apeldoorn, the Netherlands
| | - Marleen Flim
- Gelre Hospitals, Department of Intensive Care Medicine, Albert Schweiterlaan 31, 7334 DZ Apeldoorn, the Netherlands; Expertise Center for Intensive Care Rehabilitation Apeldoorn (ExpIRA), the Netherlands
| | - Ingrid D van Iperen
- Gelre Hospitals, Department of Intensive Care Medicine, Albert Schweiterlaan 31, 7334 DZ Apeldoorn, the Netherlands; Expertise Center for Intensive Care Rehabilitation Apeldoorn (ExpIRA), the Netherlands
| | - Marnix Kuindersma
- Gelre Hospitals, Department of Intensive Care Medicine, Albert Schweiterlaan 31, 7334 DZ Apeldoorn, the Netherlands.
| | - Peter E Spronk
- Gelre Hospitals, Department of Intensive Care Medicine, Albert Schweiterlaan 31, 7334 DZ Apeldoorn, the Netherlands; Expertise Center for Intensive Care Rehabilitation Apeldoorn (ExpIRA), the Netherlands
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2
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Parhar KKS, Doig C. Caution-Do Not Attempt This at Home. Airway Pressure Release Ventilation Should Not Routinely Be Used in Patients With or at Risk of Acute Respiratory Distress Syndrome Outside of a Clinical Trial. Crit Care Med 2024; 52:1451-1457. [PMID: 36661571 DOI: 10.1097/ccm.0000000000005776] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Ken Kuljit S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, ICU Administration - Ground Floor - McCaig Tower, Foothills Medical Center, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Christopher Doig
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, ICU Administration - Ground Floor - McCaig Tower, Foothills Medical Center, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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3
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Luckner KM, Seckel MA. Understanding the Evolving Pathophysiology of Coronavirus Disease 2019 and Adult Nursing Management. Crit Care Nurs Clin North Am 2024; 36:295-321. [PMID: 39069352 DOI: 10.1016/j.cnc.2024.01.002] [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: 07/30/2024]
Abstract
Coronavirus disease 2019 (COVID-19) was first identified in December 2019 and quickly became a global pandemic. The understanding of the pathophysiology, treatment, and management of the disease has evolved since the beginning of the pandemic in 2020. COVID-19 can be complicated by immune system dysfunction, lung injury with hypoxemia, acute kidney injury, and coagulopathy. The treatment and management of COVID-19 is based on the severity of illness, ranging from asymptomatic to severe and often life-threatening disease. The 3 main recommended medication classes include antivirals, immunomodulators, and anticoagulants. Other supportive therapies include ensuring adequate oxygenation, mechanical ventilation, and prone positioning.
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Fumagalli B, Giani M, Bombino M, Fumagalli D, Merelli M, Chiesa G, Rona R, Bellani G, Rezoagli E, Foti G. Pressure Support Ventilation During Extracorporeal Membrane Oxygenation Support in Patients With Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00542. [PMID: 39116298 DOI: 10.1097/mat.0000000000002285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
In the initial phases of veno-venous extracorporeal membrane oxygenation (VV ECMO) support for severe acute respiratory distress syndrome (ARDS), ultraprotective controlled mechanical ventilation (CMV) is typically employed to limit the progression of lung injury. As patients recover, transitioning to assisted mechanical ventilation can be considered to reduce the need for prolonged sedation and paralysis. This study aimed to evaluate the feasibility of transitioning to pressure support ventilation (PSV) during VV ECMO and to explore variations in respiratory mechanics and oxygenation parameters following the transition to PSV. This retrospective monocentric study included 191 adult ARDS patients treated with VV ECMO between 2009 and 2022. Within this population, 131 (69%) patients were successfully switched to PSV during ECMO. Pressure support ventilation was associated with an increase in respiratory system compliance (p = 0.02) and a reduction in pulmonary shunt fraction (p < 0.001). Additionally, improvements in the cardiovascular Sequential Organ Failure Assessment score and a reduction in pulmonary arterial pressures (p < 0.05) were recorded. Ninety-four percent of patients who successfully transitioned to PSV were weaned from ECMO, and 118 (90%) were discharged alive from the intensive care unit (ICU). Of those who did not reach PSV, 74% died on ECMO, whereas the remaining patients were successfully weaned from extracorporeal support. In conclusion, PSV is feasible during VV ECMO and potentially correlates with improvements in respiratory function and hemodynamics.
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Affiliation(s)
- Benedetta Fumagalli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marco Giani
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Denise Fumagalli
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Milena Merelli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Gaia Chiesa
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Rona
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giacomo Bellani
- Department of Medical Sciences, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari di Trento, Trento, Italy
| | - Emanuele Rezoagli
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
| | - Giuseppe Foti
- From Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Monza, Italy
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5
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Schaller SJ, Scheffenbichler FT, Bein T, Blobner M, Grunow JJ, Hamsen U, Hermes C, Kaltwasser A, Lewald H, Nydahl P, Reißhauer A, Renzewitz L, Siemon K, Staudinger T, Ullrich R, Weber-Carstens S, Wrigge H, Zergiebel D, Coldewey SM. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med 2024; 50:1211-1227. [PMID: 39073582 DOI: 10.1007/s00134-024-07532-2] [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: 02/28/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.
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Affiliation(s)
- Stefan J Schaller
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | | | | | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julius J Grunow
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Uwe Hamsen
- Ruhr University Bochum, Bochum, Germany
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Carsten Hermes
- Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany
- Akkon-Hochschule für Humanwissenschaften, Berlin, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Heidrun Lewald
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Nydahl
- University Hospital of Schleswig-Holstein, Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria
| | - Anett Reißhauer
- Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonie Renzewitz
- Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karsten Siemon
- Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | | | - Sina M Coldewey
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
- Septomics Research Center, Jena University Hospital, Jena, Germany.
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6
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Franchi F, Detti E, Fogagnolo A, Spadaro S, Cevenini G, Cataldo G, Addabbo T, Biuzzi C, Marianello D, Volta CA, Taccone FS, Scolletta S. Estimation of the transpulmonary pressure from the central venous pressure in mechanically ventilated patients. J Clin Monit Comput 2024; 38:847-858. [PMID: 38512359 PMCID: PMC11297816 DOI: 10.1007/s10877-024-01150-5] [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: 08/21/2023] [Accepted: 03/05/2024] [Indexed: 03/23/2024]
Abstract
Transpulmonary pressure (PL) calculation requires esophageal pressure (PES) as a surrogate of pleural pressure (Ppl), but its calibration is a cumbersome technique. Central venous pressure (CVP) swings may reflect tidal variations in Ppl and could be used instead of PES, but the interpretation of CVP waveforms could be difficult due to superposition of heartbeat-induced pressure changes. Thus, we developed a digital filter able to remove the cardiac noise to obtain a filtered CVP (f-CVP). The aim of the study was to evaluate the accuracy of CVP and filtered CVP swings (ΔCVP and Δf-CVP, respectively) in estimating esophageal respiratory swings (ΔPES) and compare PL calculated with CVP, f-CVP and PES; then we tested the diagnostic accuracy of the f-CVP method to identify unsafe high PL levels, defined as PL>10 cmH2O. Twenty patients with acute respiratory failure (defined as PaO2/FiO2 ratio below 200 mmHg) treated with invasive mechanical ventilation and monitored with an esophageal balloon and central venous catheter were enrolled prospectively. For each patient a recording session at baseline was performed, repeated if a modification in ventilatory settings occurred. PES, CVP and airway pressure during an end-inspiratory and -expiratory pause were simultaneously recorded; CVP, f-CVP and PES waveforms were analyzed off-line and used to calculate transpulmonary pressure (PLCVP, PLf-CVP, PLPES, respectively). Δf-CVP correlated better than ΔCVP with ΔPES (r = 0.8, p = 0.001 vs. r = 0.08, p = 0.73), with a lower bias in Bland Altman analysis in favor of PLf-CVP (mean bias - 0.16, Limits of Agreement (LoA) -1.31, 0.98 cmH2O vs. mean bias - 0.79, LoA - 3.14, 1.55 cmH2O). Both PLf-CVP and PLCVP correlated well with PLPES (r = 0.98, p < 0.001 vs. r = 0.94, p < 0.001), again with a lower bias in Bland Altman analysis in favor of PLf-CVP (0.15, LoA - 0.95, 1.26 cmH2O vs. 0.80, LoA - 1.51, 3.12, cmH2O). PLf-CVP discriminated high PL value with an area under the receiver operating characteristic curve 0.99 (standard deviation, SD, 0.02) (AUC difference = 0.01 [-0.024; 0.05], p = 0.48). In mechanically ventilated patients with acute respiratory failure, the digital filtered CVP estimated ΔPES and PL obtained from digital filtered CVP represented a reliable value of standard PL measured with the esophageal method and could identify patients with non-protective ventilation settings.
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Affiliation(s)
- Federico Franchi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy.
| | - Emanuele Detti
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Alberto Fogagnolo
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Savino Spadaro
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Gabriele Cevenini
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Gennaro Cataldo
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Tommaso Addabbo
- Department of Information Engineering and Mathematics, University of Siena, 53100, Siena, Italy
| | - Cesare Biuzzi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Daniele Marianello
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Carlo Alberto Volta
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, 1070, Belgium
| | - Sabino Scolletta
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
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Fernández J, Blasi A, Hidalgo E, Karvellas CJ. Bridging the critically ill patient with acute to chronic liver failure to liver transplantation. Am J Transplant 2024; 24:1348-1361. [PMID: 38548058 DOI: 10.1016/j.ajt.2024.03.026] [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: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
| | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Ernest Hidalgo
- Hepatolobiliary Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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Ayenew T, Gedfew M, Fetene MG, Workneh BS, Telayneh AT, Edmealem A, Tiruneh BG, Yinges GT, Getie A, Meselu MA. Prevalence of mortality among mechanically ventilated patients in the intensive care units of Ethiopian hospitals and the associated factors: A systematic review and meta-analysis. PLoS One 2024; 19:e0306277. [PMID: 39042621 PMCID: PMC11265714 DOI: 10.1371/journal.pone.0306277] [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: 01/09/2024] [Accepted: 06/13/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND In the intensive care unit (ICU), mechanical ventilation (MV) is a typical way of respiratory support. The severity of the illness raises the likelihood of death in patients who require MV. Several studies have been done in Ethiopia; however, the mortality rate differs among them. The objective of this systematic review and meta-analysis is to provide a pooled prevalence of mortality and associated factors among ICU-admitted patients receiving MV in Ethiopian hospitals. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria to conduct a comprehensive systematic review and meta-analysis in this study. We searched PubMed/Medline, SCOPUS, Embase, Hinari, and Web of Science and found 22 articles that met our inclusion criteria. We used a random-effects model. To identify heterogeneity within the included studies, meta-regression and subgroup analysis were used. We employed Egger's regression test and funnel plots for assessing publication bias. STATA version 17.0 software was used for all statistical analyses. RESULTS In this systematic review and meta-analysis, the pooled prevalence of mortality among 7507 ICU-admitted patients from 22 articles, who received MV was estimated to be 54.74% [95% CI = 47.93, 61.55]. In the subgroup analysis by region, the Southern Nations, Nationalities, and Peoples (SNNP) subgroup (64.28%, 95% CI = 51.19, 77.37) had the highest prevalence. Patients with COVID-19 have the highest mortality rate (75.80%, 95% CI = 51.10, 100.00). Sepsis (OR = 6.85, 95%CI = 3.24, 14.46), Glasgow Coma Scale (GCS) score<8 (OR = 6.58, 95%CI = 1.96, 22.11), admission with medical cases (OR = 4.12, 95%CI = 2.00, 8.48), Multi Organ Dysfunction Syndrome (MODS) (OR = 2.70, 95%CI = 4.11, 12.62), and vasopressor treatment (OR = 19.06, 95%CI = 9.34, 38.88) were all statistically associated with mortality. CONCLUSION Our review found that the pooled prevalence of mortality among mechanically ventilated ICU-admitted patients in Ethiopia was considerably high compared to similar studies in the United States (US), China, and other countries. Sepsis, GCS<8, medical cases, MODS, and use of vasopressors were statistically associated with mortality. Clinicians should exercise caution while mechanically ventilating ICU-admitted patients with these factors. However, it should be noted that the exact cause and effect relationship could not be established with this meta-analysis, as the available evidence is not sufficient. Thus, more studies using prospective methods will be required.
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Affiliation(s)
- Temesgen Ayenew
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Mihretie Gedfew
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Mamaru Getie Fetene
- Department of Midwifery, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Belayneh Shetie Workneh
- Department of Emergency Medicine and Critical Care Nursing, University of Gondar, Gondar, Ethiopia
| | - Animut Takele Telayneh
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Afework Edmealem
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Bekele Getenet Tiruneh
- Department of Internal Medicine, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | | | - Addisu Getie
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Mengistu Abebe Meselu
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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9
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Miserocchi G, Rezoagli E, Muñoz-Del-Carpio-Toia A, Paricahua-Yucra LP, Zubieta-DeUrioste N, Zubieta-Calleja G, Beretta E. Modelling lung diffusion-perfusion limitation in mechanically ventilated SARS-CoV-2 patients. Front Physiol 2024; 15:1408531. [PMID: 39072215 PMCID: PMC11272564 DOI: 10.3389/fphys.2024.1408531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/18/2024] [Indexed: 07/30/2024] Open
Abstract
This is the first study to describe the daytime evolution of respiratory parameters in mechanically ventilated COVID-19 patients. The data base refers to patients hospitalised in the intensive care unit (ICU) at Arequipa Hospital (Peru, 2335 m) in 2021. In both survivors (S) and non-survivors (NS) patients, a remarkable decrease in respiratory compliance was observed, revealing a proportional decrease in inflatable alveolar units. The S and NS patients were all hyperventilated and their SatO2 was maintained at >90%. However, while S remained normocapnic, NS developed progressive hypercapnia. We compared the efficiency of O2 uptake and CO2 removal in the air blood barrier relying on a model allowing to partition between diffusion and perfusion limitations to gas exchange. The decrease in O2 uptake was interpreted as diffusion limitation, while the impairment in CO2 removal was modelled by progressive perfusion limitation. The latter correlated with the increase in positive end-expiratory pressure (PEEP) and plateau pressure (Pplat), leading to capillary compression, increased blood velocity, and considerable shortening of the air-blood contact time.
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Affiliation(s)
- Giuseppe Miserocchi
- Dipartimento di Medicina e Chirurgia, Università Milano-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- Dipartimento di Medicina e Chirurgia, Università Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | | | | | | | - Egidio Beretta
- Dipartimento di Medicina e Chirurgia, Università Milano-Bicocca, Monza, Italy
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10
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Vicovan AG, Petrescu DC, Constantinescu D, Iftimi E, Cernescu IT, Ancuta CM, Caratașu CC, Șorodoc L, Ceasovschih A, Solcan C, Ghiciuc CM. Experimental Insights on the Use of Secukinumab and Magnolol in Acute Respiratory Diseases in Mice. Biomedicines 2024; 12:1538. [PMID: 39062111 PMCID: PMC11275060 DOI: 10.3390/biomedicines12071538] [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: 05/21/2024] [Revised: 06/26/2024] [Accepted: 07/06/2024] [Indexed: 07/28/2024] Open
Abstract
This study investigates the combined treatment of secukinumab (SECU) and magnolol (MAGN) in a mouse model of LPS-induced ALI overlapped with allergic pulmonary inflammation, aiming to better understand the mechanism behind this pathology and to assess the therapeutic potential of this novel approach in addressing the severity of ALI. The combined treatment reveals intricate immunomodulatory effects. Both treatments inhibit IL-17 and promote M2 macrophage polarization, which enhances anti-inflammatory cytokine production such as IL-4, IL-5, IL-10, and IL-13, crucial for lung repair and inflammation resolution. However, the combination treatment exacerbates allergic responses and increases OVA-specific IgE, potentially worsening ALI outcomes. MAGN pretreatment alone demonstrates higher potency in reducing neutrophils and enhancing IFN-γ, suggesting its potential in mitigating severe asthma symptoms and modulating immune responses. The study highlights the need for careful consideration in therapeutic applications due to the combination treatment's inability to reduce IL-6 and its potential to exacerbate allergic inflammation. Elevated IL-6 levels correlate with worsened oxygenation and increased mortality in ALI patients, underscoring its critical role in disease severity. These findings offer valuable insights for the advancement of precision medicine within the realm of respiratory illnesses, emphasizing the importance of tailored therapeutic strategies.
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Affiliation(s)
- Andrei Gheorghe Vicovan
- Department of Morpho-Functional Sciences II—Pharmacology and Clinical Pharmacology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy of Iași, 16 Universitatii Street, 700115 Iași, Romania; (A.G.V.); (I.T.C.); (C.M.G.)
| | - Diana Cezarina Petrescu
- Department of Morpho-Functional Sciences II—Pharmacology and Clinical Pharmacology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy of Iași, 16 Universitatii Street, 700115 Iași, Romania; (A.G.V.); (I.T.C.); (C.M.G.)
| | - Daniela Constantinescu
- Department of Immunology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iași, Romania; (D.C.); (E.I.)
| | - Elena Iftimi
- Department of Immunology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iași, Romania; (D.C.); (E.I.)
| | - Irina Teodora Cernescu
- Department of Morpho-Functional Sciences II—Pharmacology and Clinical Pharmacology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy of Iași, 16 Universitatii Street, 700115 Iași, Romania; (A.G.V.); (I.T.C.); (C.M.G.)
| | - Codrina Mihaela Ancuta
- 2nd Rheumatology Department, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Str., 700664 Iași, Romania;
- Rheumatology Department, University of Medicine and Pharmacy “Grigore T Popa”, 16 Universitatii Street, 700115 Iași, Romania
| | - Cezar-Cătălin Caratașu
- Advanced Research and Development Center for Experimental Medicine (CEMEX), Grigore T. Popa University of Medicine and Pharmacy of Iași, 16 Universității Street, 700115 Iași, Romania;
| | - Laurențiu Șorodoc
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 16 Universitatii Street, 700115 Iași, Romania; (L.Ș.); (A.C.)
| | - Alexandr Ceasovschih
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 16 Universitatii Street, 700115 Iași, Romania; (L.Ș.); (A.C.)
| | - Carmen Solcan
- Department IX—Discipline of Histology, Embryology and Molecular Biology, Faculty of Veterinary Medicine, “Ion Ionescu de la Brad” University of Life Sciences, 3 Mihail Sadoveanu Str., 700490 Iași, Romania;
| | - Cristina Mihaela Ghiciuc
- Department of Morpho-Functional Sciences II—Pharmacology and Clinical Pharmacology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy of Iași, 16 Universitatii Street, 700115 Iași, Romania; (A.G.V.); (I.T.C.); (C.M.G.)
- Pediatric Emergency Hospital Sf Maria, 700887 Iași, Romania
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11
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Xingzheng L, Weiguang G, Quanqiu Y, Huifen Z, Zijun Z, Qiming Z, Suhua Y, Fu Z, Zhigang J. The impact of positive end-expiratory pressure on right ventricular function in patients with moderate-to-severe ARDS: a prospective paired-design study. Front Med (Lausanne) 2024; 11:1424090. [PMID: 39015782 PMCID: PMC11250698 DOI: 10.3389/fmed.2024.1424090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024] Open
Abstract
Objective To determine the effects of varying positive end-expiratory pressures (PEEPs) on right ventricular function, hemodynamics, oxygenation, and the incidence of acute cor pulmonale (ACP) in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Methods This prospective paired-design study involved patients with moderate-to-severe ARDS in the ICU. Participants received lung-protective ventilation and hemodynamic monitoring. During the study, mechanical ventilation was administered with PEEPs of 5 cmH2O, 10 cmH2O, and 15 cmH2O, while maintaining an end-inspiratory plateau pressure ≤ 30 cmH2O. Various assessments, including transthoracic echocardiography, cardiac output measurement, and blood gas analysis, were conducted at baseline and after 1 h of ventilation at each PEEP. Subsequently, variations in ventilation oxygenation, echocardiographic parameters, and hemodynamic indicators under different PEEPs were analyzed to explore the potential effects of PEEP on right ventricular function and hemodynamics, as well as the incidence of ACP. Results A total of 317 ARDS patients were screened. Among them, 104 met the diagnostic criteria for moderate-to-severe ARDS, and 52 completed the study. The baseline PEEP of these 52 participants, acquired before commencement, was 11.5 ± 1.7 cmH2O, and the incidence of ACP was 25.0% (13/52). Intensive care unit mortality, overall hospital mortality, and 28-day mortality rates were 19.2% (10/52), 21.2% (11/52), and 32.7% (17/52), respectively. During the study, ACP incidences at PEEPs of 5 cmH2O, 10 cmH2O, and 15 cmH2O were 17.3% (9/52), 21.2% (11/52), and 38.5% (20/52), respectively. Meanwhile, the PaO2/FiO2 ratio improved with increasing PEEP, reaching 162.0 (140.9, 174.0), 171.0 (144.0, 182.0), and 176.5 (151.0, 196) mmHg at PEEPs of 5 cmH2O, 10 cmH2O, and 15 cmH2O, respectively. In addition, higher PEEPs were associated with a slight increase in PaCO2, showing statistically significant differences compared to moderate and low PEEPs. Compared to a PEEP of 5 cmH2O or 10 cmH2O, right ventricular function exhibited substantial changes at 15 cmH2O PEEP, manifested as increased pulmonary artery systolic pressure, enlarged right ventricular end-diastolic area, and decreased tricuspid annular plane systolic excursion, all with significant differences. Conversely, variations in left ventricular end-diastolic area and ejection fraction were not statistically significant. In terms of hemodynamics, increasing PEEP resulted in a decline in cardiac index (CI), with statistically significant differences between different PEEPs. Specifically, compared to the value at a PEEP of 5 cmH2O, the CI at a PEEP of 15 cmH2O decreased by 14.3% (2.63 [2.20, 2.95] vs. 3.07 [2.69, 3.67], p < 0.001). The decline in the stroke volume index with PEEP was more obvious (22.1 [18.4, 27.1] vs. 27.0 [24.2, 33.0], p < 0.001), reaching 18.1%. Additionally, both end-diastolic volume index and extravascular lung water index decreased significantly with increasing PEEP, while the pulmonary vascular permeability index remained unaffected. Conclusion Different PEEPs can affect the incidence of ACP in patients with moderate-to-severe ARDS. High PEEP improves oxygenation and reduces extravascular lung water without significantly affecting the pulmonary vascular permeability index and left ventricular systolic function. Nevertheless, it can cause right ventricular dilation, as well as substantial declines in right ventricular systolic function and CI, thereby causing ACP.
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Affiliation(s)
- Luo Xingzheng
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Gu Weiguang
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Ye Quanqiu
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zhou Huifen
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zheng Zijun
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zou Qiming
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Yuan Suhua
- Department of Medical Records, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Zhang Fu
- Department of Ultrasound, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
| | - Jian Zhigang
- Department of Critical Care Medicine, Xiaolan People’s Hospital of Zhongshan, Zhongshan, Guangdong, China
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12
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Marini JJ, Kummer RL, Rocco PRM. Does 'sub-threshold' ventilatory stress promote healing after lung injury? Intensive Care Med Exp 2024; 12:59. [PMID: 38954123 PMCID: PMC11219703 DOI: 10.1186/s40635-024-00644-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/22/2024] [Indexed: 07/04/2024] Open
Abstract
Excessive tidal stretching may initiate damage or retard healing after lung injury. However, it is seldom considered whether intracycle power and ventilatory forces of lesser magnitude than those required to cross an injury threshold might stimulate or accelerate beneficial adaptive responses. Acute lung injury is a dynamic process that may exhibit phase-dependent reparative responses to mechanical stress broadly similar to physical training, body trauma or sepsis. We propose that lower stress may not always be better through all phases of ARDS; moderately high tidal airway pressures that stay below the threshold of global injury may have potential to speed healing of the injured lung.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA.
| | - Rebecca L Kummer
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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13
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Sud S, Fan E, Adhikari NKJ, Friedrich JO, Ferguson ND, Combes A, Guerin C, Guyatt G. Comparison of venovenous extracorporeal membrane oxygenation, prone position and supine mechanical ventilation for severely hypoxemic acute respiratory distress syndrome: a network meta-analysis. Intensive Care Med 2024; 50:1021-1034. [PMID: 38842731 DOI: 10.1007/s00134-024-07492-7] [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: 05/13/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE Severe acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS. METHODS We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence. RESULTS Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59-0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57-0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66-0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63-1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72-1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals. CONCLUSIONS In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.
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Affiliation(s)
- Sachin Sud
- Division of Critical Care, Department of Medicine, Trillium Health Center, University of Toronto, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
- Institute of Better Health, Trillium Health Partners, Mississauga, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France
| | - Claude Guerin
- Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Université de Lyon, Lyon, France
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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14
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Randhawa VK, Lee R, Alviar CL, Rali AS, Arias A, Vaidya A, Zern EK, Fagan A, Proudfoot AG, Katz JN. Extra-cardiac management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1051-1058. [PMID: 38823968 DOI: 10.1016/j.healun.2024.03.017] [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: 12/30/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.
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Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Division of Cardiology, St Michael's Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ran Lee
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Sections of Critical Care Cardiology and Advanced Heart Failure and Transplant Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos L Alviar
- The Leon H Charney Division of Cardiovascular Medicine, NYU Langone Medical Center, New York, New York
| | - Aniket S Rali
- Department of Internal Medicine, Division of Cardiovascular Diseases, and Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra Arias
- Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program, Division of Cardiology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Emily K Zern
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medicine Center, Los Angeles General Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Andrew Fagan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine and Bellevue Hospital Center, New York, New York.
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15
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Wong JJM, Dang H, Gan CS, Phan PH, Kurosawa H, Aoki K, Lee SW, Ong JSM, Fan L, Tai CW, Chuah SL, Lee PC, Chor YK, Ngu L, Anantasit N, Liu C, Xu W, Wati DK, Gede SIB, Jayashree M, Liauw F, Pon KM, Huang L, Chong JY, Zhu X, Hon KLE, Leung KKY, Samransamruajkit R, Cheung YB, Lee JH. Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial. Crit Care Med 2024:00003246-990000000-00353. [PMID: 38920618 DOI: 10.1097/ccm.0000000000006357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVES Despite the recommendation for lung-protective mechanical ventilation (LPMV) in pediatric acute respiratory distress syndrome (PARDS), there is a lack of robust supporting data and variable adherence in clinical practice. This study evaluates the impact of an LPMV protocol vs. standard care and adherence to LPMV elements on mortality. We hypothesized that LPMV strategies deployed as a pragmatic protocol reduces mortality in PARDS. DESIGN Multicenter prospective before-and-after comparison design study. SETTING Twenty-one PICUs. PATIENTS Patients fulfilled the Pediatric Acute Lung Injury Consensus Conference 2015 definition of PARDS and were on invasive mechanical ventilation. INTERVENTIONS The LPMV protocol included a limit on peak inspiratory pressure (PIP), delta/driving pressure (DP), tidal volume, positive end-expiratory pressure (PEEP) to Fio2 combinations of the low PEEP acute respiratory distress syndrome network table, permissive hypercarbia, and conservative oxygen targets. MEASUREMENTS AND MAIN RESULTS There were 285 of 693 (41·1%) and 408 of 693 (58·9%) patients treated with and without the LPMV protocol, respectively. Median age and oxygenation index was 1.5 years (0.4-5.3 yr) and 10.9 years (7.0-18.6 yr), respectively. There was no difference in 60-day mortality between LPMV and non-LPMV protocol groups (65/285 [22.8%] vs. 115/406 [28.3%]; p = 0.104). However, total adherence score did improve in the LPMV compared to non-LPMV group (57.1 [40.0-66.7] vs. 47.6 [31.0-58.3]; p < 0·001). After adjusting for confounders, adherence to LPMV strategies (adjusted hazard ratio, 0.98; 95% CI, 0.97-0.99; p = 0.004) but not the LPMV protocol itself was associated with a reduced risk of 60-day mortality. Adherence to PIP, DP, and PEEP/Fio2 combinations were associated with reduced mortality. CONCLUSIONS Adherence to LPMV elements over the first week of PARDS was associated with reduced mortality. Future work is needed to improve implementation of LPMV in order to improve adherence.
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Affiliation(s)
- Judith Ju Ming Wong
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Children's Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Phuc Huu Phan
- Vietnam National Children's Hospital, Hanoi, Vietnam
| | | | - Kazunori Aoki
- Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Siew Wah Lee
- Sultanah Aminah Hospital, Johor, Malaysia
- Hospital Tengku Ampuan Rahimah, Selangor, Malaysia
| | | | - Lijia Fan
- Division of Paediatric Critical Care, National University Hospital, Singapore
| | - Chian Wern Tai
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | - Soo Lin Chuah
- Department of Paediatrics, University Malaya Medical Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Pei Chuen Lee
- Universiti Kebangsaan Malaysia Specialist Children's Hospital, Kuala Lumpur, Malaysia
| | | | - Louise Ngu
- Sarawak General Hospital, Sarawak, Malaysia
| | | | - Chunfeng Liu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Wei Xu
- Shengjing Hospital of China Medical University, Liaoning, China
| | - Dyah Kanya Wati
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | - Suparyatha Ida Bagus Gede
- Pediatric Emergency and Intensive Care Unit, Prof I.G.N.G Ngoerah Hospital, Bali, Indonesia
- Medical Faculty, Udayana University, Bali, Indonesia
| | | | - Felix Liauw
- Harapan Kita National Women and Children Health Center, Jakarta, Indonesia
| | | | - Li Huang
- Guangzhou Women and Children's Medical Center, Guangdong, China
| | - Jia Yueh Chong
- Hospital Tunku Azizah Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Xuemei Zhu
- Children's Hospital of Fudan University, Shanghai, China
| | - Kam Lun Ellis Hon
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yin Bun Cheung
- Duke-NUS Medical School, Singapore
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
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16
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Jørgensen VL, Adelsten J, Christensen S, Nielsen DV, Eschen CT, Sørensen HM, Sørensen M, Madsen SA, Gjedsted J, Pedersen FM, Nielsen J, Grønlykke L. The use of prone position ventilation in Danish patients with COVID-19-induced severe acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation: A nationwide cohort study with focus on pulmonary effects. Acta Anaesthesiol Scand 2024. [PMID: 38932581 DOI: 10.1111/aas.14481] [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: 08/08/2023] [Revised: 05/25/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Prone position ventilation (PPV) is recommended for patients with COVID-19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V-V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance. METHODS This study was a nationwide retrospective analysis of all COVID-19 patients in Denmark from March 2020 - December 2021 with severe ARDS and need of V-V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported. RESULTS Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within-patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course. CONCLUSION Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance.
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Affiliation(s)
- Vibeke Lind Jørgensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Janne Adelsten
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Dorthe Viemose Nielsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Camilla Tofte Eschen
- Department of Anaesthesiology and Intensive Care, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Hasse Møller Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Sørensen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Aalbæk Madsen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Gjedsted
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Møller Pedersen
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jonas Nielsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Grønlykke
- Department of Cardiothoracic Anaesthesia and Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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17
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Ogura K, Nakayama R, Bunya N, Katayama S, Yama N, Goto Y, Sawamoto K, Uemura S, Narimatsu E. Correlation between normally aerated lung and respiratory system compliance at clinical high positive end-expiratory pressure in patients with COVID-19. Sci Rep 2024; 14:14477. [PMID: 38914620 PMCID: PMC11196724 DOI: 10.1038/s41598-024-64622-3] [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: 12/09/2023] [Accepted: 06/11/2024] [Indexed: 06/26/2024] Open
Abstract
Normally aerated lung tissue on computed tomography (CT) is correlated with static respiratory system compliance (Crs) at zero end-expiratory pressure. In clinical practice, however, patients with acute respiratory failure are often managed using elevated PEEP levels. No study has validated the relationship between lung volume and tissue and Crs at the applied positive end-expiratory pressure (PEEP). Therefore, this study aimed to demonstrate the relationship between lung volume and tissue on CT and Crs during the application of PEEP for the clinical management of patients with acute respiratory distress syndrome due to COVID-19. Additionally, as a secondary outcome, the study aimed to evaluate the relationship between CT characteristics and Crs, considering recruitability using the recruitment-to-inflation ratio (R/I ratio). We analyzed the CT and respiratory mechanics data of 30 patients with COVID-19 who were mechanically ventilated. The CT images were acquired during mechanical ventilation at PEEP level of 15 cmH2O and were quantitatively analyzed using Synapse Vincent system version 6.4 (Fujifilm Corporation, Tokyo, Japan). Recruitability was stratified into two groups, high and low recruitability, based on the median R/I ratio of our study population. Thirty patients were included in the analysis with the median R/I ratio of 0.71. A significant correlation was observed between Crs at the applied PEEP (median 15 [interquartile range (IQR) 12.2, 15.8]) and the normally aerated lung volume (r = 0.70 [95% CI 0.46-0.85], P < 0.001) and tissue (r = 0.70 [95% CI 0.46-0.85], P < 0.001). Multivariable linear regression revealed that recruitability (Coefficient = - 390.9 [95% CI - 725.0 to - 56.8], P = 0.024) and Crs (Coefficient = 48.9 [95% CI 32.6-65.2], P < 0.001) were significantly associated with normally aerated lung volume (R-squared: 0.58). In this study, Crs at the applied PEEP was significantly correlated with normally aerated lung volume and tissue on CT. Moreover, recruitability indicated by the R/I ratio and Crs were significantly associated with the normally aerated lung volume. This research underscores the significance of Crs at the applied PEEP as a bedside-measurable parameter and sheds new light on the link between recruitability and normally aerated lung.
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Affiliation(s)
- Keishi Ogura
- Division of Radiology and Nuclear Medicine, Sapporo Medical University Hospital, Sapporo, Japan
| | - Ryuichi Nakayama
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, 291, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo, 060-8556, Japan.
| | - Naofumi Bunya
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, 291, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo, 060-8556, Japan
| | - Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, 329-0498, Japan
| | - Naoya Yama
- Department of Diagnostic Radiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuya Goto
- Department of Intensive Care Medicine, School of Medicine, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Keigo Sawamoto
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, 291, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo, 060-8556, Japan
| | - Shuji Uemura
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, 291, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo, 060-8556, Japan
| | - Eichi Narimatsu
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, 291, Minami 1-jo Nishi 16-chome, Chuo-ku, Sapporo, 060-8556, Japan
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18
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Rali AS, Tran L, Balakrishna A, Senussi M, Kapur NK, Metkus T, Tedford RJ, Lindenfeld J. Guide to Lung-Protective Ventilation in Cardiac Patients. J Card Fail 2024; 30:829-837. [PMID: 38513887 DOI: 10.1016/j.cardfail.2024.01.018] [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: 12/20/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 03/23/2024]
Abstract
The incidence of acute respiratory insufficiency has continued to increase among patients admitted to modern-day cardiovascular intensive care units. Positive pressure ventilation (PPV) remains the mainstay of treatment for these patients. Alterations in intrathoracic pressure during PPV has distinct effects on both the right and left ventricles, affecting cardiovascular performance. Lung-protective ventilation (LPV) minimizes the risk of further lung injury through ventilator-induced lung injury and, hence, an understanding of LPV and its cardiopulmonary interactions is beneficial for cardiologists.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN.
| | - Lena Tran
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Mourad Senussi
- Department of Medicine, Baylor St. Luke's Medical Center, Houston, TX
| | - Navin K Kapur
- Division of Cardiovascular Diseases, Tufts Medical Center, Boston, MA
| | - Thomas Metkus
- Departments of Medicine and Surgery, Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Joann Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
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19
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Sahetya SK, Rochwerg B, Fan E. Mind the gap: understanding the discordance between the ATS and ESICM ARDS guidelines-the ATS perspective. Intensive Care Med 2024; 50:937-940. [PMID: 38709292 DOI: 10.1007/s00134-024-07431-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 04/02/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St, #504, Baltimore, MD, 21224, USA.
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, ON, Canada
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20
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Alber S, Tanabe K, Hennigan A, Tregear H, Gilliland S. Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2024; 28:66-79. [PMID: 38669120 DOI: 10.1177/10892532241249582] [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: 04/28/2024]
Abstract
This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).
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21
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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Guérin C, Li J, Grasselli G. Prone positioning. Intensive Care Med 2024; 50:968-970. [PMID: 38656358 DOI: 10.1007/s00134-024-07413-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/24/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Claude Guérin
- Faculté de Médecine Lyon Est, Université Claude Bernard, Lyon, France
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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23
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Zhou Y, Cheng J, Zhu S, Dong M, Lv Y, Jing X, Kang Y. Early pathophysiology-driven airway pressure release ventilation versus low tidal volume ventilation strategy for patients with moderate-severe ARDS: study protocol for a randomized, multicenter, controlled trial. BMC Pulm Med 2024; 24:252. [PMID: 38783268 PMCID: PMC11112826 DOI: 10.1186/s12890-024-03065-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Conventional Mechanical ventilation modes used for individuals suffering from acute respiratory distress syndrome have the potential to exacerbate lung injury through regional alveolar overinflation and/or repetitive alveolar collapse with shearing, known as atelectrauma. Animal studies have demonstrated that airway pressure release ventilation (APRV) offers distinct advantages over conventional mechanical ventilation modes. However, the methodologies for implementing APRV vary widely, and the findings from clinical studies remain controversial. This study (APRVplus trial), aims to assess the impact of an early pathophysiology-driven APRV ventilation approach compared to a low tidal volume ventilation (LTV) strategy on the prognosis of patients with moderate to severe ARDS. METHODS The APRVplus trial is a prospective, multicenter, randomized clinical trial, building upon our prior single-center study, to enroll 840 patients from at least 35 hospitals in China. This investigation plans to compare the early pathophysiology-driven APRV ventilation approach with the control intervention of LTV lung-protective ventilation. The primary outcome measure will be all-cause mortality at 28 days after randomization in the intensive care units (ICU). Secondary outcome measures will include assessments of oxygenation, and physiology parameters at baseline, as well as on days 1, 2, and 3. Additionally, clinical outcomes such as ventilator-free days at 28 days, duration of ICU and hospital stay, ICU and hospital mortality, and the occurrence of adverse events will be evaluated. TRIAL ETHICS AND DISSEMINATION The research project has obtained approval from the Ethics Committee of West China Hospital of Sichuan University (2019-337). Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION The study was registered at Clinical Trials.gov (NCT03549910) on June 8, 2018.
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Affiliation(s)
- Yongfang Zhou
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China.
| | - Jiangli Cheng
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Shuo Zhu
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Meiling Dong
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Yinxia Lv
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Xiaorong Jing
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China.
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Siuba MT, Bulgarelli L, Duggal A, Cavalcanti AB, Zampieri FG, Rey DA, Lucena WDR, Maia IS, Paisani DM, Laranjeira LN, Neto AS, Deliberato RO. Differential Effect of Positive End-Expiratory Pressure Strategies in Patients With ARDS: A Bayesian Analysis of Clinical Subphenotypes. Chest 2024:S0012-3692(24)00630-5. [PMID: 38768777 DOI: 10.1016/j.chest.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/22/2024] [Accepted: 04/06/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND ARDS is a heterogeneous condition with two subphenotypes identified by different methodologies. Our group similarly identified two ARDS subphenotypes using nine routinely available clinical variables. However, whether these are associated with differential response to treatment has yet to be explored. RESEARCH QUESTION Are there differential responses to positive end-expiratory pressure (PEEP) strategies on 28-day mortality according to subphenotypes in adult patients with ARDS? STUDY DESIGN AND METHODS We evaluated data from two prior ARDS trials (Higher vs Lower Positive End-Expiratory Pressures in Patients With the ARDS [ALVEOLI] and the Alveolar Recruitment in ARDS Trial [ART]) that compared different PEEP strategies. We classified patients into one of two subphenotypes as described previously. We assessed the differential effect of PEEP with a Bayesian hierarchical logistic model for the primary outcome of 28-day mortality. RESULTS We analyzed data from 1,559 patients with ARDS. Compared with lower PEEP, a higher PEEP strategy resulted in higher 28-day mortality in patients with subphenotype A disease in the ALVEOLI study (OR, 1.61; 95% credible interval [CrI], 0.90-2.94) and ART (OR, 1.73; 95% CrI, 1.01-2.98), with a probability of harm resulting from higher PEEP in this subphenotype of 94.3% and 97.7% in the ALVEOLI and ART studies, respectively. Higher PEEP was not associated with mortality in patients with subphenotype B disease in each trial (OR, 0.95 [95% CrI, 0.51-1.73] and 1.00 [95% CrI, 0.63-1.55], respectively), with probability of benefit of 56.4% and 50.7% in the ALVEOLI and ART studies, respectively. These effects were not modified by Pao2 to Fio2 ratio, driving pressure, or the severity of illness for the cohorts. INTERPRETATION We found evidence of differential response to PEEP strategies across two ARDS subphenotypes, suggesting possible harm with a higher PEEP strategy in one subphenotype. These observations may assist with predictive enrichment in future clinical trials.
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Affiliation(s)
- Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
| | - Lucas Bulgarelli
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | | | | | | | | | | | | | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rodrigo Octávio Deliberato
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Biostatistics, Health Informatics and Data Science (BHIDS), University of Cincinnati College of Medicine, Cincinnati, OH
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25
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Giraldo-Cadavid LF, Echeverry J, Varón-Vega F, Bastidas A, Ramírez-Jaime A, Cardona AF, Lopez Vega CJ, Serrano-Mayorca CC, Garay D, Rincón DN, Oliveros H, Ramírez IA, Garcia-Gallo E, Enciso-Prieto VA, Ibáñez-Prada ED, Camelo JC, Cucunubo L, Buitrago L, Paipa LA, Longas LC, Agudelo-Otálora LM, Porras Diaz NF, Rachid RR, Henao I RD, Pedraza S, Reyes LF. The development and implementation of a low-cost mechanical ventilator in a low-middle-income country during the COVID-19 pandemic: The Unisabana-HERONS. Heliyon 2024; 10:e30671. [PMID: 38756610 PMCID: PMC11096896 DOI: 10.1016/j.heliyon.2024.e30671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/02/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024] Open
Abstract
Background The COVID-19 pandemic in Latin America generated the need to develop low-cost, fast-manufacturing mechanical ventilators. The Universidad de La Sabana and the Fundacion Neumologica Colombiana designed and manufactured the Unisabana-HERONS (USH) ventilator. Here, we present the preclinical and clinical study results to evaluate its effectiveness and safety characteristics in an animal model (Yorkshire Sow) and five patients with acute respiratory failure receiving mechanical ventilatory support for 24 h. Methods The effectiveness and safety outcomes included maintaining arterial blood gases and pulse oximetry saturation (SpO2), respiratory pressures and volumes (during continuous monitoring) in the range of ARDS and lung-protective strategy goals, and the occurrence of barotrauma. A significance level of 0.05 was used for statistical tests. This clinical trial was registered on Clinicaltrials.gov (NCT04497623) and approved by the ethics committee. Results Among patients treated with the Unisabana-HERONS, the most frequent causes of acute respiratory failure were pneumonia in 3/5 (60 %) and ARDS in 2/5 (40 %). During the treatment, the ventilatory parameters related to lung protection protocols were kept within the safety range, and vital signs and blood gas were stable. The percentage of time that the respiratory pressures or volumes were out of safety range were plateau pressure >30 cm H2O: 0.00 %; driving pressure >15 cm H2O: 0.06 %; mechanical power >15 J/min: 0.00 %; and Tidal volume >8 mL/kg: 0.00 %. There were no adverse events related to the ventilator. The usability questionnaire retrieved a median score for all items between 9 and 10 (best score: 10), indicating great ease of use. Conclusion The Unisabana-HERONS ventilator effectively provided adequate gas exchange and maintained the ventilatory parameters in the range of lung protection strategies in humans and an animal model. Furthermore, it is straightforward to use and is a low-cost medical device.
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Affiliation(s)
| | | | - Fabio Varón-Vega
- Fundación Neumológica Colombiana, Bogotá, Colombia
- Universidad de Navarra, Pamplona, Spain
| | | | - Andrés Ramírez-Jaime
- Universidad de La Sabana, Chía, Colombia
- Universidad de Los Andes, Bogotá, Colombia
| | | | - Cristian Joao Lopez Vega
- Fundación Clínica Shaio, Bogotá, Colombia
- Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia
- Universidad Nacional de Colombia, Bogotá, Colombia
| | | | - Diana Garay
- Universidad de La Sabana, Chía, Colombia
- Clínica Universidad de La Sabana, Chía, Colombia
| | | | | | | | | | | | - Elsa D. Ibáñez-Prada
- Universidad de La Sabana, Chía, Colombia
- Clínica Universidad de La Sabana, Chía, Colombia
| | | | | | | | | | | | | | | | | | | | - Santiago Pedraza
- Universidad de La Sabana, Chía, Colombia
- Clínica Universidad de La Sabana, Chía, Colombia
| | - Luis Felipe Reyes
- Universidad de La Sabana, Chía, Colombia
- Clínica Universidad de La Sabana, Chía, Colombia
- Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
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26
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Palanidurai S, Chan YH, Mukhopadhyay A. "PEEP-adjusted P/F Ratio" in Acute Respiratory Distress Syndrome: A Call for Further Enhancement of Global Definition. Am J Respir Crit Care Med 2024; 209:1279-1280. [PMID: 38507734 PMCID: PMC11146551 DOI: 10.1164/rccm.202308-1428le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 03/19/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Amartya Mukhopadhyay
- FAST and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore, Singapore
- Division of Respiratory & Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; and
- Medical Affairs, Alexandra Hospital, Singapore, Singapore
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Carvalho EV, Reboredo MM, Gomes EP, Martins PN, Mota GPS, Costa GB, Colugnati FAB, Pinheiro BV. Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients. CRITICAL CARE SCIENCE 2024; 36:e20240208en. [PMID: 38747818 PMCID: PMC11098065 DOI: 10.62675/2965-2774.20240208-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/06/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19. METHODS This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality. RESULTS We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure. CONCLUSION In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.
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Affiliation(s)
- Erich Vidal Carvalho
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Maycon Moura Reboredo
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Edimar Pedrosa Gomes
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Pedro Nascimento Martins
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Gabriel Paz Souza Mota
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Giovani Bernardo Costa
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Fernando Antonio Basile Colugnati
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Bruno Valle Pinheiro
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
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28
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Bae YK, Nam SW, Oh AY, Kim BY, Koo BW, Han J, Yim S. Effect of the alveolar recruitment maneuver during laparoscopic colorectal surgery on postoperative pulmonary complications: A randomized controlled trial. PLoS One 2024; 19:e0302884. [PMID: 38722838 PMCID: PMC11081303 DOI: 10.1371/journal.pone.0302884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/14/2024] [Indexed: 05/13/2024] Open
Abstract
Intraoperative lung-protective ventilation, including low tidal volume and positive end-expiratory pressure, reduces postoperative pulmonary complications. However, the effect and specific alveolar recruitment maneuver method are controversial. We investigated whether the intraoperative intermittent recruitment maneuver further reduced postoperative pulmonary complications while using a lung-protective ventilation strategy. Adult patients undergoing elective laparoscopic colorectal surgery were randomly allocated to the recruitment or control groups. Intraoperative ventilation was adjusted to maintain a tidal volume of 6-8 mL kg-1 and positive end-expiratory pressure of 5 cmH2O in both groups. The alveolar recruitment maneuver was applied at three time points (at the start and end of the pneumoperitoneum, and immediately before extubation) by maintaining a continuous pressure of 30 cmH2O for 30 s in the recruitment group. Clinical and radiological evidence of postoperative pulmonary complications was investigated within 7 days postoperatively. A total of 125 patients were included in the analysis. The overall incidence of postoperative pulmonary complications was not significantly different between the recruitment and control groups (28.1% vs. 31.1%, P = 0.711), while the mean ± standard deviation intraoperative peak inspiratory pressure was significantly lower in the recruitment group (10.7 ± 3.2 vs. 13.5 ± 3.0 cmH2O at the time of CO2 gas-out, P < 0.001; 9.8 ± 2.3 vs. 12.5 ± 3.0 cmH2O at the time of recovery, P < 0.001). The alveolar recruitment maneuver with a pressure of 30 cmH2O for 30 s did not further reduce postoperative pulmonary complications when a low tidal volume and 5 cmH2O positive end-expiratory pressure were applied to patients undergoing laparoscopic colorectal surgery and was not associated with any significant adverse events. However, the alveolar recruitment maneuver significantly reduced intraoperative peak inspiratory pressure. Further study is needed to validate the beneficial effect of the alveolar recruitment maneuver in patients at increased risk of postoperative pulmonary complications. Trial registration: Clinicaltrials.gov (NCT03681236).
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Affiliation(s)
- Yu Kyung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sun Woo Nam
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong si, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
| | - Bo Young Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jiwon Han
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong si, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Chung-Ang University, College of Medicine, Seoul, Republic of Korea
| | - Subin Yim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University, College of Medicine, Seoul, Republic of Korea
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Wang Z, Zhou Y, Zhu M, Wang F, Zhou Y, Yu H, Luo F. Prone positioning does not improve outcomes of intubated patients with pneumocystis pneumonia and moderate-severe acute respiratory distress syndrome: a single-center, retrospective, observational, cohort study. Eur J Med Res 2024; 29:267. [PMID: 38698478 PMCID: PMC11067229 DOI: 10.1186/s40001-024-01868-7] [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: 11/07/2023] [Accepted: 04/24/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Pneumocystis pneumonia is an uncommon precipitant of acute respiratory distress syndrome and is associated with high mortality. Prone positioning ventilation has been proven to reduce mortality in patients with moderate-severe acute respiratory distress syndrome. We investigated the effect of prone positioning on oxygenation and mortality in intubated patients with pneumocystis pneumonia comorbid with moderate-severe acute respiratory distress syndrome. METHODS In this single-center, retrospective, observational, cohort study, eligible patients were enrolled at West China Hospital of Sichuan University from January 1, 2017, to December 31, 2021. Data on demographics, clinical features, ventilation parameters, arterial blood gas, and outcomes were collected. Patients were assigned to the prone cohort or supine cohort according to whether they received prone positioning ventilation. The main outcome was 28-day mortality. FINDINGS A total of 79 patients were included in the study. Sixty-three patients were enrolled in the prone cohort, and 16 patients were enrolled in the supine cohort. The 28-day mortality was 61.9% in the prone cohort and 68.8% in the supine cohort (P = 0.26), and 90-day mortality was 66.7% in the prone cohort and 68.8% in the supine cohort (P = 0.55). Patients in the supine cohort had fewer invasive mechanical ventilation days and more ventilator-free days. The incidence of complications was higher in the prone cohort than in the supine cohort. CONCLUSIONS In patients with pneumocystis pneumonia and moderate-severe acute respiratory distress syndrome, prone positioning did not decrease 28-day or 90-day mortality. Trial registration ClinicalTrials.gov number, ChiCTR2200063889. Registered on 20 September 2022, https://www.chictr.org.cn/showproj.html?proj=174886 .
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Affiliation(s)
- Zhen Wang
- Department of Respiratory Care, Sichuan University West China Hospital, Chengdu, Sichuan, China
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
| | - Yuyan Zhou
- Department of Respiratory Care, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Min Zhu
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041
- Laboratory of Pulmonary Immunology and Inflammation, Department of Respiratory and Critical Care Medicine, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Faping Wang
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041
- Laboratory of Pulmonary Immunology and Inflammation, Department of Respiratory and Critical Care Medicine, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yubei Zhou
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041
| | - He Yu
- Department of Respiratory Care, Sichuan University West China Hospital, Chengdu, Sichuan, China
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China
| | - Fengming Luo
- State Key Laboratory of Respiratory Health and Multimorbidity, West China hospital, Sichuan University, Chengdu, China.
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China, 610041.
- Laboratory of Pulmonary Immunology and Inflammation, Department of Respiratory and Critical Care Medicine, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
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30
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Becker AP, Mang S, Rixecker T, Lepper PM. [COVID-19 in the intensive care unit]. Pneumologie 2024; 78:330-345. [PMID: 38759701 DOI: 10.1055/a-1854-2693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
The acute respiratory failure as well as ARDS (acute respiratory distress syndrome) have challenged clinicians since the initial description over 50 years ago. Various causes can lead to ARDS and therapeutic approaches for ARDS/ARF are limited to the support or replacement of organ functions and the prevention of therapy-induced consequences. In recent years, triggered by the SARS-CoV-2 pathogen, numerous cases of acute lung failure (C-ARDS) have emerged. The pathophysiological processes of classical ARDS and C-ARDS are essentially similar. In their final stages of inflammation, both lead to a disruption of the blood-air barrier. Treatment strategies for C-ARDS, like classical ARDS, focus on supporting or replacing organ functions and preventing consequential damage. This article summarizes the treatment strategies in the intensive care unit.
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Songsangvorn N, Xu Y, Lu C, Rotstein O, Brochard L, Slutsky AS, Burns KEA, Zhang H. Electrical impedance tomography-guided positive end-expiratory pressure titration in ARDS: a systematic review and meta-analysis. Intensive Care Med 2024; 50:617-631. [PMID: 38512400 PMCID: PMC11078723 DOI: 10.1007/s00134-024-07362-2] [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: 12/16/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE Assessing efficacy of electrical impedance tomography (EIT) in optimizing positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) patients to enhance respiratory system mechanics and prevent ventilator-induced lung injury (VILI), compared to traditional methods. METHODS We carried out a systematic review and meta-analysis, spanning literature from January 2012 to May 2023, sourced from Scopus, PubMed, MEDLINE (Ovid), Cochrane, and LILACS, evaluated EIT-guided PEEP strategies in ARDS versus conventional methods. Thirteen studies (3 randomized, 10 non-randomized) involving 623 ARDS patients were analyzed using random-effects models for primary outcomes (respiratory mechanics and mechanical power) and secondary outcomes (PaO2/FiO2 ratio, mortality, stays in intensive care unit (ICU), ventilator-free days). RESULTS EIT-guided PEEP significantly improved lung compliance (n = 941 cases, mean difference (MD) = 4.33, 95% confidence interval (CI) [2.94, 5.71]), reduced mechanical power (n = 148, MD = - 1.99, 95% CI [- 3.51, - 0.47]), and lowered driving pressure (n = 903, MD = - 1.20, 95% CI [- 2.33, - 0.07]) compared to traditional methods. Sensitivity analysis showed consistent positive effect of EIT-guided PEEP on lung compliance in randomized clinical trials vs. non-randomized studies pooled (MD) = 2.43 (95% CI - 0.39 to 5.26), indicating a trend towards improvement. A reduction in mortality rate (259 patients, relative risk (RR) = 0.64, 95% CI [0.45, 0.91]) was associated with modest improvements in compliance and driving pressure in three studies. CONCLUSIONS EIT facilitates real-time, individualized PEEP adjustments, improving respiratory system mechanics. Integration of EIT as a guiding tool in mechanical ventilation holds potential benefits in preventing ventilator-induced lung injury. Larger-scale studies are essential to validate and optimize EIT's clinical utility in ARDS management.
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Affiliation(s)
- Nickjaree Songsangvorn
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Yonghao Xu
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Cong Lu
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Ori Rotstein
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen E A Burns
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Haibo Zhang
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Physiology, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
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Marini JJ, Rocco PRM, Thornton LT, Crooke PS. Stress & strain in mechanically nonuniform alveoli using clinical input variables: a simple conceptual model. Crit Care 2024; 28:141. [PMID: 38679712 PMCID: PMC11057067 DOI: 10.1186/s13054-024-04918-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
Clinicians currently monitor pressure and volume at the airway opening, assuming that these observations relate closely to stresses and strains at the micro level. Indeed, this assumption forms the basis of current approaches to lung protective ventilation. Nonetheless, although the airway pressure applied under static conditions may be the same everywhere in healthy lungs, the stresses within a mechanically non-uniform ARDS lung are not. Estimating actual tissue stresses and strains that occur in a mechanically non-uniform environment must account for factors beyond the measurements from the ventilator circuit of airway pressures, tidal volume, and total mechanical power. A first conceptual step for the clinician to better define the VILI hazard requires consideration of lung unit tension, stress focusing, and intracycle power concentration. With reasonable approximations, better understanding of the value and limitations of presently used general guidelines for lung protection may eventually be developed from clinical inputs measured by the caregiver. The primary purpose of the present thought exercise is to extend our published model of a uniform, spherical lung unit to characterize the amplifications of stress (tension) and strain (area change) that occur under static conditions at interface boundaries between a sphere's surface segments having differing compliances. Together with measurable ventilating power, these are incorporated into our perspective of VILI risk. This conceptual exercise brings to light how variables that are seldom considered by the clinician but are both recognizable and measurable might help gauge the hazard for VILI of applied pressure and power.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
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Ke Y, Yang R, Liu N. Comparing Open-Access Database and Traditional Intensive Care Studies Using Machine Learning: Bibliometric Analysis Study. J Med Internet Res 2024; 26:e48330. [PMID: 38630522 PMCID: PMC11063894 DOI: 10.2196/48330] [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: 04/19/2023] [Revised: 08/01/2023] [Accepted: 01/14/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Intensive care research has predominantly relied on conventional methods like randomized controlled trials. However, the increasing popularity of open-access, free databases in the past decade has opened new avenues for research, offering fresh insights. Leveraging machine learning (ML) techniques enables the analysis of trends in a vast number of studies. OBJECTIVE This study aims to conduct a comprehensive bibliometric analysis using ML to compare trends and research topics in traditional intensive care unit (ICU) studies and those done with open-access databases (OADs). METHODS We used ML for the analysis of publications in the Web of Science database in this study. Articles were categorized into "OAD" and "traditional intensive care" (TIC) studies. OAD studies were included in the Medical Information Mart for Intensive Care (MIMIC), eICU Collaborative Research Database (eICU-CRD), Amsterdam University Medical Centers Database (AmsterdamUMCdb), High Time Resolution ICU Dataset (HiRID), and Pediatric Intensive Care database. TIC studies included all other intensive care studies. Uniform manifold approximation and projection was used to visualize the corpus distribution. The BERTopic technique was used to generate 30 topic-unique identification numbers and to categorize topics into 22 topic families. RESULTS A total of 227,893 records were extracted. After exclusions, 145,426 articles were identified as TIC and 1301 articles as OAD studies. TIC studies experienced exponential growth over the last 2 decades, culminating in a peak of 16,378 articles in 2021, while OAD studies demonstrated a consistent upsurge since 2018. Sepsis, ventilation-related research, and pediatric intensive care were the most frequently discussed topics. TIC studies exhibited broader coverage than OAD studies, suggesting a more extensive research scope. CONCLUSIONS This study analyzed ICU research, providing valuable insights from a large number of publications. OAD studies complement TIC studies, focusing on predictive modeling, while TIC studies capture essential qualitative information. Integrating both approaches in a complementary manner is the future direction for ICU research. Additionally, natural language processing techniques offer a transformative alternative for literature review and bibliometric analysis.
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Affiliation(s)
- Yuhe Ke
- Division of Anesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore, Singapore
| | - Rui Yang
- Centre for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Nan Liu
- Centre for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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Golino G, Forin E, Boni E, Martin M, Perbellini G, Rizzello V, Toniolo A, Danzi V. Secondary pneumomediastinum in COVID-19 patient: A case managed with VV-ECMO. IDCases 2024; 36:e01956. [PMID: 38681081 PMCID: PMC11047182 DOI: 10.1016/j.idcr.2024.e01956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/10/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024] Open
Abstract
Air leak syndrome, including pneumomediastinum (PM), pneumopericardium, pneumothorax, or subcutaneous emphysema, is primarily caused by chest trauma, cardiothoracic surgery, esophageal perforation, and mechanical ventilation. Secondary pneumomediastinum (SP) is a rare complication, with a much lower incidence reported in patients with coronavirus disease 2019 (COVID-19). Our patient was a 44-year-old nonsmoker male with a previous history of obesity (Body Mass Index [BMI] 35 kg/m2), hyperthyroidism, hypokinetic cardiopathy and atrial fibrillation in treatment with flecainide, who presented to the emergency department with 6 days of fever, cough, dyspnea, and respiratory distress. The COVID-19 diagnosis was confirmed based on a polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). After initiation of mechanical ventilation, a chest computed tomography (CT) on the first day revealed bilateral multifocal ground-glass opacities, consolidation and an extensive SP and pneumoperitoneum. Our therapeutic strategy was initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to recovery after positioning 2 drains (mediastinal and pleural), for both oxygenation and carbon dioxide clearance, to allow protective and ultra-protective ventilation to limit ventilator-induced lung injury (VILI) and the intensity of mechanical power for lung recovery. After another chest CT scan which showed a clear reduction of the PM, 2 pronation and neuromuscular relaxation cycles were also required, with improvement of gas exchange and respiratory mechanics. On the 15th day, lung function recovered and the patient was then weaned from VV-ECMO, and ultimately made a good recovery and was discharged. In conclusion, SP may be a reflection of extensive alveolar damage and should be considered as a potential predictive factor for adverse outcome in critically ill SARS-CoV2 patients.
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Affiliation(s)
- Gianlorenzo Golino
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Edoardo Forin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Elisa Boni
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Marina Martin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Guido Perbellini
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Veronica Rizzello
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Anna Toniolo
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Vinicio Danzi
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
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Maclean N, Davies P, Lewis S. Is prone positioning a valid intervention for ARDS in the deployed intensive care unit? BMJ Mil Health 2024:e002302. [PMID: 38569719 DOI: 10.1136/military-2022-002302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
Prone positioning is an intervention used for patients with acute respiratory distress syndrome (ARDS) whose hypoxia is worsening despite conventional treatment. Previously used infrequently, it became an important treatment escalation strategy for hypoxia during the COVID-19 pandemic. Current evidence for prone positioning suggests increased survivability in intubated patients with moderate to severe ARDS who are prone for >12 hours a day. As a relatively low-cost, low-tech intervention with a growing evidence base, the viability of prone positioning in the deployed land environment is considered in this article. The practical technique of prone positioning is easy to teach to healthcare staff experienced in manual handling. However, it requires significant resources, in particular staff numbers, and time to execute and maintain, and necessitates a pressure-minimising mattress. Additionally, staff are placed at increased risk of musculoskeletal injuries and potential exposure to aerosolised microbes if there is a disconnection of the breathing system. We conclude that in the deployed 2/1/2/12 facility (or larger), with access to higher staff numbers and high-specification mattresses, prone positioning is a valid escalation technique for intubated hypoxic patients with ARDS. However, in smaller facilities where resources are constrained, its implementation is unlikely to be achievable.
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Affiliation(s)
| | - P Davies
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
- Joint Hosptial Group (South East), Frimley, UK
| | - S Lewis
- Frimley Park Hospital NHS Foundation Trust, Frimley, UK
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Szuldrzynski K, Kowalewski M, Swol J. Mechanical ventilation during extracorporeal membrane oxygenation support - New trends and continuing challenges. Perfusion 2024; 39:107S-114S. [PMID: 38651573 DOI: 10.1177/02676591241232270] [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: 04/25/2024]
Abstract
BACKGROUND The impact of mechanical ventilation on the survival of patients supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) due to severe acute respiratory distress syndrome (ARDS) remains still a focus of research. METHODS Recent guidelines, randomized trials, and registry data underscore the importance of lung-protective ventilation during respiratory and cardiac support on ECMO. RESULTS This approach includes decreasing mechanical power delivery by reducing tidal volume and driving pressure as much as possible, using low or very low respiratory rate, and a personalized approach to positive-end expiratory pressure (PEEP) setting. Notably, the use of ECMO in awake and spontaneously breathing patients is increasing, especially as a bridging strategy to lung transplantation. During respiratory support in V-V ECMO, native lung function is of highest importance and adjustments of blood flow on ECMO, or ventilator settings significantly impact the gas exchange. These interactions are more complex in veno-arterial (V-A) ECMO configuration and cardiac support. The fraction on delivered oxygen in the sweep gas and sweep gas flow rate, blood flow per minute, and oxygenator efficiency have an impact on gas exchange on device side. On the patient side, native cardiac output, native lung function, carbon dioxide production (VCO2), and oxygen consumption (VO2) play a role. Avoiding pulmonary oedema includes left ventricle (LV) distension monitoring and prevention, pulse pressure >10 mm Hg and aortic valve opening assessment, higher PEEP adjustment, use of vasodilators, ECMO flow adjustment according to the ejection fraction, moderate use of inotropes, diuretics, or venting strategies as indicated and according to local expertise and resources. CONCLUSION Understanding the physiological principles of gas exchange during cardiac support on femoro-femoral V-A ECMO configuration and the interactions with native gas exchange and haemodynamics are essential for the safe applications of these techniques in clinical practice. Proning during ECMO remains to be discussed until further data is available from prospective, randomized trials implementing individualized PEEP titration during proning.
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Affiliation(s)
- Konstanty Szuldrzynski
- Department of Anaesthesiology and Intensive Care, National Institute of Medicine of the Ministry of Interior and Administration in Warsaw, Warsaw, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Justyna Swol
- Department of Respiratory Medicine, Paracelsus Medical University, Nuremberg, Germany
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Patel BM, Reilly JP, Bhalla AK, Smith LS, Khemani RG, Jones TK, Meyer NJ, Harhay MO, Yehya N. Association between Age and Mortality in Pediatric and Adult Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:871-878. [PMID: 38306669 PMCID: PMC10995578 DOI: 10.1164/rccm.202310-1926oc] [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: 10/30/2023] [Accepted: 02/02/2024] [Indexed: 02/04/2024] Open
Abstract
Rationale: The epidemiology, management, and outcomes of acute respiratory distress syndrome (ARDS) differ between children and adults, with lower mortality rates in children despite comparable severity of hypoxemia. However, the relationship between age and mortality is unclear.Objective: We aimed to define the association between age and mortality in ARDS, hypothesizing that it would be nonlinear.Methods: We performed a retrospective cohort study using data from two pediatric ARDS observational cohorts (n = 1,236), multiple adult ARDS trials (n = 5,547), and an adult observational ARDS cohort (n = 1,079). We aligned all datasets to meet Berlin criteria. We performed unadjusted and adjusted logistic regression using fractional polynomials to assess the potentially nonlinear relationship between age and 90-day mortality, adjusting for sex, PaO2/FiO2, immunosuppressed status, year of study, and observational versus randomized controlled trial, treating each individual study as a fixed effect.Measurements and Main Results: There were 7,862 subjects with median ages of 4 years in the pediatric cohorts, 52 years in the adult trials, and 61 years in the adult observational cohort. Most subjects (43%) had moderate ARDS by Berlin criteria. Ninety-day mortality was 19% in the pediatric cohorts, 33% in the adult trials, and 67% in the adult observational cohort. We found a nonlinear relationship between age and mortality, with mortality risk increasing at an accelerating rate between 11 and 65 years of age, after which mortality risk increased more slowly.Conclusions: There was a nonlinear relationship between age and mortality in pediatric and adult ARDS.
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Affiliation(s)
- Bhavesh M Patel
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Anoopindar K Bhalla
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Robinder G Khemani
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California; and
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Center for Translational Lung Biology, and
| | - Michael O Harhay
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Gatti S, Rezoagli E, Madotto F, Foti G, Bellani G. A non-invasive continuous and real-time volumetric monitoring in spontaneous breathing subjects based on bioimpedance-ExSpiron®Xi: a validation study in healthy volunteers. J Clin Monit Comput 2024; 38:539-551. [PMID: 38238635 PMCID: PMC10994998 DOI: 10.1007/s10877-023-01107-0] [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: 03/13/2023] [Accepted: 11/10/2023] [Indexed: 04/06/2024]
Abstract
Tidal volume (TV) monitoring breath-by-breath is not available at bedside in non-intubated patients. However, TV monitoring may be useful to evaluate the work of breathing. A non-invasive device based on bioimpedance provides continuous and real-time volumetric tidal estimation during spontaneous breathing. We performed a prospective study in healthy volunteers aimed at evaluating the accuracy, the precision and the trending ability of measurements of ExSpiron®Xi as compared with the gold standard (i.e. spirometry). Further, we explored whether the differences between the 2 devices would be improved by the calibration of ExSpiron®Xi with a pre-determined tidal volume. Analysis accounted for the repeated nature of measurements within each subject. We enrolled 13 healthy volunteers, including 5 men and 8 women. Tidal volume, TV/ideal body weight (IBW) and respiratory rate (RR) measured with spirometer (TVSpirometer) and with ExSpiron®Xi (TVExSpiron) showed a robust correlation, while minute ventilation (MV) showed a weak correlation, in both non/calibrated and calibrated steps. The analysis of the agreement showed that non-calibrated TVExSpiron underestimated TVspirometer, while in the calibrated steps, TVExSpiron overestimated TVspirometer. The calibration procedure did not reduce the average absolute difference (error) between TVSpirometer and TVExSpiron. This happened similarly for TV/IBW and MV, while RR showed high accuracy and precision. The trending ability was excellent for TV, TV/IBW and RR. The concordance rate (CR) was >95% in both calibrated and non-calibrated measurements. The trending ability of minute ventilation was limited. Absolute error for both calibrated and not calibrated values of TV, TV/IBW and MV accounting for repeated measurements was variably associated with BMI, height and smoking status. Conclusions: Non-invasive TV, TV/IBW and RR estimation by ExSpiron®Xi was strongly correlated with tidal ventilation according to the gold standard spirometer technique. This data was not confirmed for MV. The calibration of the device did not improve its performance. Although the accuracy of ExSpiron®Xi was mild and the precision was limited for TV, TV/IBW and MV, the trending ability of the device was strong specifically for TV, TV/IBW and RR. This makes ExSpiron®Xi a non-invasive monitoring system that may detect real-time tidal volume ventilation changes and then suggest the need to better optimize the patient ventilatory support.
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Affiliation(s)
- Stefano Gatti
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fabiana Madotto
- Department of Area Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento Largo Medaglie d'Oro, Trento, Italy.
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39
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Levy E, Reilly JP. Pharmacologic Treatments in Acute Respiratory Failure. Crit Care Clin 2024; 40:275-289. [PMID: 38432696 DOI: 10.1016/j.ccc.2023.12.002] [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: 03/05/2024]
Abstract
Acute respiratory failure relies on supportive care using non-invasive and invasive oxygen and ventilatory support. Pharmacologic therapies for the most severe form of respiratory failure, acute respiratory distress syndrome (ARDS), are limited. This review focuses on the most promising therapies for ARDS, targeting different mechanisms that contribute to dysregulated inflammation and resultant hypoxemia. Significant heterogeneity exists within the ARDS population. Treatment requires prompt recognition of ARDS and an understanding of which patients may benefit most from specific pharmacologic interventions. The key to finding effective pharmacotherapies for ARDS may rely on deeper understanding of pathophysiology and bedside identification of ARDS subphenotypes.
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Affiliation(s)
- Elizabeth Levy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19146, USA.
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40
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Trieu M, Qadir N. Adjunctive Therapies in Acute Respiratory Distress Syndrome. Crit Care Clin 2024; 40:329-351. [PMID: 38432699 DOI: 10.1016/j.ccc.2023.12.004] [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: 03/05/2024]
Abstract
Despite significant advances in understanding acute respiratory distress syndrome (ARDS), mortality rates remain high. The appropriate use of adjunctive therapies can improve outcomes, particularly for patients with moderate to severe hypoxia. In this review, the authors discuss the evidence basis behind prone positioning, recruitment maneuvers, neuromuscular blocking agents, corticosteroids, pulmonary vasodilators, and extracorporeal membrane oxygenation and considerations for their use in individual patients and specific clinical scenarios. Because the heterogeneity of ARDS poses challenges in finding universally effective treatments, an individualized approach and continued research efforts are crucial for optimizing the utilization of adjunctive therapies and improving patient outcomes.
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Affiliation(s)
- Megan Trieu
- Division of Pulmonary Critical Care Sleep Medicine and Physiology, Department of Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037-1300, USA
| | - Nida Qadir
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Room 43-229 CHS, Los Angeles, CA 90095, USA.
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41
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Yang P, Sjoding MW. Acute Respiratory Distress Syndrome: Definition, Diagnosis, and Routine Management. Crit Care Clin 2024; 40:309-327. [PMID: 38432698 DOI: 10.1016/j.ccc.2023.12.003] [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: 03/05/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is an acute inflammatory lung injury characterized by severe hypoxemic respiratory failure, bilateral opacities on chest imaging, and low lung compliance. ARDS is a heterogeneous syndrome that is the common end point of a wide variety of predisposing conditions, with complex pathophysiology and underlying mechanisms. Routine management of ARDS is centered on lung-protective ventilation strategies such as low tidal volume ventilation and targeting low airway pressures to avoid exacerbation of lung injury, as well as a conservative fluid management strategy.
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Affiliation(s)
- Philip Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, 6335 Hospital Parkway, Physicians Plaza Suite 310, Johns Creek, GA 30097, USA.
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, University of Michigan, 2800 Plymouth Road, NCRC, Building 16, G027W, Ann Arbor, MI 48109, USA
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42
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Jiang L, Chen H, Xie J, Liu L, Yang Y. Prognostic value of time-varying dead space estimates in mechanically ventilated patients with acute respiratory distress syndrome. JOURNAL OF INTENSIVE MEDICINE 2024; 4:187-193. [PMID: 38681797 PMCID: PMC11043632 DOI: 10.1016/j.jointm.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 05/01/2024]
Abstract
Background The dead space fraction (VD/VT) has proven to be a powerful predictor of higher mortality in acute respiratory distress syndrome (ARDS). However, its measurement relies on expired carbon dioxide, limiting its widespread application in clinical practice. Several estimates employing routine variables have been found to be reliable substitutes for direct measurement of VD/VT. In this study, we evaluated the prognostic value of these dead space estimates obtained in the first 7 days following the initiation of ventilation. Methods This retrospective observational study was conducted using data from the Chinese database in intensive care (CDIC). Eligible participants were adult ARDS patients receiving invasive mechanical ventilation while in the intensive care unit between 1st January 2014 and 31st March 2021. We collected data during the first 7 days of ventilation to calculate various dead space estimates, including ventilatory ratio (VR), corrected minute ventilation (V ˙ Ecorr ), VD/VT (Harris-Benedict), VD/VT (Siddiki estimate), and VD/VT (Penn State estimate) longitudinally. A time-dependent Cox model was used to handle these time-varying estimates. Results A total of 392 patients (median age 66 [interquartile range: 55-77] years, median SOFA score 9 [interquartile range: 7-12]) were finally included in our analysis, among whom 132 (33.7%) patients died within 28 days of admission. VR (hazard ratio [HR]=1.04 per 0.1 increase, 95% confidence interval [CI]: 1.01 to 1.06; P=0.013), V ˙ Ecorr (HR=1.08 per 1 increase, 95% CI: 1.04 to 1.12; P < 0.001), VD/VT (Harris-Benedict) (HR=1.25 per 0.1 increase, 95% CI: 1.06 to 1.47; P=0.006), and VD/VT (Penn State estimate) (HR=1.22 per 0.1 increase, 95% CI: 1.04 to 1.44; P=0.017) remained significant after adjustment, while VD/VT (Siddiki estimate) (HR=1.10 per 0.1 increase, 95% CI: 1.00 to 1.20; P=0.058) did not. Given a large number of negative values, VD/VT (Siddiki estimate) and VD/VT (Penn State estimate) were not recommended as reliable substitutes. Long-term exposure to VR >1.3, V ˙ Ecorr >7.53, and VD/VT (Harris-Benedict) >0.59 was independently associated with an increased risk of mortality in ARDS patients. These findings were validated in the fluid and catheter treatment trial (FACTT) database. Conclusions In cases where VD/VT cannot be measured directly, early time-varying estimates of VD/VT such as VR, V ˙ Ecorr , and VD/VT (Harris-Benedict) can be considered for predicting mortality in ARDS patients, offering a rapid bedside application.
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Affiliation(s)
- Lianlian Jiang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Szafran JC, Patel BK. Invasive Mechanical Ventilation. Crit Care Clin 2024; 40:255-273. [PMID: 38432695 DOI: 10.1016/j.ccc.2024.01.003] [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: 03/05/2024]
Abstract
Invasive mechanical ventilation allows clinicians to support gas exchange and work of breathing in patients with respiratory failure. However, there is also potential for iatrogenesis. By understanding the benefits and limitations of different modes of ventilation and goals for gas exchange, clinicians can choose a strategy that provides appropriate support while minimizing harm. The ventilator can also provide crucial diagnostic information in the form of respiratory mechanics. These, and the mechanical ventilation strategy, should be regularly reassessed.
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Affiliation(s)
- Jennifer C Szafran
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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44
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Dolinay T, Hsu L, Maller A, Walsh BC, Szűcs A, Jerng JS, Jun D. Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review. J Clin Med 2024; 13:1909. [PMID: 38610674 PMCID: PMC11012923 DOI: 10.3390/jcm13071909] [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: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.
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Affiliation(s)
- Tamás Dolinay
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Lillian Hsu
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Abigail Maller
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Brandon Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Department of Medicine, Division of Palliative Care Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Attila Szűcs
- Department of Anesthesiology, András Jósa County Hospital, 4400 Nyíregyháza, Hungary;
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Dale Jun
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA
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45
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Kummer RL, Marini JJ. The Respiratory Mechanics of COVID-19 Acute Respiratory Distress Syndrome-Lessons Learned? J Clin Med 2024; 13:1833. [PMID: 38610598 PMCID: PMC11012401 DOI: 10.3390/jcm13071833] [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: 01/31/2024] [Revised: 03/13/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a well-defined clinical entity characterized by the acute onset of diffuse pulmonary injury and hypoxemia not explained by fluid overload. The COVID-19 pandemic brought about an unprecedented volume of patients with ARDS and challenged our understanding and clinical approach to treatment of this clinical syndrome. Unique to COVID-19 ARDS is the disruption and dysregulation of the pulmonary vascular compartment caused by the SARS-CoV-2 virus, which is a significant cause of hypoxemia in these patients. As a result, gas exchange does not necessarily correlate with respiratory system compliance and mechanics in COVID-19 ARDS as it does with other etiologies. The purpose of this review is to relate the mechanics of COVID-19 ARDS to its underlying pathophysiologic mechanisms and outline the lessons we have learned in the management of this clinic syndrome.
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Affiliation(s)
- Rebecca L. Kummer
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, Minneapolis, MN 55455, USA
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, MN 55101, USA
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46
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Van Oosten JP, Francovich JE, Somhorst P, van der Zee P, Endeman H, Gommers DAMPJ, Jonkman AH. Flow-controlled ventilation decreases mechanical power in postoperative ICU patients. Intensive Care Med Exp 2024; 12:30. [PMID: 38502268 PMCID: PMC10951187 DOI: 10.1186/s40635-024-00616-9] [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: 10/27/2023] [Accepted: 03/08/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Mechanical power (MP) is the energy delivered by the ventilator to the respiratory system and combines factors related to the development of ventilator-induced lung injury (VILI). Flow-controlled ventilation (FCV) is a new ventilation mode using a constant low flow during both inspiration and expiration, which is hypothesized to lower the MP and to improve ventilation homogeneity. Data demonstrating these effects are scarce, since previous studies comparing FCV with conventional controlled ventilation modes in ICU patients suffer from important methodological concerns. OBJECTIVES This study aims to assess the difference in MP between FCV and pressure-controlled ventilation (PCV). Secondary aims were to explore the effect of FCV in terms of minute volume, ventilation distribution and homogeneity, and gas exchange. METHODS This is a physiological study in post-cardiothoracic surgery patients requiring mechanical ventilation in the ICU. During PCV at baseline and 90 min of FCV, intratracheal pressure, airway flow and electrical impedance tomography (EIT) were measured continuously, and hemodynamics and venous and arterial blood gases were obtained repeatedly. Pressure-volume loops were constructed for the calculation of the MP. RESULTS In 10 patients, optimized FCV versus PCV resulted in a lower MP (7.7 vs. 11.0 J/min; p = 0.004). Although FCV did not increase overall ventilation homogeneity, it did lead to an improved ventilation of the dependent lung regions. A stable gas exchange at lower minute volumes was obtained. CONCLUSIONS FCV resulted in a lower MP and improved ventilation of the dependent lung regions in post-cardiothoracic surgery patients on the ICU. Trial registration Clinicaltrials.gov identifier: NCT05644418. Registered 1 December 2022, retrospectively registered.
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Affiliation(s)
- Julien P Van Oosten
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - Juliette E Francovich
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
- Technical Medicine Program, Delft University of Technology, Delft, The Netherlands
| | - Peter Somhorst
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Philip van der Zee
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Henrik Endeman
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Diederik A M P J Gommers
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Annemijn H Jonkman
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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Zaidi SF, Shaikh A, Khan DA, Surani S, Ratnani I. Driving pressure in mechanical ventilation: A review. World J Crit Care Med 2024; 13:88385. [PMID: 38633474 PMCID: PMC11019631 DOI: 10.5492/wjccm.v13.i1.88385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024] Open
Abstract
Driving pressure (∆P) is a core therapeutic component of mechanical ventilation (MV). Varying levels of ∆P have been employed during MV depending on the type of underlying pathology and severity of injury. However, ∆P levels have also been shown to closely impact hard endpoints such as mortality. Considering this, conducting an in-depth review of ∆P as a unique, outcome-impacting therapeutic modality is extremely important. There is a need to understand the subtleties involved in making sure ∆P levels are optimized to enhance outcomes and minimize harm. We performed this narrative review to further explore the various uses of ∆P, the different parameters that can affect its use, and how outcomes vary in different patient populations at different pressure levels. To better utilize ∆P in MV-requiring patients, additional large-scale clinical studies are needed.
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Affiliation(s)
- Syeda Farheen Zaidi
- Department of Medicine, Queen Mary University, London E1 4NS, United Kingdom
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Sindh, Karachi 74500, Pakistan
| | - Daniyal Aziz Khan
- Department of Medicine, Jinnah Postgraduate Medical Center, Sindh, Karachi 75510, Pakistan
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A and M University, College Station, TX 77843, United States
| | - Iqbal Ratnani
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, TX 77030, United States
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Huang D, He D, Gong L, Jiang W, Yao R, Liang Z. A Nomogram for Predicting Mortality in Patients with Pneumonia-Associated Acute Respiratory Distress Syndrome (ARDS). J Inflamm Res 2024; 17:1549-1560. [PMID: 38476470 PMCID: PMC10929650 DOI: 10.2147/jir.s454992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/29/2024] [Indexed: 03/14/2024] Open
Abstract
Background There is no predictive tool developed for pneumonia-associated acute respiratory distress syndrome (ARDS) specifically so far, and the clinical risk classification of these patients is not well defined. Our study aims to construct an early prediction model for hospital mortality in patients with pneumonia-associated ARDS. Methods In this single-center retrospective study, consecutive patients with pneumonia-associated ARDS admitted into intensive care units (ICUs) in West China Hospital of Sichuan University in China between January 2012 and December 2018 were enrolled. The least absolute shrinkage and selection operator (LASSO) regression and then multivariate logistic regression analysis were used to identify independent predictors which were used to develop a nomogram. We evaluated the performance of differentiation, calibration, and clinical utility of the nomogram. Results The included patients were divided into the training cohort (442 patients) and the testing cohort (190 patients) with comparable baseline characteristics. The independent predictors for hospital mortality included age (OR: 1.04; 95% CI: 1.02, 1.05), chronic cardiovascular diseases (OR: 2.62; 95% CI: 1.54, 4.45), chronic respiratory diseases (OR: 1.87; 95% CI: 1.02, 3.43), lymphocytes (OR: 0.56; 95% CI: 0.39, 0.81), albumin (OR: 0.94; 95% CI: 0.90, 1.00), creatinine (OR: 1.00; 95% CI: 1.00, 1.01), D-dimer (OR: 1.06; 95% CI: 1.03, 1.09) and procalcitonin (OR: 1.14; 95% CI: 1.07, 1.22). A web-based dynamic nomogram (https://h1234.shinyapps.io/dynnomapp/) was constructed based on these factors. The concordance index (C index) of the nomogram was 0.798 (95% CI: 0.756, 0.840) in the training cohort and 0.808 (95% CI: 0.747, 0.870) in testing cohort. The precision-recall (PR) curves, calibration curves, decision curve analyses (DCA) and clinical impact curves showed that the nomogram has good predictive value and clinical utility. Conclusion We developed and evaluated a convenient nomogram consisting of 8 clinical characteristics for predicting mortality in patients with pneumonia-associated ARDS.
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Affiliation(s)
- Dong Huang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Dingxiu He
- Department of Emergency Medicine, The People’s Hospital of Deyang, Deyang, Sichuan, People’s Republic of China
| | - Linjing Gong
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Wei Jiang
- Department of Emergency Medicine, The People’s Hospital of Deyang, Deyang, Sichuan, People’s Republic of China
| | - Rong Yao
- Department of Emergency Medicine, Emergency Medical Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Gonzalez C, Musso G, Louzan JR, Dominguez JM, Gomez C, Appendino G, Abaca A, Clemente L, Latasa D, Manago M, Lovesio C, Estenssoro E. Characteristics and risk factors associated with mortality during the first cycle of prone secondary to ARDS due to SARS-CoV-2 pneumonia. Med Intensiva 2024; 48:133-141. [PMID: 37714730 DOI: 10.1016/j.medine.2023.07.011] [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: 03/31/2023] [Accepted: 07/07/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE To analyze characteristics, changes in oxygenation, and pulmonary mechanics, in mechanically ventilated patients with ARDS due to SARS-CoV-2 treated with prone position and evaluate the response to this maneuver. DESIGN Cohort study including patients with PaO2/FiO2 <150mmHg requiring prone position over 18 months. We classified patients according to PaO2/FiO2 changes from basal to 24h after the first prone cycle as: 1) no increase 2) increase <25%, 3) 25%-50% increase 4) increase >50%. SETTING 33-bed medical-surgical Intensive Care Unit (ICU) in Argentina. PATIENTS 273 patients. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Epidemiological characteristics, respiratory mechanics and oxygenation were compared between survivors and non-survivors. Independent factors associated with in-hospital mortality were identified. RESULTS Baseline PaO2/FiO2 was 116 [97-135]mmHg (115 [94-136] in survivors vs. 117 [98-134] in non-survivors; p=0.50). After prone positioning, 22 patients (8%) had similar PaO2/FiO2 values; 46(16%) increased PaO2/FiO2 ≤25%; 55 (21%) increased it 25%-50%; and 150 (55%), >50%. Mortality was 86%, 87%, 72% and 50% respectively (p<0.001). Baseline PaO2/FiO2, <100mmHg did not imply that patients were refractory to prone position. Factors independently associated with mortality were age, percentage increase in PaO2/FiO2 after 24h being in prone, and number of prone cycles. CONCLUSIONS Older patients unable to improve PaO2/FiO2 after 24h in prone position and who require >1 cycle might early receive additional treatments for refractory hypoxemia. After the first 24h in the prone position, a low percentage of PaO2/FiO2 increase over baseline, beyond the initial value, was independently associated with higher mortality.
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Affiliation(s)
| | - Gabriel Musso
- Sanatorio Parque, Bv. Oroño 860, Rosario, Santa Fe, Argentina
| | | | | | - Celeste Gomez
- Sanatorio Parque, Bv. Oroño 860, Rosario, Santa Fe, Argentina
| | | | - Analía Abaca
- Sanatorio Parque, Bv. Oroño 860, Rosario, Santa Fe, Argentina
| | - Lucio Clemente
- Sanatorio Parque, Bv. Oroño 860, Rosario, Santa Fe, Argentina
| | - Diana Latasa
- Sanatorio Parque, Bv. Oroño 860, Rosario, Santa Fe, Argentina
| | - Martin Manago
- Sanatorio Parque, Bv. Oroño 860, Rosario, Santa Fe, Argentina
| | - Carlos Lovesio
- Sanatorio Parque, Bv. Oroño 860, Rosario, Santa Fe, Argentina
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos General San Martín de La Plata, Av. 1 1850, La Plata, Argentina
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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.
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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
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