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Boesing C, Rocco PRM, Luecke T, Krebs J. Positive end-expiratory pressure management in patients with severe ARDS: implications of prone positioning and extracorporeal membrane oxygenation. Crit Care 2024; 28:277. [PMID: 39187853 PMCID: PMC11348554 DOI: 10.1186/s13054-024-05059-y] [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: 07/02/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024] Open
Abstract
The optimal strategy for positive end-expiratory pressure (PEEP) titration in the management of severe acute respiratory distress syndrome (ARDS) patients remains unclear. Current guidelines emphasize the importance of a careful risk-benefit assessment for PEEP titration in terms of cardiopulmonary function in these patients. Over the last few decades, the primary goal of PEEP usage has shifted from merely improving oxygenation to emphasizing lung protection, with a growing focus on the individual pattern of lung injury, lung and chest wall mechanics, and the hemodynamic consequences of PEEP. In moderate-to-severe ARDS patients, prone positioning (PP) is recommended as part of a lung protective ventilation strategy to reduce mortality. However, the physiologic changes in respiratory mechanics and hemodynamics during PP may require careful re-assessment of the ventilation strategy, including PEEP. For the most severe ARDS patients with refractory gas exchange impairment, where lung protective ventilation is not possible, veno-venous extracorporeal membrane oxygenation (V-V ECMO) facilitates gas exchange and allows for a "lung rest" strategy using "ultraprotective" ventilation. Consequently, the importance of lung recruitment to improve oxygenation and homogenize ventilation with adequate PEEP may differ in severe ARDS patients treated with V-V ECMO compared to those managed conservatively. This review discusses PEEP management in severe ARDS patients and the implications of management with PP or V-V ECMO with respect to respiratory mechanics and hemodynamic function.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Maldonado-Beltrán I, Ríos-Ayala MA, Osuna-Padilla IA, Rodríguez-Moguel NC, Lugo-Goytia G, Hernández-Cárdenas CM. Changes in pulmonary mechanics from supine to prone position measured through esophageal manometry in critically ill patients with COVID-19 severe acute respiratory distress syndrome. Med Intensiva 2024; 48:386-391. [PMID: 37580222 DOI: 10.1016/j.medine.2023.07.013] [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: 08/16/2023]
Abstract
OBJECTIVE To describe changes in pulmonary mechanics when changing from supine position (SP) to prone position (PP) in mechanically ventilated (MV) patients with Acute Respiratory Distress Syndrome (ARDS) due to severe COVID-19. DESIGN Retrospective cohort. SETTING Intensive Care Unit of the National Institute of Respiratory Diseases (Mexico City). PATIENTS COVID-19 patients on MV due to ARDS, with criteria for PP. INTERVENTION Measurement of pulmonary mechanics in patients on SP to PP, using esophageal manometry. MAIN VARIABLES OF INTEREST Changes in lung and thoracic wall mechanics in SP and PP RESULTS: Nineteen patients were included. Changes during first prone positioning were reported. Reductions in lung stress (10.6 vs 7.7, p=0.02), lung strain (0.74 vs 0.57, p=0.02), lung elastance (p=0.01), chest wall elastance (p=0.003) and relation of respiratory system elastances (p=0.001) were observed between patients when changing from SP to PP. No differences were observed in driving pressure (p=0.19) and transpulmonary pressure during inspiration (p=0.70). CONCLUSIONS Changes in pulmonary mechanics were observed when patients were comparing values of supine position with measurements obtained 24h after prone positioning. Esophageal pressure monitoring may facilitate ventilator management despite patient positioning.
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Affiliation(s)
- Ismael Maldonado-Beltrán
- Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México, Mexico
| | - Martín Armando Ríos-Ayala
- Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México, Mexico
| | - Iván Armando Osuna-Padilla
- Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México, Mexico
| | - Nadia Carolina Rodríguez-Moguel
- Departamento de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México, Mexico
| | - Gustavo Lugo-Goytia
- Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México, Mexico
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Karabulut M, Uslu HS. Effect of sleeping position on cardiac output, pulmonary pressure, and superior vena cava flow in healthy term infants. Pediatr Neonatol 2024; 65:229-236. [PMID: 37973502 DOI: 10.1016/j.pedneo.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Although the mechanism of action in newborns is unknown, sleep positioning is associated with many pathophysiological events. This study aimed to compare the effects of supine and prone sleeping positions on cardiac output (CO), systolic pulmonary arterial pressure (SPAP), and superior vena cava (SVC) flow in healthy newborns. METHODS In the first 24-72 h of life, 40 healthy term newborns born in the same hospital were included in this prospective, cross-sectional, observational study. CO, SVC flow, and SPAP values of newborns in the supine and prone sleeping positions were calculated using echocardiographic examination. The measurements were statistically compared. RESULTS In the supine sleeping position, CO, SVC flow, and SPAP were 235.00 (193.07-283.30) ml/kg/min, 92.80 (77.82-121.87) ml/kg/min, and 27.85 (24.70-30.48) mmHg. In the prone sleeping position, CO, SVC flow, and SPAP were measured as 195.35 (166.00-229.40) ml/kg/min, 67.25 (51.82-96.66) ml/kg/min, 31.60 (28.45-37.20) mmHg, respectively. Depending on sleeping position, these variables were significantly different between the groups. CONCLUSION SVC flow and CO decreased in the prone sleeping position compared to the supine sleeping position in healthy newborns, whereas SPAP increased. The different hemodynamic effects of sleeping position on the cardiac, pulmonary, and nervous systems should be considered as flow and pressure changes are important in newborns.
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Affiliation(s)
- Muhammed Karabulut
- Department of Paediatric Cardiology, Clinical of Paediatric Health and Diseases, Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey.
| | - Hasan Sinan Uslu
- Department of Neonatal İntensive Care, Clinical of Paediatric Health and Diseases, Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
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Boesing C, Krebs J, Conrad AM, Otto M, Beck G, Thiel M, Rocco PRM, Luecke T, Schaefer L. Effects of prone positioning on lung mechanical power components in patients with acute respiratory distress syndrome: a physiologic study. Crit Care 2024; 28:82. [PMID: 38491457 PMCID: PMC10941550 DOI: 10.1186/s13054-024-04867-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Prone positioning (PP) homogenizes ventilation distribution and may limit ventilator-induced lung injury (VILI) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The static and dynamic components of ventilation that may cause VILI have been aggregated in mechanical power, considered a unifying driver of VILI. PP may affect mechanical power components differently due to changes in respiratory mechanics; however, the effects of PP on lung mechanical power components are unclear. This study aimed to compare the following parameters during supine positioning (SP) and PP: lung total elastic power and its components (elastic static power and elastic dynamic power) and these variables normalized to end-expiratory lung volume (EELV). METHODS This prospective physiologic study included 55 patients with moderate to severe ARDS. Lung total elastic power and its static and dynamic components were compared during SP and PP using an esophageal pressure-guided ventilation strategy. In SP, the esophageal pressure-guided ventilation strategy was further compared with an oxygenation-guided ventilation strategy defined as baseline SP. The primary endpoint was the effect of PP on lung total elastic power non-normalized and normalized to EELV. Secondary endpoints were the effects of PP and ventilation strategies on lung elastic static and dynamic power components non-normalized and normalized to EELV, respiratory mechanics, gas exchange, and hemodynamic parameters. RESULTS Lung total elastic power (median [interquartile range]) was lower during PP compared with SP (6.7 [4.9-10.6] versus 11.0 [6.6-14.8] J/min; P < 0.001) non-normalized and normalized to EELV (3.2 [2.1-5.0] versus 5.3 [3.3-7.5] J/min/L; P < 0.001). Comparing PP with SP, transpulmonary pressures and EELV did not significantly differ despite lower positive end-expiratory pressure and plateau airway pressure, thereby reducing non-normalized and normalized lung elastic static power in PP. PP improved gas exchange, cardiac output, and increased oxygen delivery compared with SP. CONCLUSIONS In patients with moderate to severe ARDS, PP reduced lung total elastic and elastic static power compared with SP regardless of EELV normalization because comparable transpulmonary pressures and EELV were achieved at lower airway pressures. This resulted in improved gas exchange, hemodynamics, and oxygen delivery. TRIAL REGISTRATION German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://drks.de/search/en/trial/DRKS00017449.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Alice Marguerite Conrad
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Matthias Otto
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Grietje Beck
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Chiappero C, Mattei A, Guidelli L, Millotti S, Ceccherini E, Oczkowski S, Scala R. Prone positioning during CPAP therapy in SARS-CoV-2 pneumonia: a concise clinical review. Ther Adv Respir Dis 2024; 18:17534666231219630. [PMID: 38159215 PMCID: PMC10757797 DOI: 10.1177/17534666231219630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
During the COVID-19 pandemic, the number of patients with hypoxemic acute respiratory failure (ARF) due to SARS-CoV-2 pneumonia threatened to overwhelm intensive care units. To reduce the need for invasive mechanical ventilation (IMV), clinicians tried noninvasive strategies to manage ARF, including the use of awake prone positioning (PP) with continuous positive airway pressure (CPAP). In this article, we review the patho-physiologic rationale, clinical effectiveness and practical issues of the use of PP during CPAP in non-intubated, spontaneously breathing patients affected by SARS-CoV-2 pneumonia with ARF. Use of PP during CPAP appears to be safe and feasible and may have a lower rate of adverse events compared to IMV. A better response to PP is observed among patients in early phases of acute respiratory distress syndrome. While PP during CPAP may improve oxygenation, the impact on the need for intubation and mortality remains unclear. It is possible to speculate on the role of PP during CPAP in terms of improvement of ventilation mechanics and reduction of strain stress.
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Affiliation(s)
- Chiara Chiappero
- Cardiovascular and Thoracic Department, Pneumology, AOU Città della Salute e della Scienza di Torino – Molinette hospital, c.so Bramante 88, Turin 10126, Italy
| | - Alessio Mattei
- Cardiovascular and Thoracic Department, Pneumology, AOU Città della Salute e della Scienza di Torino – Molinette hospital, Turin, Italy
| | - Luca Guidelli
- CardioThoraco-Neuro-Vascular Department, Pulmonology and RICU, S Donato Hospital USL Toscana Sudest, Arezzo, Italy
| | - Serena Millotti
- UOP RF Arezzo, Department of Healthcare technical professions, Rehabilitation and Prevention, USL Toscana Sudest, Arezzo, Italy
| | - Emiliano Ceccherini
- UOP RF Arezzo, Department of Healthcare technical professions, Rehabilitation and Prevention, USL Toscana Sudest, Arezzo, Italy
| | - Simon Oczkowski
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Raffaele Scala
- CardioThoraco-Neuro-Vascular Department, Pulmonology and RICU, S Donato Hospital USL Toscana Sudest, Arezzo, Italy
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Duhem H, Terzi N, Segond N, Bellier A, Sanchez C, Louis B, Debaty G, Guérin C. Effect of automated head-thorax elevation during chest compressions on lung ventilation: a model study. Sci Rep 2023; 13:20393. [PMID: 37989865 PMCID: PMC10663599 DOI: 10.1038/s41598-023-47727-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 11/17/2023] [Indexed: 11/23/2023] Open
Abstract
Our goal was to investigate the effects of head-thorax elevation (HUP) during chest compressions (CC) on lung ventilation. A prospective study was performed on seven human cadavers. Chest was automatically compressed-decompressed in flat position and during progressive HUP from 18 to 35°. Lung ventilation was measured with electrical impedance tomography. In each cadaver, 5 sequences were randomly performed: one without CC at positive end-expiratory pressure (PEEP) 0cmH2O, 3 s with CC at PEEP0, 5 or 10cmH2O and 1 with CC and an impedance threshold device at PEEP0cmH2O. The minimal-to-maximal change in impedance (VTEIT in arbitrary unit a.u.) and the minimal impedance in every breathing cycle (EELI) the) were compared between flat, 18°, and 35° in each sequence by a mixed-effects model. Values are expressed as median (1st-3rd quartiles). With CC, between flat, 18° and 35° VTEIT decreased at each level of PEEP. It was 12416a.u. (10,689; 14,442), 11,239 (7667; 13,292), and 6457 (4631; 9516), respectively, at PEEP0. The same was true with the impedance threshold device. EELI/VTEIT significantly decreased from - 0.30 (- 0.40; - 0.15) before to - 1.13 (- 1.70; - 0.61) after the CC (P = 0.009). With HUP lung ventilation decreased with CC as compared to flat position. CC are associated with decreased in EELI.
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Affiliation(s)
- Hélène Duhem
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Nicolas Terzi
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
| | - Nicolas Segond
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Alexandre Bellier
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Caroline Sanchez
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM-UPEC UMR 955 Eq13 - CNRS EMR 7000, 8 rue du Général Sarrail, 94010, Créteil, France
| | - Guillaume Debaty
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France.
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France.
| | - Claude Guérin
- Institut Mondor de Recherches Biomédicales INSERM-UPEC UMR 955 Eq13 - CNRS EMR 7000, 8 rue du Général Sarrail, 94010, Créteil, France
- Faculté de médecine Lyon Est, Université de Lyon, 8 avenue Rockefeller, 69373, Lyon cedex 08, France
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Morais CCA, Alcala G, De Santis Santiago RR, Valsecchi C, Diaz E, Wanderley H, Fakhr BS, Di Fenza R, Gianni S, Foote S, Chang MG, Bittner EA, Carroll RW, Costa ELV, Amato MBP, Berra L. Pronation Reveals a Heterogeneous Response of Global and Regional Respiratory Mechanics in Patients With Acute Hypoxemic Respiratory Failure. Crit Care Explor 2023; 5:e0983. [PMID: 37795456 PMCID: PMC10547249 DOI: 10.1097/cce.0000000000000983] [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] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Experimental models suggest that prone position and positive end-expiratory pressure (PEEP) homogenize ventral-dorsal ventilation distribution and regional respiratory compliance. However, this response still needs confirmation on humans. Therefore, this study aimed to assess the changes in global and regional respiratory mechanics in supine and prone positions over a range of PEEP levels in acute respiratory distress syndrome (ARDS) patients. DESIGN A prospective cohort study. PATIENTS Twenty-two intubated patients with ARDS caused by COVID-19 pneumonia. INTERVENTIONS Electrical impedance tomography and esophageal manometry were applied during PEEP titrations from 20 cm H2O to 6 cm H2O in supine and prone positions. MEASUREMENTS Global respiratory system compliance (Crs), chest wall compliance, regional lung compliance, ventilation distribution in supine and prone positions. MAIN RESULTS Compared with supine position, the maximum level of Crs changed after prone position in 59% of ARDS patients (n = 13), of which the Crs decreased in 32% (n = 7) and increased in 27% (n = 6). To reach maximum Crs after pronation, PEEP was changed in 45% of the patients by at least 4 cm H2O. After pronation, the ventilation and compliance of the dorsal region did not consistently change in the entire sample of patients, increasing specifically in a subgroup of patients who showed a positive change in Crs when transitioning from supine to prone position. These combined changes in ventilation and compliance suggest dorsal recruitment postpronation. In addition, the subgroup with increased Crs postpronation demonstrated the most pronounced difference between dorsal and ventral ventilation distribution from supine to prone position (p = 0.01), indicating heterogeneous ventilation distribution in prone position. CONCLUSIONS Prone position modifies global respiratory compliance in most patients with ARDS. Only a subgroup of patients with a positive change in Crs postpronation presented a consistent improvement in dorsal ventilation and compliance. These data suggest that the response to pronation on global and regional mechanics can vary among ARDS patients, with some patients presenting more dorsal lung recruitment than others.
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Affiliation(s)
- Caio C A Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Roberta R De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Eduardo Diaz
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Hatus Wanderley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Sara Foote
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ryan W Carroll
- Division of Pediatric Critical Care, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA
| | - 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 São Paulo, Sao 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 São Paulo, Sao Paulo, Brazil
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Martinsson A, Houltz E, Wallinder A, Magnusson J, Lindgren S, Stenqvist O, Thorén A. Inspiratory and end-expiratory effects of lung recruitment in the prone position on dorsal lung aeration - new physiological insights in a secondary analysis of a randomised controlled study in post-cardiac surgery patients. BJA OPEN 2022; 4:100105. [PMID: 37588783 PMCID: PMC10430825 DOI: 10.1016/j.bjao.2022.100105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/20/2022] [Indexed: 08/18/2023]
Abstract
Background Cardiac surgery produces dorso-basal atelectasis and ventilation/perfusion mismatch, associated with infection and prolonged intensive care. A postoperative lung volume recruitment manoeuvre to decrease the degree of atelectasis is routine. In patients with severe respiratory failure, prone positioning and recruitment manoeuvres may increase survival, oxygenation, or both. We compared the effects of lung recruitment in prone vs supine positions on dorsal inspiratory and end-expiratory lung aeration. Methods In a prospective RCT, 30 post-cardiac surgery patients were randomly allocated to recruitment manoeuvres in the prone (n=15) or supine position (n=15). The primary endpoints were late dorsal inspiratory volume (arbitrary units [a.u.]) and left/right dorsal end-expiratory lung volume change (a.u.), prone vs supine after extubation, measured using electrical impedance tomography. Secondary outcomes included left/right dorsal inspiratory volumes (a.u.) and left/right dorsal end-expiratory lung volume change (a.u.) after prone recruitment and extubation. Results The last part of dorsal end-inspiratory volume after extubation was higher after prone (49.1 a.u.; 95% confidence interval [CI], 37.4-60.6) vs supine recruitment (24.2 a.u.; 95% CI, 18.4-29.6; P=0.024). Improvement in left dorsal end-expiratory lung volume after extubation was higher after prone (382 a.u.; 95% CI, 261-502) vs supine recruitment (-71 a.u., 95% CI, -140 to -2; n=15; P<0.001). After prone recruitment, left vs right predominant end-expiratory dorsal lung volume change disappeared after extubation. However, both left and right end-expiratory volumes were higher in the prone group, after extubation. Conclusions Recruitment in the prone position improves dorsal inspiratory and end-expiratory lung volumes after cardiac surgery. Clinical trial registration NCT03009331.
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Affiliation(s)
- Andreas Martinsson
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Erik Houltz
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Andreas Wallinder
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jesper Magnusson
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sophie Lindgren
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ola Stenqvist
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Anders Thorén
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Evrard B, Goudelin M, Vaidie J, Fedou AL, Vignon P. Severe Acute Cor Pulmonale in Patients with COVID-19 Acute Respiratory Distress Syndrome: Caution with Left Turn. Am J Respir Crit Care Med 2022; 205:961-964. [PMID: 35120295 PMCID: PMC9838634 DOI: 10.1164/rccm.202107-1568le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Bruno Evrard
- Limoges University HospitalLimoges, France,Inserm Clinical Investigation Center 1435Limoges, France,Corresponding author (e-mail: )
| | - Marine Goudelin
- Limoges University HospitalLimoges, France,Inserm Clinical Investigation Center 1435Limoges, France
| | | | | | - Philippe Vignon
- Limoges University HospitalLimoges, France,Inserm Clinical Investigation Center 1435Limoges, France
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10
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Boesing C, Graf PT, Schmitt F, Thiel M, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study. Crit Care 2022; 26:82. [PMID: 35346325 PMCID: PMC8962042 DOI: 10.1186/s13054-022-03956-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/19/2022] [Indexed: 01/01/2023] Open
Abstract
Background Prone positioning in combination with the application of low tidal volume and adequate positive end-expiratory pressure (PEEP) improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the effects of PEEP on end-expiratory transpulmonary pressure (Ptpexp) during prone positioning require clarification. For this purpose, the effects of three different PEEP titration strategies on Ptpexp, respiratory mechanics, mechanical power, gas exchange, and hemodynamics were evaluated comparing supine and prone positioning. Methods In forty consecutive patients with moderate to severe ARDS protective ventilation with PEEP titrated according to three different titration strategies was evaluated during supine and prone positioning: (A) ARDS Network recommendations (PEEPARDSNetwork), (B) the lowest static elastance of the respiratory system (PEEPEstat,RS), and (C) targeting a positive Ptpexp (PEEPPtpexp). The primary endpoint was to analyze whether Ptpexp differed significantly according to PEEP titration strategy during supine and prone positioning. Results Ptpexp increased progressively with prone positioning compared with supine positioning as well as with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork (positioning effect p < 0.001, PEEP strategy effect p < 0.001). PEEP was lower during prone positioning with PEEPEstat,RS and PEEPPtpexp (positioning effect p < 0.001, PEEP strategy effect p < 0.001). During supine positioning, mechanical power increased progressively with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork, and prone positioning attenuated this effect (positioning effect p < 0.001, PEEP strategy effect p < 0.001). Prone compared with supine positioning significantly improved oxygenation (positioning effect p < 0.001, PEEP strategy effect p < 0.001) while hemodynamics remained stable in both positions. Conclusions Prone positioning increased transpulmonary pressures while improving oxygenation and hemodynamics in patients with moderate to severe ARDS when PEEP was titrated according to the ARDS Network lower PEEP table. This PEEP titration strategy minimized parameters associated with ventilator-induced lung injury induction, such as transpulmonary driving pressure and mechanical power. We propose that a lower PEEP strategy (PEEPARDSNetwork) in combination with prone positioning may be part of a lung protective ventilation strategy in patients with moderate to severe ARDS. Trial registration German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03956-8.
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11
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Cammarota G, Simonte R, De Robertis E. Comfort During Non-invasive Ventilation. Front Med (Lausanne) 2022; 9:874250. [PMID: 35402465 PMCID: PMC8988041 DOI: 10.3389/fmed.2022.874250] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/28/2022] [Indexed: 01/03/2023] Open
Abstract
Non-invasive ventilation (NIV) has been shown to be effective in avoiding intubation and improving survival in patients with acute hypoxemic respiratory failure (ARF) when compared to conventional oxygen therapy. However, NIV is associated with high failure rates due, in most cases, to patient discomfort. Therefore, increasing attention has been paid to all those interventions aimed at enhancing patient's tolerance to NIV. Several practical aspects have been considered to improve patient adaptation. In particular, the choice of the interface and the ventilatory setting adopted for NIV play a key role in the success of respiratory assistance. Among the different NIV interfaces, tolerance is poorest for the nasal and oronasal masks, while helmet appears to be better tolerated, resulting in longer use and lower NIV failure rates. The choice of fixing system also significantly affects patient comfort due to pain and possible pressure ulcers related to the device. The ventilatory setting adopted for NIV is associated with varying degrees of patient comfort: patients are more comfortable with pressure-support ventilation (PSV) than controlled ventilation. Furthermore, the use of electrical activity of the diaphragm (EADi)-driven ventilation has been demonstrated to improve patient comfort when compared to PSV, while reducing neural drive and effort. If non-pharmacological remedies fail, sedation can be employed to improve patient's tolerance to NIV. Sedation facilitates ventilation, reduces anxiety, promotes sleep, and modulates physiological responses to stress. Judicious use of sedation may be an option to increase the chances of success in some patients at risk for intubation because of NIV intolerance consequent to pain, discomfort, claustrophobia, or agitation. During the Coronavirus Disease-19 (COVID-19) pandemic, NIV has been extensively employed to face off the massive request for ventilatory assistance. Prone positioning in non-intubated awake COVID-19 patients may improve oxygenation, reduce work of breathing, and, possibly, prevent intubation. Despite these advantages, maintaining prone position can be particularly challenging because poor comfort has been described as the main cause of prone position discontinuation. In conclusion, comfort is one of the major determinants of NIV success. All the strategies aimed to increase comfort during NIV should be pursued.
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12
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Roldán R, Rodriguez S, Barriga F, Tucci M, Victor M, Alcala G, Villamonte R, Suárez-Sipmann F, Amato M, Brochard L, Tusman G. Sequential lateral positioning as a new lung recruitment maneuver: an exploratory study in early mechanically ventilated Covid-19 ARDS patients. Ann Intensive Care 2022; 12:13. [PMID: 35150355 PMCID: PMC8840950 DOI: 10.1186/s13613-022-00988-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/21/2022] [Indexed: 12/16/2022] Open
Abstract
Background A sequential change in body position from supine-to-both lateral positions under constant ventilatory settings could be used as a postural recruitment maneuver in case of acute respiratory distress syndrome (ARDS), provided that sufficient positive end-expiratory pressure (PEEP) prevents derecruitment. This study aims to evaluate the feasibility and physiological effects of a sequential postural recruitment maneuver in early mechanically ventilated COVID-19 ARDS patients. Methods A cohort of 15 patients receiving lung-protective mechanical ventilation in volume-controlled with PEEP based on recruitability were prospectively enrolled and evaluated in five sequentially applied positions for 30 min each: Supine-baseline; Lateral-1st side; 2nd Supine; Lateral-2nd side; Supine-final. PEEP level was selected using the recruitment-to-inflation ratio (R/I ratio) based on which patients received PEEP 12 cmH2O for R/I ratio ≤ 0.5 or PEEP 15 cmH2O for R/I ratio > 0.5. At the end of each period, we measured respiratory mechanics, arterial blood gases, lung ultrasound aeration, end-expiratory lung impedance (EELI), and regional distribution of ventilation and perfusion using electric impedance tomography (EIT). Results Comparing supine baseline and final, respiratory compliance (29 ± 9 vs 32 ± 8 mL/cmH2O; p < 0.01) and PaO2/FIO2 ratio (138 ± 36 vs 164 ± 46 mmHg; p < 0.01) increased, while driving pressure (13 ± 2 vs 11 ± 2 cmH2O; p < 0.01) and lung ultrasound consolidation score decreased [5 (4–5) vs 2 (1–4); p < 0.01]. EELI decreased ventrally (218 ± 205 mL; p < 0.01) and increased dorsally (192 ± 475 mL; p = 0.02), while regional compliance increased in both ventral (11.5 ± 0.7 vs 12.9 ± 0.8 mL/cmH2O; p < 0.01) and dorsal regions (17.1 ± 1.8 vs 18.8 ± 1.8 mL/cmH2O; p < 0.01). Dorsal distribution of perfusion increased (64.8 ± 7.3% vs 66.3 ± 7.2%; p = 0.01). Conclusions Without increasing airway pressure, a sequential postural recruitment maneuver improves global and regional respiratory mechanics and gas exchange along with a redistribution of EELI from ventral to dorsal lung areas and less consolidation. Trial registration ClinicalTrials.gov, NCT04475068. Registered 17 July 2020, https://clinicaltrials.gov/ct2/show/NCT04475068 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00988-9.
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Affiliation(s)
- Rollin Roldán
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru.,Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Shalim Rodriguez
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Barriga
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Mauro Tucci
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcus Victor
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Electronics Engineering, Aeronautics Institute of Technology, São Paulo, Brazil
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Renán Villamonte
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Suárez-Sipmann
- Intensive Care Unit, Hospital Universitario de La Princesa, Madrid, Spain.,Hedenstierna Laboratory, Surgical Sciences, Uppsala University, Uppsala, Sweden.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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13
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Dorsal Push and Abdominal Binding Improve Respiratory Compliance and Driving Pressure in Proned Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0593. [PMID: 34841252 PMCID: PMC8613362 DOI: 10.1097/cce.0000000000000593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We describe seven proned patients with coronavirus disease 2019-related acute respiratory distress syndrome in whom a paradoxical decrease in driving pressure reversibly occurred during passive, volume-controlled ventilation when compressing the lower back by a sustained "dorsal push." We offer a potential explanation for these unexpected observations and suggest the possible importance of eliciting this response for lung-protective ventilation of similar patients. DESIGN/SETTING Case series at a single teaching hospital affiliated with the University of Minnesota. Measurements were recorded from continuously monitored airway pressure and flow data. PATIENTS Nonconsecutive and nonrandomized sample of coronavirus disease 2019 acute respiratory distress syndrome patients who were already prone and paralyzed for optimized lung protective clinical management while inhaling pure oxygen. INTERVENTIONS Sustained, firm manual pressure applied over the lower back in all patients, followed by abdominal binding in a subset of these. MEASUREMENTS AND MAIN RESULTS Respiratory system driving pressure declined and respiratory system compliance improved in seven patients with the dorsal push maneuver. In a subset of four of these, abdominal binding sustained those improvements over >3 hours. CONCLUSIONS Sustained compressive force applied to the dorsum of the passive and prone patient with severe respiratory failure due to coronavirus disease pneumonia may elicit a paradoxical response characterized by improved compliance and for a given tidal volume, lower plateau, and driving pressures. Such findings, which suggest end-tidal overinflation within the aerated part of the diseased lung despite the already compressed anterior chest wall of prone positioning, complement and extend those observations recently described for the supine position in coronavirus disease 2019 acute respiratory distress syndrome.
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14
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Cammarota G, Rossi E, Vitali L, Simonte R, Sannipoli T, Anniciello F, Vetrugno L, Bignami E, Becattini C, Tesoro S, Azzolina D, Giacomucci A, Navalesi P, De Robertis E. Effect of awake prone position on diaphragmatic thickening fraction in patients assisted by noninvasive ventilation for hypoxemic acute respiratory failure related to novel coronavirus disease. Crit Care 2021; 25:305. [PMID: 34429131 PMCID: PMC8383244 DOI: 10.1186/s13054-021-03735-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/18/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Awake prone position is an emerging rescue therapy applied in patients undergoing noninvasive ventilation (NIV) for acute hypoxemic respiratory failure (ARF) related to novel coronavirus disease (COVID-19). Although applied to stabilize respiratory status, in awake patients, the application of prone position may reduce comfort with a consequent increase in the workload imposed on respiratory muscles. Thus, we primarily ascertained the effect of awake prone position on diaphragmatic thickening fraction, assessed through ultrasound, in COVID-19 patients undergoing NIV. METHODS We enrolled all COVID-19 adult critically ill patients, admitted to intensive care unit (ICU) for hypoxemic ARF and undergoing NIV, deserving of awake prone positioning as a rescue therapy. Exclusion criteria were pregnancy and any contraindication to awake prone position and NIV. On ICU admission, after NIV onset, in supine position, and at 1 h following awake prone position application, diaphragmatic thickening fraction was obtained on the right side. Across all the study phases, NIV was maintained with the same setting present at study entry. Vital signs were monitored throughout the entire study period. Comfort was assessed through numerical rating scale (0 the worst comfort and 10 the highest comfort level). Data were presented in median and 25th-75th percentile range. RESULTS From February to May 2021, 20 patients were enrolled and finally analyzed. Despite peripheral oxygen saturation improvement [96 (94-97)% supine vs 98 (96-99)% prone, p = 0.008], turning to prone position induced a worsening in comfort score from 7.0 (6.0-8.0) to 6.0 (5.0-7.0) (p = 0.012) and an increase in diaphragmatic thickening fraction from 33.3 (25.7-40.5)% to 41.5 (29.8-50.0)% (p = 0.025). CONCLUSIONS In our COVID-19 patients assisted by NIV in ICU, the application of awake prone position improved the oxygenation at the expense of a greater diaphragmatic thickening fraction compared to supine position. Trial registration ClinicalTrials.gov, number NCT04904731. Registered on 05/25/2021, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04904731 .
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Affiliation(s)
- Gianmaria Cammarota
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy.
- Anestesia and Intensive Care Service 2, Azienda Ospedaliera di Perugia, Perugia, Italy.
| | - Elisa Rossi
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Leonardo Vitali
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Tiziano Sannipoli
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Francesco Anniciello
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Luigi Vetrugno
- Department of Medicine, Anesthesia and Intensive Care Clinic, Università di Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Cecilia Becattini
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Simonetta Tesoro
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
- Anestesia and Intensive Care Service 2, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Danila Azzolina
- Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Angelo Giacomucci
- Anestesia and Intensive Care Service 2, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padova, Padova, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
- Anestesia and Intensive Care Service 2, Azienda Ospedaliera di Perugia, Perugia, Italy
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15
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Ghanem MA, El-Hefnawy AS. Cardiopulmonary effects of prolonged surgical abdominal retractors application during general anesthesia: a prospective observational comparative study. Braz J Anesthesiol 2021; 73:291-300. [PMID: 34298077 DOI: 10.1016/j.bjane.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 04/25/2021] [Accepted: 06/20/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Increasing abdominal pressures could affect pulmonary compliance and cardiac performance, a fact based on which the aim of the present study to detect the cardiopulmonary burden of multiple retractors application during supine versus lateral abdominal surgeries. We hypothesized that surgical ring multiple retractors application would affect the pulmonary and cardiac functions during both lateral and supine abdominal surgeries. METHODS Prospective observational comparative study on forty surgical patients subdivided into two groups twenty each, comparing pulmonary compliance and cardiac performance before, during and after retractors application, group (S) supine position cystectomy surgery, and group (L) lateral position nephrectomy surgery under general anesthesia, Composite 1ry outcome; dynamic compliance C-dyn and cardiac index CI and Other outcome variables ICON cardio-meter were also recorded. RESULTS C-dyn and C-stat were significantly decreased late during retractor application in lateral compared to supine surgery with significant decrease compared to basal values all over the surgical time. CI was significantly increased after retractor removal in both of the study groups compared to basal values. PAWP was significantly increased in -lateral compared to supine surgery -with significant increase compared to basal value all over the surgical time in both of the study groups. significant increase in DO2I compared to basal value during both supine and lateral positions. CONCLUSION Surgical retraction results in a short-lived significant decreases in lung compliance and cardiac output particularly during the lateral-kidney position than the supine position compliance.
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Affiliation(s)
- Mohamed A Ghanem
- Mansoura University, Faculty of Medicine, Anesthesia Department, Anesthesia and Surgical Intensive Care, Almançora, Egypt.
| | - Ahmed S El-Hefnawy
- Mansoura University, Faculty of Medicine, Urology Surgery, Urology and Nephrology Center, Almançora, Egypt
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16
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Abstract
The estimation of pleural pressure with esophageal manometry has been used for decades, and it has been a fertile area of physiology research in healthy subject as well as during mechanical ventilation in patients with lung injury. However, its scarce adoption in clinical practice takes its roots from the (false) ideas that it requires expertise with years of training, that the values obtained are not reliable due to technical challenges or discrepant methods of calculation, and that measurement of esophageal pressure has not proved to benefit patient outcomes. Despites these criticisms, esophageal manometry could contribute to better monitoring, optimization, and personalization of mechanical ventilation from the acute initial phase to the weaning period. This review aims to provide a comprehensive but comprehensible guide addressing the technical aspects of esophageal catheter use, its application in different clinical situations and conditions, and an update on the state of the art with recent studies on this topic and on remaining questions and ways for improvement.
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Affiliation(s)
- Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada. .,Keenan Research Centre, Li Ka Shing Knowledge Institute, St.Michael's Hospital, Toronto, Ontario, Canada.,Service de médecine intensive-réanimation, Hôpitaux universitaires Paris-Saclay, Hôpital de Bicêtre, APHP, Le Kremlin-Bicêtre, France.,Faculté de Médecine Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St.Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto, Canada
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians & Surgeons, New York, New York
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17
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Perier F, Tuffet S, Maraffi T, Alcala G, Victor M, Haudebourg AF, De Prost N, Amato M, Carteaux G, Mekontso Dessap A. Effect of Positive End-Expiratory Pressure and Proning on Ventilation and Perfusion in COVID-19 Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2020; 202:1713-1717. [PMID: 33075235 PMCID: PMC7737587 DOI: 10.1164/rccm.202008-3058le] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- François Perier
- Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor Créteil, France.,Université Paris Est-Créteil Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor Créteil, France.,Université Paris Est-Créteil Créteil, France
| | - Tommaso Maraffi
- Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor Créteil, France.,Centre Hospitalier Intercommunal de Créteil Créteil, France and
| | | | | | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor Créteil, France.,Université Paris Est-Créteil Créteil, France
| | - Nicolas De Prost
- Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor Créteil, France.,Université Paris Est-Créteil Créteil, France
| | | | - Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor Créteil, France.,Université Paris Est-Créteil Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor Créteil, France.,Université Paris Est-Créteil Créteil, France
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18
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Telias I, Katira BH, Brochard L. Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19? JAMA 2020; 323:2265-2267. [PMID: 32412579 DOI: 10.1001/jama.2020.8539] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Irene Telias
- Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Department of Medicine, Division of Respirology, Sinai Health System, Toronto, Ontario, Canada
| | - Bhushan H Katira
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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19
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Guérin C, Terzi N, Galerneau LM, Mezidi M, Yonis H, Baboi L, Kreitmann L, Turbil E, Cour M, Argaud L, Louis B. Lung and chest wall mechanics in patients with acute respiratory distress syndrome, expiratory flow limitation, and airway closure. J Appl Physiol (1985) 2020; 128:1594-1603. [PMID: 32352339 DOI: 10.1152/japplphysiol.00059.2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Tidal expiratory flow limitation (EFL), which may herald airway closure (AC), is a mechanism of loss of aeration in ARDS. In this prospective, short-term, two-center study, we measured static and dynamic chest wall (Est,cw and Edyn,cw) and lung (Est,L and Edyn,L) elastance with esophageal pressure, EFL, and AC at 5 cmH2O positive end-expiratory pressure (PEEP) in intubated, sedated, and paralyzed ARDS patients. For EFL determination, we used the atmospheric method and a new device allowing comparison of tidal flow during expiration to PEEP and to atmosphere. AC was validated when airway opening pressure (AOP) assessed from volume-pressure curve was found greater than PEEP by at least 1 cmH2O. EFL was defined whenever flow did not increase between exhalation to PEEP and to atmosphere over all or part of expiration. Elastance values were expressed as percentage of normal predicted values (%N). Among the 25 patients included, eight had EFL (32%) and 13 AOP (52%). Between patients with and without EFL Edyn,cw [median (1st to 3rd quartiles)] was 70 (16-127) and 102 (70-142) %N (P = 0.32) and Edyn,L338 (332-763) and 224 (160-275) %N (P < 0.001). The corresponding values for Est,cw and Est,L were 70 (56-88) and 85 (64-103) %N (P = 0.35) and 248 (206-348) and 170 (144-195) (P = 0.02), respectively. Dynamic EL had an area receiver operating characteristic curve of 0.88 [95% confidence intervals 0.83-0.92] for EFL and 0.74[0.68-0.79] for AOP. Higher Edyn,L was accurate to predict EFL in ARDS patients; AC can occur independently of EFL, and both should be assessed concurrently in ARDS patients.NEW & NOTEWORTHY Expiratory flow limitation (EFL) and airway closure (AC) were observed in 32% and 52%, respectively, of 25 patients with ARDS investigated during mechanical ventilation in supine position with a positive end-expiratory pressure of 5 cmH2O. The performance of dynamic lung elastance to detect expiratory flow limitation was good and better than that to detect airway closure. The vast majority of patients with EFL also had AC; however, AC can occur in the absence of EFL.
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Affiliation(s)
- Claude Guérin
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France.,Institut Mondor de Recherches Biomédicales INSERM 955 CNRS ERL 7000, Créteil, France
| | - Nicolas Terzi
- Medecine Intensive-Réanimation, CHU Grenoble-Alpes, Grenoble, France.,Université de Grenoble-Alpes, Grenoble, France
| | - Louis-Marie Galerneau
- Medecine Intensive-Réanimation, CHU Grenoble-Alpes, Grenoble, France.,Université de Grenoble-Alpes, Grenoble, France
| | - Mehdi Mezidi
- Université de Lyon, Lyon, France.,Médecine Intensive-Réanimation, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Hodane Yonis
- Médecine Intensive-Réanimation, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Loredana Baboi
- Médecine Intensive-Réanimation, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Louis Kreitmann
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Emanuele Turbil
- Department of Anesthesia and Critical Care, University of Sassari, Sassari, Italy
| | - Martin Cour
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Laurent Argaud
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM 955 CNRS ERL 7000, Créteil, France
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20
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Influence of different PEEP levels on electrical impedance tomography findings in patients under general anesthesia ventilated in the lateral decubitus position. J Clin Monit Comput 2020; 34:311-318. [PMID: 31062131 PMCID: PMC7223527 DOI: 10.1007/s10877-019-00318-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/30/2019] [Indexed: 12/12/2022]
Abstract
To determine the effect of various PEEP levels on electrical impedance tomography (EIT) measured differences in regional ventilation, hemodynamics, lung mechanics and parameters of alveolar gas exchange. Thirty three patients scheduled for elective urologic surgery in general anesthesia in lateral decubitus position were randomized into three groups-PEEP 0, 5 and 10 mbar. EIT recording, arterial blood gas analysis and hemodynamic parameters were captured at three timepoints-before induction (T0), 5 min after lateral positioning (T1) and 90 min after positioning (T2). Dynamic compliance (Cdyn) was measured at T1 and T2. Offline EIT data analysis was performed to calculate EIT derived parameters of ventilation distribution. Patients ventilated with PEEP of 10 mbar had a significantly lower A-a (alveolo arterial) gradient over measurements and symmetrical distribution of ventilation measured by EIT. There was no significant difference in Cdyn, center of ventilation indices and inhomogeneity index between groups. There was no difference of mean arterial pressure, cardiac index and heart rate between groups. Patients with 5 mbar of PEEP had higher stroke volume index compared to 0 and 10 mbar at baseline and over measurements. Nondependent/dependent TV ratio as well as global inhomogeneity index were correlated with A-a gradient. Dynamic compliance showed no correlation to A-a gradient. In our study, a PEEP level of 10 mbar improved alveolar gas exchange without compromising hemodynamic stability in patients mechanically ventilated in the lateral decubitus position. EIT measured parameters may be used to determine optimal ventilation parameters in these patients with inhomogeneous lung mechanics. Further studies are needed in patients with various lung pathologies.
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21
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Bergez M, Fritsch N, Tran-Van D, Saghi T, Bounkim T, Gentile A, Labadie P, Fontaine B, Ouattara A, Rozé H. PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure. Ann Intensive Care 2019; 9:81. [PMID: 31312921 PMCID: PMC6635540 DOI: 10.1186/s13613-019-0554-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although lung protection with low tidal volume and limited plateau pressure (Pplat) improves survival in acute respiratory distress syndrome patients (ARDS), the best way to set positive end-expiratory pressure (PEEP) is still debated. METHODS This study aimed to compare two strategies using individual PEEP based on a maximum Pplat (28-30 cmH2O, the Express group) or on keeping end-expiratory transpulmonary pressure positive (0-5 cmH2O, PLexpi group). We estimated alveolar recruitment (Vrec), end-expiratory lung volume and alveolar distension based on elastance-related end-inspiratory transpulmonary pressure (PL,EL). RESULTS Nineteen patients with moderate to severe ARDS (PaO2/FiO2 < 150 mmHg) were included with a baseline PEEP of 7.0 ± 1.8 cmH2O and a PaO2/FiO2 of 91.2 ± 31.2 mmHg. PEEP and oxygenation increased significantly from baseline with both protocols; PEEP Express group was 14.2 ± 3.6 cmH2O versus 16.7 ± 5.9 cmH2O in PLexpi group. No patient had the same PEEP with the two protocols. Vrec was higher with the latter protocol (299 [0 to 875] vs. 222 [47 to 483] ml, p = 0.049) and correlated with improved oxygenation (R2 = 0.45, p = 0.002). Two and seven patients in the Express and PL,expi groups, respectively, had PL,EL > 25 cmH2O. CONCLUSIONS There is a great heterogeneity of PLexpi when Pplat is used to titrate PEEP but with limited risk of over-distension. A PEEP titration for a moderate positive level of PLexpi might slightly improve alveolar recruitment and oxygenation but increases the risk of over-distension in one-third of patients.
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Affiliation(s)
- Marie Bergez
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Nicolas Fritsch
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - David Tran-Van
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Tahar Saghi
- Intensive Care Unit, North Bordeaux Aquitaine Clinic, Bordeaux, France
| | - Tan Bounkim
- Medical and Surgical Intensive Care, Saint Joseph Saint Luc Teaching Hospital, Lyon, France
| | - Ariane Gentile
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Philippe Labadie
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Bruno Fontaine
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Alexandre Ouattara
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France.,Biology of Cardiovascular Diseases, INSERM, UMR 1034, Univ. Bordeaux, 33600, Pessac, France
| | - Hadrien Rozé
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France.
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22
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Physiological Effect of Prone Position in Children with Severe Bronchiolitis: A Randomized Cross-Over Study (BRONCHIO-DV). J Pediatr 2019; 205:112-119.e4. [PMID: 30448014 DOI: 10.1016/j.jpeds.2018.09.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation. STUDY DESIGN Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmH2O continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed. RESULTS Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmH2O*s/minute [IQR, 156-282] cmH2O*s/minute vs 353 cmH2O*s/minute [IQR, 249-386 cmH2O*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmH2O/µV [IQR, 0.9-1.3 cmH2O/µV] vs 0.7 cmH2O/µV [IQR, 0.6-1.2 cmH2O/µV], respectively; P = .022). CONCLUSIONS This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population. TRIAL REGISTRATION Clinicaltrials.gov: NCT02602678.
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Comparison of geometric and algebraic methods to determine mechanical power in patients with acute respiratory distress syndrome. Intensive Care Med 2019; 45:738-740. [DOI: 10.1007/s00134-019-05521-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
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24
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Effect of body position and inclination in supine and prone position on respiratory mechanics in acute respiratory distress syndrome. Intensive Care Med 2018; 45:292-294. [DOI: 10.1007/s00134-018-5493-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
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Mezidi M, Guérin C. Effects of patient positioning on respiratory mechanics in mechanically ventilated ICU patients. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:384. [PMID: 30460258 DOI: 10.21037/atm.2018.05.50] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Changes in the body position of patients receiving mechanical ventilation in intensive care unit are frequent. Contrary to healthy humans, little data has explored the physiological impact of position on respiratory mechanics. The objective of present paper is to review the available data on the effect of changing body position on respiratory mechanics in ICU patients receiving mechanical ventilation. Supine position (lying flat) or lateral position do not seem beneficial for critically ill patients in terms of respiratory mechanics. The sitting position (with thorax angulation >30° from the horizontal plane) is associated with improvement of functional residual capacity (FRC), oxygenation and reduction of work of breathing. There is a critical angle of inclination in the seated position above which the increase in abdominal pressure contributes to increase chest wall elastance and offset the increase in FRC. The impact of prone position on respiratory mechanics is complex, but the increase in chest wall elastance is a central mechanism. To sum up, both sitting and prone positions provides beneficial impact on respiratory mechanics of mechanically ventilated patients as compared to supine position.
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Affiliation(s)
- Mehdi Mezidi
- Service de réanimation médicale, Hôpital de la Croix Rousse, Hospices civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Claude Guérin
- Service de réanimation médicale, Hôpital de la Croix Rousse, Hospices civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France.,Institut Mondor de Recherche Biomédicale, INSERM 955, Créteil, France
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26
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Mezidi M, Parrilla FJ, Yonis H, Riad Z, Böhm SH, Waldmann AD, Richard JC, Lissonde F, Tapponnier R, Baboi L, Mancebo J, Guérin C. Effects of positive end-expiratory pressure strategy in supine and prone position on lung and chest wall mechanics in acute respiratory distress syndrome. Ann Intensive Care 2018; 8:86. [PMID: 30203117 PMCID: PMC6134472 DOI: 10.1186/s13613-018-0434-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/01/2018] [Indexed: 02/05/2023] Open
Abstract
Background In acute respiratory distress syndrome (ARDS) patients, it has recently been proposed to set positive end-expiratory pressure (PEEP) by targeting end-expiratory transpulmonary pressure. This approach, which relies on the measurement of absolute esophageal pressure (Pes), has been used in supine position (SP) and has not been investigated in prone position (PP). Our purposes were to assess Pes-guided strategy to set PEEP in SP and in PP as compared with a PEEP/FIO2 table and to explore the early (1 h) and late (16 h) effects of PP on lung and chest wall mechanics. Results We performed a prospective, physiologic study in two ICUs in university hospitals on ARDS patients with PaO2/FIO2 < 150 mmHg. End-expiratory Pes (Pes,ee) was measured in static (zero flow) condition. Patients received PEEP set according to a PEEP/FIO2 table then according to the Pes-guided strategy targeting a positive (3 ± 2 cmH2O) static end-expiratory transpulmonary pressure in SP. Then, patients were turned to PP and received same amount of PEEP from PEEP/FIO2 table then Pes-guided strategy. Respiratory mechanics, oxygenation and end-expiratory lung volume (EELV) were measured after 1 h of each PEEP in each position. For the rest of the 16-h PP session, patients were randomly allocated to either PEEP strategy with measurements done at the end. Thirty-eight ARDS patients (27 male), mean ± SD age 63 ± 13 years, were included. There were 33 primary ARDS and 26 moderate ARDS. PaO2/FIO2 ratio was 120 ± 23 mmHg. At same PEEP/FIO2 table-related PEEP, Pes,ee averaged 9 ± 4 cmH2O in both SP and PP (P = 0.88). With PEEP/FIO2 table and Pes-guided strategy, PEEP was 10 ± 2 versus 12 ± 4 cmH2O in SP and 10 ± 2 versus 12 ± 5 cmH2O in PP (PEEP strategy effect P = 0.05, position effect P = 0.96, interaction P = 0.96). With the Pes-guided strategy, chest wall elastance increased regardless of position. Lung elastance and transpulmonary driving pressure decreased in PP, with no effect of PEEP strategy. Both PP and Pes-guided strategy improved oxygenation without interaction. EELV did not change with PEEP strategy. At the end of PP session, respiratory mechanics did not vary but EELV and PaO2/FIO2 increased while PaCO2 decreased. Conclusions There was no impact of PP on Pes measurements. PP had an immediate improvement effect on lung mechanics and a late lung recruitment effect independent of PEEP strategy. Electronic supplementary material The online version of this article (10.1186/s13613-018-0434-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mehdi Mezidi
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | | | - Hodane Yonis
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Zakaria Riad
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Stephan H Böhm
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Schillingallee 35, 18057, Rostock, Germany
| | - Andreas D Waldmann
- Swisstom AG, Lanquart, Switzerland.,Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Koln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Jean-Christophe Richard
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Floriane Lissonde
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Romain Tapponnier
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Loredana Baboi
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Jordi Mancebo
- Intensive Care Unit, Sant Pau Hospital, Barcelona, Spain
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France. .,Université de Lyon, Lyon, France. .,INSERM 955, Créteil, France.
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