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Ghiani A, Walcher S, Lutfi A, Paderewska J, Jaeger SU, Kneidinger N, Stecher SS, Trudzinski FC, Neurohr C. Mechanical power density, spontaneous breathing indexes, and prolonged weaning failure: a prospective cohort study. Sci Rep 2024; 14:16297. [PMID: 39009821 PMCID: PMC11251183 DOI: 10.1038/s41598-024-67237-w] [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] [Accepted: 07/09/2024] [Indexed: 07/17/2024] Open
Abstract
A prospective observational study comparing mechanical power density (MP normalized to dynamic compliance) with traditional spontaneous breathing indexes (e.g., predicted body weight normalized tidal volume [VT/PBW], rapid shallow breathing index [RSBI], or the integrative weaning index [IWI]) for predicting prolonged weaning failure in 140 tracheotomized patients. We assessed the diagnostic accuracy of these indexes at the start and end of the weaning procedure using ROC curve analysis, expressed as the area under the receiver operating characteristic curve (AUROC). Weaning failure occurred in 41 out of 140 patients (29%), demonstrating significantly higher MP density (6156 cmH2O2/min [4402-7910] vs. 3004 cmH2O2/min [2153-3917], P < 0.01), lower spontaneous VT/PBW (5.8 mL*kg-1 [4.8-6.8] vs. 6.6 mL*kg-1 [5.7-7.9], P < 0.01) higher RSBI (68 min-1*L-1 [44-91] vs. 55 min-1*L-1 [41-76], P < 0.01) and lower IWI (41 L2/cmH2O*%*min*10-3 [25-72] vs. 71 L2/cmH2O*%*min*10-3 [50-106], P < 0.01) and at the end of weaning. MP density was more accurate at predicting weaning failures (AUROC 0.91 [95%CI 0.84-0.95]) than VT/PBW (0.67 [0.58-0.74]), RSBI (0.62 [0.53-0.70]), or IWI (0.73 [0.65-0.80]), and may help clinicians in identifying patients at high risk for long-term ventilator dependency.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Swenja Walcher
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Azal Lutfi
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Joanna Paderewska
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Simon Ulrich Jaeger
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, LMU University Hospital, LMU Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Munich, Germany
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Franziska Christina Trudzinski
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
- Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Munich, Germany
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Li L, Zhang H, Dai T, Liu D, Xiao S, Xiao Y, Huang L. Development of a Preoperative Screening Tool to Reduce Morbidity and Mortality of COVID-19-positive Hepatobiliary Patients. J Perianesth Nurs 2024:S1089-9472(24)00121-7. [PMID: 39001741 DOI: 10.1016/j.jopan.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/17/2024] [Accepted: 03/29/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE This study aimed to create a preoperative risk assessment form for COVID-19-positive hepatobiliary patients to guide further prevention of complications after surgery and reduce morbidity and mortality. DESIGN Based on the literature, focus groups, and case studies, a multidisciplinary panel of 15 experts conducted three rounds of a Delphi study that resulted in the development of a preoperative risk assessment form to be used by healthcare professionals in the treatment of COVID-19-positive hepatobiliary patients. METHODS A preoperative risk assessment form for health professionals to use among COVID-19-positive hepatobiliary patients was developed based on literature, focus groups, and case studies. A 3-round Delphi study was conducted to validate and revise the risk assessment form using a multidisciplinary panel of 15 experts involved in hepatobiliary surgery. FINDINGS The experts demonstrated high cooperation and familiarity with the research topic, with positive coefficients ranging from 93.33% to 100% and authority coefficients ranging from 0.83 to 0.86. The coordination coefficients were 0.33, 0.26, and 0.22, respectively, indicating good coordination among expert opinions. The final risk assessment form included 9 primary (first-level) indicators, 38 secondary (second-level) indicators, and 122 tertiary (third-level) indicators. CONCLUSIONS The preoperative risk assessment form for hepatobiliary surgery patients infected with COVID-19 is scientifically rigorous, reliable, and valid. This screening tool may be used by health providers to identify high-risk patients, prevent postoperative complications, and reduce morbidity and mortality.
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Affiliation(s)
- Lihui Li
- Hunan Provincial People's Hospital (The First Hospital Affiliated to Hunan Normal University), Changsha, Hunan, China
| | - Honghui Zhang
- Hunan Provincial People's Hospital (The First Hospital Affiliated to Hunan Normal University), Changsha, Hunan, China.
| | - Ting Dai
- Hunan Provincial People's Hospital (The First Hospital Affiliated to Hunan Normal University), Changsha, Hunan, China
| | - Dan Liu
- Hunan Provincial People's Hospital (The First Hospital Affiliated to Hunan Normal University), Changsha, Hunan, China
| | - Shan Xiao
- Hunan Provincial People's Hospital (The First Hospital Affiliated to Hunan Normal University), Changsha, Hunan, China
| | - Yuting Xiao
- Hunan Provincial People's Hospital (The First Hospital Affiliated to Hunan Normal University), Changsha, Hunan, China
| | - Ling Huang
- Tibet Autonomous Region Blood Center, Lhasa, Tibet Autonomous Region, China
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Al-Husinat L, Azzam S, Al Sharie S, Al Sharie AH, Battaglini D, Robba C, Marini JJ, Thornton LT, Cruz FF, Silva PL, Rocco PRM. Effects of mechanical ventilation on the interstitial extracellular matrix in healthy lungs and lungs affected by acute respiratory distress syndrome: a narrative review. Crit Care 2024; 28:165. [PMID: 38750543 PMCID: PMC11094887 DOI: 10.1186/s13054-024-04942-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Mechanical ventilation, a lifesaving intervention in critical care, can lead to damage in the extracellular matrix (ECM), triggering inflammation and ventilator-induced lung injury (VILI), particularly in conditions such as acute respiratory distress syndrome (ARDS). This review discusses the detailed structure of the ECM in healthy and ARDS-affected lungs under mechanical ventilation, aiming to bridge the gap between experimental insights and clinical practice by offering a thorough understanding of lung ECM organization and the dynamics of its alteration during mechanical ventilation. MAIN TEXT Focusing on the clinical implications, we explore the potential of precise interventions targeting the ECM and cellular signaling pathways to mitigate lung damage, reduce inflammation, and ultimately improve outcomes for critically ill patients. By analyzing a range of experimental studies and clinical papers, particular attention is paid to the roles of matrix metalloproteinases (MMPs), integrins, and other molecules in ECM damage and VILI. This synthesis not only sheds light on the structural changes induced by mechanical stress but also underscores the importance of cellular responses such as inflammation, fibrosis, and excessive activation of MMPs. CONCLUSIONS This review emphasizes the significance of mechanical cues transduced by integrins and their impact on cellular behavior during ventilation, offering insights into the complex interactions between mechanical ventilation, ECM damage, and cellular signaling. By understanding these mechanisms, healthcare professionals in critical care can anticipate the consequences of mechanical ventilation and use targeted strategies to prevent or minimize ECM damage, ultimately leading to better patient management and outcomes in critical care settings.
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Affiliation(s)
- Lou'i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Saif Azzam
- Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | | | - Ahmed H Al Sharie
- Department of Pathology and Microbiology, Jordan University of Science and Technology, Irbid, Jordan
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche, Università Degli Studi di Genova, Genoa, Italy
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA
| | - Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Gutierrez G. A non-invasive method to monitor respiratory muscle effort during mechanical ventilation. J Clin Monit Comput 2024:10.1007/s10877-024-01164-z. [PMID: 38733504 DOI: 10.1007/s10877-024-01164-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/08/2024] [Indexed: 05/13/2024]
Abstract
PURPOSE This study introduces a method to non-invasively and automatically quantify respiratory muscle effort (Pmus) during mechanical ventilation (MV). The methodology hinges on numerically solving the respiratory system's equation of motion, utilizing measurements of airway pressure (Paw) and airflow (Faw). To evaluate the technique's effectiveness, Pmus was correlated with expected physiological responses. In volume-control (VC) mode, where tidal volume (VT) is pre-determined, Pmus is expected to be linked to Paw fluctuations. In contrast, during pressure-control (PC) mode, where Paw is held constant, Pmus should correlate with VT variations. METHODS The study utilized data from 250 patients on invasive MV. The data included detailed recordings of Paw and Faw, sampled at 31.25 Hz and saved in 131.1-second epochs, each covering 34 to 41 breaths. The algorithm identified 51,268 epochs containing breaths on either VC or PC mode exclusively. In these epochs, Pmus and its pressure-time product (PmusPTP) were computed and correlated with Paw's pressure-time product (PawPTP) and VT, respectively. RESULTS There was a strong correlation of PmusPTP with PawPTP in VC mode (R² = 0.91 [0.76, 0.96]; n = 17,648 epochs) and with VT in PC mode (R² = 0.88 [0.74, 0.94]; n = 33,620 epochs), confirming the hypothesis. As expected, negligible correlations were observed between PmusPTP and VT in VC mode (R² = 0.03) and between PmusPTP and PawPTP in PC mode (R² = 0.06). CONCLUSION The study supports the feasibility of assessing respiratory effort during MV non-invasively through airway signal analysis. Further research is warranted to validate this method and investigate its clinical applications.
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Affiliation(s)
- Guillermo Gutierrez
- Professor Emeritus Medicine, Anesthesiology and Engineering, The George Washington University, 700 New Hampshire Ave, NW Suite 510, Washington, DC, 20037, USA.
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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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Feng J, Huang X, Xu Q, Tang R, Zhou Y, Qin S, Xing S, Gao Y, Mei S, He Z. Pharmacological inhibition of the ACE/Ang-2/AT1 axis alleviates mechanical ventilation-induced pulmonary fibrosis. Int Immunopharmacol 2024; 131:111855. [PMID: 38493697 DOI: 10.1016/j.intimp.2024.111855] [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: 11/17/2023] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 03/19/2024]
Abstract
Mechanical ventilation (MV) is an essential therapy for acute respiratory distress syndrome (ARDS) and pulmonary fibrosis. However, it can also induce mechanical ventilation-induced pulmonary fibrosis (MVPF) and the underlying mechanism remains unknown. Based on a mouse model of MVPF, the present study aimed to explore the role of the angiotensin-converting enzyme/angiotensin II/angiotensin type 1 receptor (ACE/Ang-2/AT1R) axis in the process of MVPF. In addition, recombinant angiotensin-converting enzyme 2(rACE2), AT1R inhibitor valsartan, AGTR1-directed shRNA and ACE inhibitor perindopril were applied to verify the effect of inhibiting ACE/Ang-2/AT1R axis in the treatment of MVPF. Our study found MV induced an inflammatory reaction and collagen deposition in mouse lung tissue accompanied by the activation of ACE in lung tissue, increased concentration of Ang-2 in bronchoalveolar lavage fluid (BALF), and upregulation of AT1R in alveolar epithelial cells. The process of pulmonary fibrosis could be alleviated by the application of the ACE inhibitor perindopril, ATIR inhibitor valsartan and AGTR1-directed shRNA. Meanwhile, rACE2 could also alleviate MVPF through the degradation of Ang-2. Our finding indicated the ACE/Ang-2/AT1R axis played an essential role in the pathogenesis of MVPF. Pharmacological inhibition of the ACE/Ang-2/AT1R axis might be a promising strategy for the treatment of MVPF.
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Affiliation(s)
- Jinhua Feng
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Xi Huang
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Qiaoyi Xu
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Ri Tang
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Yang Zhou
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Shaojie Qin
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Shunpeng Xing
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Yuan Gao
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Shuya Mei
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China.
| | - Zhengyu He
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China.
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De Pascale G, Posteraro B, De Maio F, Pafundi PC, Tanzarella ES, Cutuli SL, Lombardi G, Grieco DL, Franchini E, Santarelli G, Infante A, Sanguinetti M, Antonelli M. Lung microbiota composition, respiratory mechanics, and outcomes in COVID-19-related ARDS. Microbiol Spectr 2024; 12:e0357423. [PMID: 38466118 PMCID: PMC10986322 DOI: 10.1128/spectrum.03574-23] [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: 10/04/2023] [Accepted: 01/29/2024] [Indexed: 03/12/2024] Open
Abstract
Few data are available on the lung microbiota composition of patients with coronavirus disease 2019-related acute respiratory distress syndrome (C-ARDS) receiving invasive mechanical ventilation (IMV). Moreover, it has never been investigated whether there is a potential correlation between lung microbiota communities and respiratory mechanics. We performed a prospective observational study in two intensive care units of a university hospital in Italy. Lung microbiota was investigated by bacterial 16S rRNA gene sequencing, performed on bronchoalveolar lavage fluid samples withdrawn after intubation. The lung bacterial communities were analyzed after stratification by respiratory system compliance/predicted body weight (Crs) and ventilatory ratio (VR). Weaning from IMV and hospital survival were assessed as secondary outcomes. In 70 C-ARDS patients requiring IMV from 1 April through 31 December 2020, the lung microbiota composition (phylum taxonomic level, permutational multivariate analysis of variance test) significantly differed between who had low Crs vs those with high Crs (P = 0.010), as well as in patients with low VR vs high VR (P = 0.012). As difference-driving taxa, Proteobacteria (P = 0.017) were more dominant and Firmicutes (P = 0.040) were less dominant in low- vs high-Crs patients. Similarly, Proteobacteria were more dominant in low- vs high-VR patients (P = 0.013). After multivariable regression analysis, we further observed lung microbiota diversity as a negative predictor of weaning from IMV and hospital survival (hazard ratio = 3.31; 95% confidence interval, 1.52-7.20, P = 0.048). C-ARDS patients with low Crs/low VR had a Proteobacteria-dominated lung microbiota. Whether patients with a more diverse lung bacterial community may have more chances to be weaned from IMV and discharged alive from the hospital warrants further large-scale investigations. IMPORTANCE Lung microbiota characteristics were demonstrated to predict ventilator-free days and weaning from mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). In this study, we observed that in severe coronavirus disease 2019 patients with ARDS who require invasive mechanical ventilation, lung microbiota characteristics were associated with respiratory mechanics. Specifically, the lung microbiota of patients with low respiratory system compliance and low ventilatory ratio was characterized by Proteobacteria dominance. Moreover, after multivariable regression analysis, we also found an association between patients' microbiota diversity and a higher possibility of being weaned from mechanical ventilation and discharged alive from the hospital. For these reasons, lung microbiota characterization may help to stratify patient characteristics and orient the delivery of target interventions. (This study has been registered at ClinicalTrials.gov on 17 February 2020 under identifier NCT04271345.). Registered at ClinicalTrials.gov, 17 February 2020 (NCT0427135).
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Affiliation(s)
- Gennaro De Pascale
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Brunella Posteraro
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Flavio De Maio
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pia Clara Pafundi
- Epidemiology and Biostatistics Research Core Facility, Gemelli Science & Technology Park, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gianmarco Lombardi
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Emanuele Franchini
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Santarelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Amato Infante
- Dipartimento di Scienze Radiologiche ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Le Pape S, Joly F, Arrivé F, Frat JP, Rodriguez M, Joos M, Marchasson L, Wairy M, Thille AW, Coudroy R. Factors associated with decreased compliance after on-site extracorporeal membrane oxygenation cannulation for acute respiratory distress syndrome: A retrospective, observational cohort study. JOURNAL OF INTENSIVE MEDICINE 2024; 4:194-201. [PMID: 38681786 PMCID: PMC11043634 DOI: 10.1016/j.jointm.2023.09.004] [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: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) is systematically associated with decreased respiratory system compliance (CRS). It remains unclear whether transportation to the referral ECMO center, changes in ventilatory mode or settings to achieve ultra-protective ventilation, or the natural evolution of ARDS drives this change in respiratory mechanics. Herein, we assessed the precise moment when CRS decreases after ECMO cannulation and identified factors associated with decreased CRS. Methods To rule out the effect of transportation and the different modes of ventilation on CRS, we conducted a retrospective, single-center, observational cohort study from January 2013 to May 2020, on 22 patients with severe ARDS requiring on-site ECMO and ventilated in pressure-controlled mode to achieve ultra-protective ventilation. CRS was assessed at different time points ranging from 12 h before ECMO cannulation to 72 h after ECMO cannulation. The primary outcome was the relative change in CRS between 3 h before and 3 h after ECMO cannulation. The secondary outcomes included variables associated with the relative changes in CRS within the first 3 h after ECMO cannulation and the relative changes in CRS at each time point. Results CRS decreased within the first 3 h after ECMO cannulation (-28.3%, 95% confidence interval [CI]: -38.8 to -17.9, P<0.001), while the decrease was mild before and after these first 3 h after ECMO cannulation. To achieve ultra-protective ventilation, respiratory rate decreased in the mean by -13 breaths/min (95% CI: -15 to -11) and driving pressure by -8.3 cmH2O (95% CI: -11.2 to -5.3), resulting in decreased tidal volume by -3.3 mL/kg of predicted body weight (95% CI: -3.9 to -2.6) as compared to before ECMO cannulation (P <0.001 for all). Plateau pressure reduction, driving pressure reduction, and tidal volume reduction were significantly associated with decreased CRS after ECMO cannulation, whereas neither respiratory rate, positive end-expiratory pressure, inspired fraction of oxygen, fluid balance, nor mean airway pressure was associated with decreased CRS. Conclusions Decreased driving pressure resulting in lower tidal volume to achieve ultra-protective ventilation after ECMO cannulation was associated with a marked decrease in CRS in ARDS patients with on-site ECMO cannulation.
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Affiliation(s)
- Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Florent Joly
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Maeva Rodriguez
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Maïa Joos
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Mathilde Wairy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Arnaud W. Thille
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
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9
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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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10
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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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11
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Zhou Y, Jiang Y, Ding Y, Gu L, Tan J. Placement of bronchial occluder outside the tracheal tube in a patient combined with airway compression undergoing mediastinal tumors resection: a case report. BMC Anesthesiol 2024; 24:100. [PMID: 38475719 DOI: 10.1186/s12871-024-02480-2] [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: 11/24/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Mediastinal tumors pose a challenging respiratory and circulatory management during anesthesia procedures, there is a risk of circulatory collapse or complete airway obstruction, which in severe cases can lead to cardiac arrest. We reported a case of anesthetic management using a bronchial blocker placed outside the tracheal tube. In this case report, the patient's trachea was so severely compressed that the airway was extremely narrow, only 4 mm at its narrowest point. By reporting the anesthetic management of this patient, we intend to provide an unusual approach for airway management. CASE PRESENTATION A 52-year-old male patient was admitted to the hospital due to cough and expectoration for one year. Additionally, the patient experienced chest tightness and asthma after physical activity. The enhanced computed tomography revealed there existed an irregular soft tissue mass in the right upper mediastinum, which significantly compressed the trachea and esophagus. The results of the mediastinal puncture pathology showed the presence of mesenchymal tumors. According to the results above, the patient was diagnosed with a mediastinal tumor and scheduled to undergo tumor resection under general anesthesia. We used a bronchial occluder outside the tracheal tube for general anesthesia. After surgery, the patient received thorough treatment and was subsequently discharged from the hospital. CONCLUSION In patients with severe airway compression from a mediastinal tumor airway compression, positioning a bronchial occluder externally to the tracheal tube is an effective method of airway management. However, we still need more clinical practice to help the process become more standardized.
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Affiliation(s)
- Yihu Zhou
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 21009, People's Republic of China
| | - Yueyi Jiang
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 21009, People's Republic of China
| | - Yuyan Ding
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 21009, People's Republic of China
| | - Lianbing Gu
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 21009, People's Republic of China.
| | - Jing Tan
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 21009, People's Republic of China.
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12
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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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Luo J, Yan R, Ding L, Ning J, Chen M, Guo Y, Liu J, Chen Z, Zhou R. Electroacupuncture Attenuates Ventilator-Induced Lung Injury by Modulating the Nrf2/HO-1 Pathway. J Surg Res 2024; 295:811-819. [PMID: 38160492 DOI: 10.1016/j.jss.2023.11.055] [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: 12/19/2022] [Revised: 10/06/2023] [Accepted: 11/12/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Ventilator-induced lung injury (VILI) is the most common complication associated with mechanical ventilation. Electroacupuncture (EA) has shown potent anti-inflammatory effects. This study aimed to investigate the effects of EA on VILI and explore the underlying mechanisms. METHODS Male C57BL/6 mice were subjected to high tidal volume ventilation to induce VILI. Prior to mechanical ventilation, mice received treatment with EA, nonacupoint EA, or EA combined with zinc protoporphyrin. RESULTS EA treatment significantly improved oxygenation, as indicated by increased PaO2 levels in VILI mice. Moreover, EA reduced lung injury score, lung wet/dry weight ratio, and protein concentration in bronchoalveolar lavage fluid. EA also decreased the expression of pro-inflammatory cytokines including interleukin (IL)-1β, IL-6, tumor necrosis factor-α, IL-18, chemokine keratinocyte chemoattractant, macrophage inflammatory protein 2, and malondialdehyde. Furthermore, EA increased the activities of antioxidant enzymes superoxide dismutase, catalase, and glutathione peroxidase in VILI mice. At the molecular level, EA upregulated the expression of Nrf2 (nucleus) and heme oxygenase -1, while down-regulating the expression of p-NF-κB p65, NLR Family Pyrin Domain Containing 3, Cleaved Caspase-1, and ASC in VILI mice. Notably, the effects of EA were reversed by zinc protoporphyrin treatment, nonacupoint EA did not affect the aforementioned indicators of VILI. CONCLUSIONS EA alleviates VILI by inhibiting the NLR Family Pyrin Domain Containing three inflammasome through activation of the Nrf2/HO-1 pathway.
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Affiliation(s)
- Jiansheng Luo
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Ruyu Yan
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Lingling Ding
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.
| | - Jiaqi Ning
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Mengjie Chen
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Yuhong Guo
- Department of Emergency, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Jiaxi Liu
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Zhuoya Chen
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Ruiling Zhou
- Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
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El-Khatib M, Zeeni C, Shebbo FM, Karam C, Safi B, Toukhtarian A, Nafeh NA, Mkhayel S, Shadid CA, Chalhoub S, Beresian J. Intraoperative mechanical power and postoperative pulmonary complications in low-risk surgical patients: a prospective observational cohort study. BMC Anesthesiol 2024; 24:82. [PMID: 38413871 PMCID: PMC10898029 DOI: 10.1186/s12871-024-02449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/08/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Inadequate intraoperative mechanical ventilation (MV) can lead to ventilator-induced lung injury and increased risk for postoperative pulmonary complications (PPCs). Mechanical power (MP) was shown to be a valuable indicator for MV outcomes in critical care patients. The aim of this study is to assess the association between intraoperative MP in low-risk surgical patients undergoing general anesthesia and PPCs. METHODS Two-hundred eighteen low-risk surgical patients undergoing general anesthesia for elective surgery were included in the study. Intraoperative mechanical ventilatory support parameters were collected for all patients. Postoperatively, patients were followed throughout their hospital stay and up to seven days post discharge for the occurrence of any PPCs. RESULTS Out of 218 patients, 35% exhibited PPCs. The average body mass index, tidal volume per ideal body weight, peak inspiratory pressure, and MP were significantly higher in the patients with PPCs than in the patients without PPCs (30.3 ± 8.1 kg/m2 vs. 26.8 ± 4.9 kg.m2, p < 0.001; 9.1 ± 1.9 ml/kg vs. 8.6 ± 1.4 ml/kg, p = 0.02; 20 ± 4.9 cmH2O vs. 18 ± 3.7 cmH2O, p = 0.001; 12.9 ± 4.5 J/min vs. 11.1 ± 3.7 J/min, p = 0.002). A multivariable regression analysis revealed MP as the sole significant predictor for the risk of postoperative pulmonary complications [OR 1.1 (95% CI 1.0-1.2, p = 0.036]. CONCLUSIONS High intraoperative mechanical power is a risk factor for developing postoperative pulmonary complications. Furthermore, intraoperative mechanical power is superior to other traditional mechanical ventilation variables in identifying surgical patients who are at risk for developing postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION NCT03551899; 24/02/2017.
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Affiliation(s)
- Mohamad El-Khatib
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Carine Zeeni
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Fadia M Shebbo
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Cynthia Karam
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Bilal Safi
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Aline Toukhtarian
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Nancy Abou Nafeh
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Samar Mkhayel
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Carol Abi Shadid
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Sana Chalhoub
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean Beresian
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon.
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15
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Shan F, Tang F, Liu Y, Han X, Wu W, Tang Y, Zhan Q, Zhang N. The effect of adoptive transferring myeloid-derived suppressor cells in ventilator-induced lung injury mice. Heliyon 2024; 10:e25595. [PMID: 38356581 PMCID: PMC10865327 DOI: 10.1016/j.heliyon.2024.e25595] [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: 11/07/2022] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
The effects of adoptive transferring myeloid-derived suppressor cells (MDSCs) to mice with ventilator-induced lung injury (VILI) are unclear. Our objective was to investigate the effects of adoptively transferring MDSCs in VILI. The mouse model was created by introducing mechanical ventilation through a high tidal volume of 20 ml/kg for 4 h. Inflammation-induced MDSCs (iMDSCs) were collected from the bone marrow of mice with cecal ligation and puncture. iMDSCs were administrated through retrobulbar angular vein 1 h before the mechanical ventilation. The control group was anesthetized and maintained spontaneous respiration. After the termination of mechanical ventilation, bronchoalveolar lavage fluid (BALF) and lung samples 6 h were collected. The concentrations of BALF protein, levels of inflammatory mediators, and white blood cells were all significantly decreased in mice treated with iMDSCs. Histological examinations indicated reduced lung damage after iMDSCs treatment. Moreover, adoptive transfer of iMDSCs could reduce CD4+ T-cell counts and inhibit its inflammatory cytokine secretion. iMDSCs treatment was found to had no immunostimulatory effects or cause secondary infections in mice. In conclusion, MDSCs might be a potential targeted therapy for alleviating the inflammatory response of VILI mice in a T-cell dependent manner.
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Affiliation(s)
- Fangzhen Shan
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jining Medical University, Shandong, China
- Medical Research Center, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Fenglian Tang
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Yuan Liu
- Department of Intensive care unit III, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Xiao Han
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Wei Wu
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Yanhua Tang
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jining Medical University, Shandong, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Nannan Zhang
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jining Medical University, Shandong, China
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
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Landeck T, Schwarz H, Hammermüller S, Noreikat K, Reske S, Gottschaldt U, Nestler C, Wolf SJ, Ramm J, Lange M, Wrigge H, Girrbach F, Brehm W, Reske AW. High positive end-expiratory pressure ventilation mitigates the progression from unilateral pulmonary contusion to ARDS: An animal study. J Trauma Acute Care Surg 2024; 96:287-296. [PMID: 37335128 DOI: 10.1097/ta.0000000000004077] [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: 06/21/2023]
Abstract
BACKGROUND Pulmonary contusion (PC) is common in severely traumatized patients and can lead to respiratory failure requiring mechanical ventilation (MV). Ventilator-induced lung injury (VILI) might aggravate lung damage. Despite underrepresentation of trauma patients in trials on lung-protective MV, results are extrapolated to these patients, potentially disregarding important pathophysiological differences. METHODS Three MV protocols with different positive end-expiratory pressure (PEEP) levels: ARDSnetwork lower PEEP (ARDSnet-low), ARDSnetwork higher PEEP (ARDSnet-high), and open lung concept (OLC) were applied in swine for 24 hours following PC. Gas exchange, lung mechanics, quantitative computed tomography, and diffuse alveolar damage (DAD) score were analyzed. Results are given as median (interquartile range) at 24 hours. Statistical testing was performed using general linear models (group effect) over all measurement points and pairwise Mann-Whitney U tests for DAD. RESULTS There were significant differences between groups: PEEP ( p < 0.0001) ARDSnet-low (8 [8-10] cmH 2 O), ARDSnet-high (12 [12-12] cmH 2 O), OLC (21 [20-22] cmH 2 O). The fraction of arterial partial pressure of oxygen and inspired oxygen fraction ( p = 0.0016) was lowest in ARDSnet-low (78 (73-111) mm Hg) compared with ARDSnet-high (375 (365-423) mm Hg) and OLC (499 (430-523) mm Hg). The end-expiratory lung volume (EELV) differed significantly ( p < 0.0001), with highest values in OLC (64% [60-70%]) and lowest in ARDSnet-low (34% [24-37%]). Costa's surrogate for mechanical power differed significantly ( p < 0.0001), with lowest values for ARDSnet-high (73 [58-76]) compared with OLC (105 [108-116]). Diffuse alveolar damage was lower in ARDSnet-high compared with ARDSnet-low (0.0007). CONCLUSION Progression to ARDS, 24 hours after PC, was mitigated by OLC and ARDSnet-high. Both concepts restored EELV. ARDSnet-high had the lowest mechanical power surrogate and DAD. Our data suggest, that ARDSnet-high restored oxygenation and functional lung volume and reduced physiological and histological surrogates for VILI. ARDSnet-low generated unfavorable outcomes, such as loss of EELV, increased mechanical power and DAD after PC in swine. The high respiratory rate in the OLC may blunt favorable effects of lung recruitment.
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Affiliation(s)
- Tobias Landeck
- From the Department of Anesthesiology and Intensive Care Medicine (T.L., H.S., S.H., M.L.), University Hospital Leipzig; Department of Pediatric Cardiology and Intensive Care Medicine (H.S.), Georg-August-University Göttingen, University Medical Center, Göttingen; Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine, and Pain Therapy (T.L., U.G., C.N., S.J.W., A.W.R.), Heinrich-Braun-Hospital, Zwickau; Innovation Center Computer Assisted Surgery (ICCAS) (T.L., U.G., A.W.R.), University of Leipzig, Medical Faculty, Leipzig, Germany; Bonitas Holding GmbH (S.H.), Herford; Medizinisch-Experimentelles Zentrum (K.N.), University of Leipzig, Medical Faculty, Leipzig; Department Diagnostic and Interventional Radiology (S.R.), Heinrich-Braun-Hospital Zwickau, Zwickau; Department of Urology (J.R.), Sana Kliniken Leipziger Land, Borna; Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy (H.W.), Bergmannstrost Hospital Halle; Martin-Luther-University of Halle-Wittenberg (H.W.), Halle; Department of Anesthesiology and Intensive Care Medicine (F.G.), University Hospital Augsburg, Augsburg; Deutsche Fachpflege Holding, GmbH (S.H.), Herford; and Department for Horses, Faculty of Veterinary Medicine, Leipzig University, Leipzig, Germany (W.B.)
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Rubulotta F, Blanch Torra L, Naidoo KD, Aboumarie HS, Mathivha LR, Asiri AY, Sarlabous Uranga L, Soussi S. Mechanical Ventilation, Past, Present, and Future. Anesth Analg 2024; 138:308-325. [PMID: 38215710 DOI: 10.1213/ane.0000000000006701] [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: 01/14/2024]
Abstract
Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.
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Affiliation(s)
- Francesca Rubulotta
- From the Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Lluis Blanch Torra
- Department of Critical Care, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Kuban D Naidoo
- Division of Critical Care, University of Witwatersrand, Johannesburg, South Africa
| | - Hatem Soliman Aboumarie
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield Hospitals, London, United Kingdom
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom
| | - Lufuno R Mathivha
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, The Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
| | - Abdulrahman Y Asiri
- Department of Internal Medicine and Critical Care, King Khalid University Medical City, Abha, Saudi Arabia
- Department of Critical Care Medicine, McGill University
| | - Leonardo Sarlabous Uranga
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto
- UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Institut national de la santé et de la recherche médicale (INSERM), Université de Paris Cité, France
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18
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Boesing C, Schaefer L, Graf PT, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies on mechanical power during ultraprotective ventilation in ARDS patients treated with veno-venous extracorporeal membrane oxygenation: A prospective interventional study. J Crit Care 2024; 79:154406. [PMID: 37690365 DOI: 10.1016/j.jcrc.2023.154406] [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: 09/23/2022] [Revised: 05/13/2023] [Accepted: 07/09/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Ultraprotective ventilation in acute respiratory distress syndrome (ARDS) patients with veno-venous extracorporeal membrane oxygenation (VV ECMO) reduces mechanical power (MP) through changes in positive end-expiratory pressure (PEEP); however, the optimal approach to titrate PEEP is unknown. This study assesses the effects of three PEEP titration strategies on MP, hemodynamic parameters, and oxygen delivery in twenty ARDS patients with VV ECMO. MATERIAL AND METHODS PEEP was titrated according to: (A) a PEEP of 10 cmH2O representing the lowest recommendation by the Extracorporeal Life Support Organization (PEEPELSO), (B) the highest static compliance of the respiratory system (PEEPCstat,RS), and (C) a target end-expiratory transpulmonary pressure of 0 cmH2O (PEEPPtpexp). RESULTS PEEPELSO was lower compared to PEEPCstat,RS and PEEPPtpexp (10.0 ± 0.0 vs. 16.2 ± 4.7 cmH2O and 17.3 ± 4.0 cmH2O, p < 0.001 each, respectively). PEEPELSO reduced MP compared to PEEPCstat,RS and PEEPPtpexp (5.3 ± 1.3 vs. 6.8 ± 2.0 and 6.9 ± 2.3 J/min, p < 0.001 each, respectively). PEEPELSO resulted in less lung stress compared to PEEPCstat,RS (p = 0.011) and PEEPPtpexp (p < 0.001) and increased cardiac output and oxygen delivery (p < 0.001 each). CONCLUSIONS An empirical PEEP of 10 cmH2O minimized MP, provided favorable hemodynamics, and increased oxygen delivery in ARDS patients treated with VV ECMO. TRIAL REGISTRATION German Clinical Trials Register (DRKS00013967). Registered 02/09/2018https://drks.de/search/en/trial/DRKS00013967.
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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, Mannheim 68167, 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, Mannheim 68167, Germany.
| | - Peter T Graf
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - 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, Mannheim 68167, 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, Mannheim 68167, Germany.
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19
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Pellet PL, Stevic N, Degivry F, Louis B, Argaud L, Guérin C, Cour M. Effects on mechanical power of different devices used for inhaled sedation in a bench model of protective ventilation in ICU. Ann Intensive Care 2024; 14:18. [PMID: 38285231 PMCID: PMC10825094 DOI: 10.1186/s13613-024-01245-x] [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: 10/16/2023] [Accepted: 01/06/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Inhaled sedation during invasive mechanical ventilation in patients with acute respiratory distress syndrome (ARDS) has received increasing attention. However, inhaled sedation devices increase dead-space ventilation and an undesirable effect is the increase in minute ventilation needed to maintain CO2 removal. A consequence of raising minute ventilation is an increase in mechanical power (MP) that can promote lung injury. However, the effect of inhaled sedation devices on MP remains unknown. METHODS We conducted a bench study to assess and compare the effects of three devices delivering inhaled sevoflurane currently available in ICU (AnaConDa-50 mL (ANA-50), AnaConDa-100 mL (ANA-100), and MIRUS) on MP by using a test lung model set with three compliances (20, 40, and 60 mL/cmH2O). We simulated lung-protective ventilation using a low tidal volume and two levels of positive end-expiratory pressure (5 and 15 cmH2O) under ambient temperature and dry conditions. Following the insertion of the devices, either the respiratory rate or tidal volume was increased in 15%-steps until end-tidal CO2 (EtCO2) returned to the baseline value. MP was calculated at baseline and after EtCO2 correction using a simplified equation. RESULTS Following device insertion, the EtCO2 increase was significantly greater with MIRUS (+ 78 ± 13%) and ANA-100 (+ 100 ± 11%) than with ANA-50 (+ 49 ± 7%). After normalizing EtCO2 by adjusting minute ventilation, MP significantly increased by more than 50% with all inhaled sedation devices compared to controls. The lowest increase in MP was observed with ANA-50 (p < 0.05 versus ANA-100 and MIRUS). The Costa index, another parameter assessing the mechanical energy delivered to the lungs, calculated as driving pressure × 4 + respiratory rate, significantly increased by more than 20% in all experimental conditions. Additional experiments performed under body temperature, ambient pressure, and gas saturated with water vapor conditions, confirmed the main results with an increase in MP > 50% with all devices after normalizing EtCO2 by adjusting minute ventilation. CONCLUSION Inhaled sedation devices substantially increased MP in this bench model of protective ventilation, which might limit their benefits in ARDS.
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Affiliation(s)
- Pierre-Louis Pellet
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Neven Stevic
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Florian Degivry
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM 955 CNRS 7000, Créteil, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Claude Guérin
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France
| | - Martin Cour
- Hospices Civils de Lyon, Service de Médecine Intensive -Réanimation, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France.
- Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon-Est, 69373, Lyon, France.
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20
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Patirelis A, Elia S, Cristino B, Puxeddu E, Cavalli F, Rogliani P, Pompeo E. Spontaneous Ventilation Thoracoscopic Lung Biopsy in Undetermined Interstitial Lung Disease: Systematic Review and Meta-Analysis. J Clin Med 2024; 13:374. [PMID: 38256508 PMCID: PMC10815978 DOI: 10.3390/jcm13020374] [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: 12/07/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Thoracoscopic surgical biopsy has shown excellent histological characterization of undetermined interstitial lung diseases, although the morbidity rates reported are not negligible. In delicate patients, interstitial lung disease and restrictive ventilatory impairment morbidity are thought to be due at least in part to tracheal intubation with single-lung mechanical ventilation; therefore, spontaneous ventilation thoracoscopic lung biopsy (SVTLB) has been proposed as a potentially less invasive surgical option. This systematic review summarizes the results of SVTLB, focusing on diagnostic yield and operative morbidity. A systematic search for original studies regarding SVTLB published between 2010 to 2023 was performed. In addition, articles comparing SVTLB to mechanical ventilation thoracoscopic lung biopsy (MVTLB) were selected for a meta-analysis. Overall, 13 studies (two before 2017 and eleven between 2018 and 2023) entailing 675 patients were included. Diagnostic yield ranged from 84.6% to 100%. There were 64 (9.5%) complications, most of which were minor. There was no 30-day operative mortality. When comparing SVTLB to MVTLB, the former group showed a significantly lower risk of complications (p < 0.001), whereas no differences were found in diagnostic accuracy. The results of this review suggest that SVTLB is being increasingly adopted worldwide and has proven to be a safe procedure with excellent diagnostic accuracy.
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Affiliation(s)
- Alexandro Patirelis
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (A.P.); (B.C.)
- Division of Thoracic Surgery, University Hospital Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Stefano Elia
- Division of Thoracic Surgery, University Hospital Policlinico Tor Vergata, 00133 Rome, Italy;
- Department of Medicine and Health Sciences, Università degli Studi del Molise, 86100 Campobasso, Italy
| | - Benedetto Cristino
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (A.P.); (B.C.)
- Division of Thoracic Surgery, University Hospital Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Ermanno Puxeddu
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (E.P.); (P.R.)
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Francesco Cavalli
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy; (E.P.); (P.R.)
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Eugenio Pompeo
- Unit of Thoracic Surgery, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (A.P.); (B.C.)
- Division of Thoracic Surgery, University Hospital Policlinico Tor Vergata, 00133 Rome, Italy;
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21
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Xie Y, Shi J, Liu S, Chen X, Wang Y, Li X, Yan Y. Association of elastic power in mechanical ventilation with the severity of acute respiratory distress syndrome: a retrospective study. Eur J Med Res 2024; 29:5. [PMID: 38173033 PMCID: PMC10763103 DOI: 10.1186/s40001-023-01577-7] [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: 05/01/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Mechanical power (MP) is the total energy released into the entire respiratory system per minute which mainly comprises three components: elastic static power, Elastic dynamic power and resistive power. However, the energy to overcome resistance to the gas flow is not the key factor in causing lung injury, but the elastic power (EP) which generates the baseline stretch of the lung fibers and overcomes respiratory system elastance may be closely related to the ARDS severity. Thus, this study aimed to investigate whether EP is superior to other ventilator variables for predicting the severity of lung injury in ARDS patients. METHODS We retrieved patient data from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The retrieved data involved adults (≥ 18 years) diagnosed with ARDS and subjected to invasive mechanical ventilation for ≥ 48 h. We employed univariate and multivariate logistic regression analyses to investigate the correlation between EP and development of moderate-severe ARDS. Furthermore, we utilized restricted cubic spline models to assess whether there is a linear association between EP and incidence of moderate-severe ARDS. In addition, we employed a stratified linear regression model and likelihood ratio test in subgroups to identify potential modifications and interactions. RESULTS Moderate-severe ARDS occurred in 73.4% (296/403) of the patients analyzed. EP and MP were significantly associated with moderate-severe ARDS (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.15-1.28, p < 0.001; and OR 1.15, 95%CI 1.11-1.20, p < 0.001; respectively), but EP showed a higher area-under-curve (95%CI 0.72-0.82, p < 0.001) than plateau pressure, driving pressure, and static lung compliance in predicting ARDS severity. The optimal cutoff value for EP was 14.6 J/min with a sensitivity of 75% and specificity of 66%. Quartile analysis revealed that the relationship between EP and ARDS severity remained robust and reliable in subgroup analysis. CONCLUSION EP is a good ventilator variable associated with ARDS severity and can be used for grading ARDS severity. Close monitoring of EP is advised in patients undergoing mechanical ventilation. Additional experimental trials are needed to investigate whether adjusting ventilator variables according to EP can yield significant improvements in clinical outcomes.
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Affiliation(s)
- Yongpeng Xie
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Jiaxin Shi
- Department of Respiratory and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Suxia Liu
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Xiaobing Chen
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Yanli Wang
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Xiaomin Li
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China.
| | - Yao Yan
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China.
- Department of Critical Care Medicine, The Second people,s Hospital of Lianyungang City, Lianyungang, 222000, Jiangsu, China.
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22
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Wang W, Zhang Z, Xia F. Impact of different oxygen therapy strategies on the risk of endotracheal reintubation in mechanically ventilated patients: A systematic review and meta-analysis. Technol Health Care 2024; 32:2009-2022. [PMID: 38306070 DOI: 10.3233/thc-231024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Mechanical ventilation (MV) is a crucial intervention for the support of patients with acute and severe respiratory failure in modern intensive care medicine. However, the mechanical forces resulting from the interplay between the ventilator and the respiratory system may cause pulmonary injury. OBJECTIVE To compare the effects of high-flow nasal cannula (HFNC) therapy and other oxygen therapy modalities on the risk of endotracheal reintubation in mechanically ventilated patients after extubation in the intensive care unit (ICU). METHODS An electronic search was carried out across various databases including PubMed, Embase, Ovid, Medline, Cochrane Library, Embase, VIP, and Wanfang. The objective of this search was to locate prospective randomized controlled trials that examined the effects of multiple oxygen therapy approaches on the incidence of reintubation in patients in the ICU after undergoing mechanical ventilation. The meta package in R language was used to analyze parameters adopted by the included studies such as reintubation rate, mortality rate, and length of hospital stay. RESULTS This study enrolled 22 articles, involving 4,160 participants, with 2,061 in the study group and 2,099 in the control group. Among these, 20 articles presented data on the reintubation rate of the patients included with an odds ratio (OR) of 0.90 (95% CI: 0.74, 1.09) for HFNC and an OR of 1.77 (95% CI: 0.93, 3.38) for HFNC in the chronic obstructive pulmonary disease (COPD) subgroup. Moreover, 10 articles assessed the incidence of respiratory failure after extubation, revealing an OR for HFNC was 0.68 (95% CI: 0.55, 0.84) using a fixed-effects model. Nine articles addressed ICU mortality, while 13 pieces of literature examined hospital mortality. HFNC showed no significant impact on either ICU mortality or hospital mortality. CONCLUSION HFNC therapy markedly reduces the incidence of respiratory failure in mechanically ventilated patients following extubation in the ICU. Furthermore, it specifically reduces the risk of reintubation in patients diagnosed with COPD.
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23
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Buiteman-Kruizinga LA, van der Heiden PLJ, Paulus F, Schultz MJ. Closed-loop ventilation in COVID-19 patients with acute hypoxemic respiratory failure-A case series. Nurs Crit Care 2024; 29:219-225. [PMID: 37144426 DOI: 10.1111/nicc.12924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/13/2023] [Accepted: 04/16/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND INTELLiVENT-adaptive support ventilation (ASV) is an automated closed-loop mode of invasive ventilation for use in critically ill patients. INTELLiVENT-ASV automatically adjusts, without the intervention of the caregiver, ventilator settings to achieve the lowest work and force of breathing. AIMS The aim of this case series is to describe the specific adjustments of INTELLiVENT-ASV in patients with acute hypoxemic respiratory failure, who were intubated for invasive ventilation. STUDY DESIGN We describe three patients with severe acute respiratory distress syndrome (ARDS) because of COVID-19 who received invasive ventilation in our intensive care unit (ICU) in the first year of the COVID-19 pandemic. RESULTS INTELLiVENT-ASV could be used successfully, but only after certain adjustments in the settings of the ventilator. Specifically, the high oxygen targets that are automatically chosen by INTELLiVENT-ASV when the lung condition 'ARDS' is ticked had to be lowered, and the titration ranges for positive end expiratory pressure (PEEP) and inspired oxygen fraction (FiO2 ) had to be narrowed. CONCLUSIONS The challenges taught us how to adjust the ventilator settings so that INTELLiVENT-ASV could be used in successive COVID-19 ARDS patients, and we experienced the benefits of this closed-loop ventilation in clinical practice. RELEVANCE TO CLINICAL PRACTICE INTELLiVENT-ASV is attractive to use in clinical practice. It is safe and effective in providing lung-protective ventilation. A closely observing user always remains needed. INTELLiVENT-ASV has a strong potential to reduce the workload associated with ventilation because of the automated adjustments.
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Affiliation(s)
- Laura A Buiteman-Kruizinga
- Department of Intensive Care, Reinier de Graaf Hospital, Delft, the Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, the Netherlands
| | | | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, the Netherlands
- ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Arce FT, Younger S, Gaber AA, Mascarenhas JB, Rodriguez M, Dudek SM, Garcia JGN. Lamellipodia dynamics and microrheology in endothelial cell paracellular gap closure. Biophys J 2023; 122:4730-4747. [PMID: 37978804 PMCID: PMC10754712 DOI: 10.1016/j.bpj.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/06/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Abstract
Vascular endothelial cells (ECs) form a semipermeable barrier separating vascular contents from the interstitium, thereby regulating the movement of water and molecular solutes across small intercellular gaps, which are continuously forming and closing. Under inflammatory conditions, however, larger EC gaps form resulting in increased vascular leakiness to circulating fluid, proteins, and cells, which results in organ edema and dysfunction responsible for key pathophysiologic findings in numerous inflammatory disorders. In this study, we extend our earlier work examining the biophysical properties of EC gap formation and now address the role of lamellipodia, thin sheet-like membrane projections from the leading edge, in modulating EC spatial-specific contractile properties and gap closure. Micropillars, fabricated by soft lithography, were utilized to form reproducible paracellular gaps in human lung ECs. Using time-lapse imaging via optical microscopy, rates of EC gap closure and motility were measured with and without EC stimulation with the barrier-enhancing sphingolipid, sphingosine-1-phosphate. Peripheral ruffle formation was ubiquitous during gap closure. Kymographs were generated to quantitatively compare the lamellipodia dynamics of sphingosine-1-phosphate-stimulated and -unstimulated ECs. Utilizing atomic force microscopy, we characterized the viscoelastic behavior of EC lamellipodia. Our results indicate decreased stiffness and increased liquid-like behavior of expanding lamellipodia compared with regions away from the cellular edge (lamella and cell body) during EC gap closure, results in sync with the rapid kinetics of protrusion/retraction motion. We hypothesize this dissipative EC behavior during gap closure is linked to actomyosin cytoskeletal rearrangement and decreased cross-linking during lamellipodia expansion. In summary, these studies of the kinetic and mechanical properties of EC lamellipodia and ruffles at gap boundaries yield insights into the mechanisms of vascular barrier restoration and potentially a model system for examining the druggability of lamellipodial protein targets to enhance vascular barrier integrity.
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Affiliation(s)
- Fernando Teran Arce
- The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, Florida.
| | - Scott Younger
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona
| | - Amir A Gaber
- Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - Marisela Rodriguez
- The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, Florida; Department of Medicine, University of Arizona, Tucson, Arizona
| | - Steven M Dudek
- Department of Medicine, The University of Illinois at Chicago, Chicago, Illinois
| | - Joe G N Garcia
- The Herbert Wertheim UF Scripps Institute for Biomedical Innovation & Technology, University of Florida, Jupiter, Florida.
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25
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Xie Y, Yan Y, Shi J, Luo J, Wang Y, Chen H, Li X. Elastic power, a novel predictor of the severity and prognosis of ARDS. J Crit Care 2023; 78:154380. [PMID: 37480658 DOI: 10.1016/j.jcrc.2023.154380] [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: 11/01/2022] [Revised: 04/13/2023] [Accepted: 07/11/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE To explore the predictive value of the new comprehensive respiratory mechanics parameters elastic power (EP) and elastic power normalized to the compliance (Cst-EP) in the evaluation of the severity and 28-day prognosis of ARDS patients. METHODS The MIMIC-III database was used to identify ARDS patients under invasive mechanical ventilation for at least 48 h. Their baseline data and ventilatory variables were collected. EP, elastic energy, driving pressure and mechanical power were calculated according to the corresponding formulas. Their value in assessing the severity of ARDS was evaluated. The correlation between Cst-EP and 28-day prognosis of ARDS patients was analyzed. RESULTS EP was independently associated with the severity of the ARDS and the odds ratio (OR) was 1.301 [95% CI (1.190-1.423), p < 0.001]. It has higher accuracy for the severity of ARDS, with an optimal cut-off value of 14.6 J/min. The Cst-EP was significantly associated with increased risk of death and the hazard ratio (HR) per 100 J/min × cmH2O/ml × 10-3 was 1.169 [95% CI (1.093-1.250), p < 0.001]. In addition, the 28-day cumulative survival rate of the high Cst-EP group was significantly lower than that of the low Cst-EP group. CONCLUSION EP can be used to predict the severity of ARDS, and Cst-EP is associated with mortality during controlled mechanical ventilation in ARDS.
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Affiliation(s)
- Yongpeng Xie
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Yao Yan
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China; Department of Critical Care Medicine, The Second People's Hospital of Lianyungang City, Lianyungang 222000, Jiangsu, China
| | - Jiaxin Shi
- Department of Respiratory and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Jiye Luo
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Yanli Wang
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, Jiangsu,China..
| | - Xiaomin Li
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China.
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Damiani LF, Basoalto R, Retamal J, Bruhn A, Bugedo G. Mechanical Power of Ventilation: From Computer to Clinical Implications. Respir Care 2023; 68:1748-1756. [PMID: 37935527 PMCID: PMC10676264 DOI: 10.4187/respcare.11462] [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: 11/09/2023]
Abstract
Mechanical ventilation is a lifesaving intervention that may also induce further lung injury by exerting excessive mechanical forces on susceptible lung tissue, a phenomenon termed ventilator-induced lung injury (VILI). The concept of mechanical power (MP) aims to unify in one single variable the contribution of the different ventilatory parameters that could induce VILI by measuring the energy transfer to the lung over time. Despite an increasing amount of evidence demonstrating that high MP values can be associated with VILI development in experimental studies, the evidence regarding the association of MP and clinical outcomes remains controversial. In the present review, we describe the different determinants of VILI, the concept and computation of MP, and discuss the experimental and clinical studies related to MP. Currently, due to different limitations, the clinical application of MP is debatable. Further clinical studies are required to enhance our understanding of the relationship between MP and the development of VILI, as well as its potential impact on clinical outcomes.
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Affiliation(s)
- L Felipe Damiani
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; and Cardiorespiratory Research Laboratory, Departamento Ciencias de la Salud, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Roque Basoalto
- Cardiorespiratory Research Laboratory, Departamento Ciencias de la Salud, Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile. Santiago, Chile; and Programa de Medicina Física y Rehabilitación, Red Salud UC-CHRISTUS, Santiago, Chile
| | - Jaime Retamal
- Cardiorespiratory Research Laboratory, Departamento Ciencias de la Salud, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Bruhn
- Cardiorespiratory Research Laboratory, Departamento Ciencias de la Salud, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Guillermo Bugedo
- Cardiorespiratory Research Laboratory, Departamento Ciencias de la Salud, Pontificia Universidad Católica de Chile, Santiago, Chile
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Thornton LT, Marini JJ. Optimized ventilation power to avoid VILI. J Intensive Care 2023; 11:57. [PMID: 37986109 PMCID: PMC10658809 DOI: 10.1186/s40560-023-00706-y] [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: 10/23/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023] Open
Abstract
The effort to minimize VILI risk must be multi-pronged. The need to adequately ventilate, a key determinant of hazardous power, is reduced by judicious permissive hypercapnia, reduction of innate oxygen demand, and by prone body positioning that promotes both efficient pulmonary gas exchange and homogenous distributions of local stress. Modifiable ventilator-related determinants of lung protection include reductions of tidal volume, plateau pressure, driving pressure, PEEP, inspiratory flow amplitude and profile (using longer inspiration to expiration ratios), and ventilation frequency. Underappreciated conditional cofactors of importance to modulate the impact of local specific power may include lower vascular pressures and blood flows. Employed together, these measures modulate ventilation power with the intent to avoid VILI while achieving clinically acceptable targets for pulmonary gas exchange.
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Affiliation(s)
- Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA.
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28
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Liu H, Fan P, Jin F, Ren H, Xu F, Li J. Targeting biophysical microenvironment for improved treatment of chronic obstructive pulmonary disease. Trends Mol Med 2023; 29:926-938. [PMID: 37704492 DOI: 10.1016/j.molmed.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/15/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is responsible for high disability rates, high death rates, and significant cost to health systems. Growing evidence in recent decades shows significant biophysical microenvironment changes in COPD, impacting lung tissues, cells, and treatment response. Furthermore, such biophysical changes have shown great potential as novel targets for improved therapeutic strategy of COPD, where both pharmacological and non-pharmacological therapies focusing on repairing the biophysical microenvironment of the lung have emerged. We present the first comprehensive review of four distinct biophysical hallmarks [i.e., extracellular matrix (ECM) microarchitecture, stiffness, fluid shear stress, and mechanical stretch] in COPD, the possible involvement of pathological changes, possible effects, and correlated in vitro models and sum up the emerging COPD treatments targeting these biophysical hallmarks.
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Affiliation(s)
- Han Liu
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Academy of Chinese Medical Sciences, Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China; Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases co-constructed by Henan Province and Education Ministry of China, Zhengzhou, Henan 450046, China
| | - Pengbei Fan
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Academy of Chinese Medical Sciences, Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China; Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases co-constructed by Henan Province and Education Ministry of China, Zhengzhou, Henan 450046, China
| | - Fanli Jin
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Academy of Chinese Medical Sciences, Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China; Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases co-constructed by Henan Province and Education Ministry of China, Zhengzhou, Henan 450046, China
| | - Hui Ren
- Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an 710049, China; Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Feng Xu
- Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an 710049, China; MOE Key Laboratory of Biomedical Information Engineering, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an 710049, China.
| | - Jiansheng Li
- Henan Key Laboratory of Chinese Medicine for Respiratory Disease, Academy of Chinese Medical Sciences, Henan University of Chinese Medicine, Zhengzhou, Henan 450046, China; Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases co-constructed by Henan Province and Education Ministry of China, Zhengzhou, Henan 450046, China.
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29
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Kneyber MCJ, Cheifetz IM. Mechanical ventilation during pediatric extracorporeal life support. Curr Opin Pediatr 2023; 35:596-602. [PMID: 37497765 DOI: 10.1097/mop.0000000000001277] [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] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW To discuss the role of ventilator induced lung injury (VILI) and patient self-inflicted lung injury in ventilated children supported on extracorporeal membrane oxygenation (ECMO). RECENT FINDINGS While extracorporeal life support is used routinely used every day around the globe to support neonatal, pediatric, and adult patients with refractory cardiac and/or respiratory failure, the optimal approach to mechanical ventilation, especially for those with acute respiratory distress syndrome (ARDS), remains unknown and controversial. Given the lack of definitive data in this population, one must rely on available evidence in those with ARDS not supported with ECMO and extrapolate adult observations. Ventilatory management should include, as a minimum standard, limiting inspiratory and driving pressures, providing a sufficient level of positive end-expiratory pressure, and setting a low rate to reduce mechanical power. Allowing for spontaneous breathing and use of pulmonary specific ancillary treatment modalities must be individualized, while balancing the risk and benefits. Future studies delineating the best strategies for optimizing MV during pediatric extracorporeal life support are much needed. SUMMARY Future investigations will hopefully provide the needed evidence and better understanding of the overall goal of reducing mechanical ventilation intensity to decrease risk for VILI and promote lung recovery for those supported with ECMO.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen
- Critical care, Anesthesiology, Peri-operative & Emergency medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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30
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Pistillo N, Castelluccio P, Suzuki I, Castiblanco L. Mechanical Power Correlates With Stress, Strain, and Atelectrauma Only When Normalized to Aerated Lung Size in Patients With Acute Respiratory Distress Syndrome. Crit Care Explor 2023; 5:e0982. [PMID: 37753234 PMCID: PMC10519489 DOI: 10.1097/cce.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
OBJECTIVES First, to investigate whether the severity of acute respiratory distress syndrome (ARDS) influences ventilator-induced lung injury (VILI) risk in ventilated patients with similar mechanical power of respiratory system (MPRS). Second, to determine whether, under these circumstances, there is a relationship between transpulmonary mechanical power (MPTp) normalized to the aerated lung (specific lung mechanical power or SLMP) and VILI risk, and third, to determine whether normalizing MPRS to compliance of respiratory system (CRS) can replace SLMP to bedside. DESIGN Prospective cohort study. SETTING The study was conducted in a tertiary academic ICU. PATIENTS The study included 18 patients with ARDS. INTERVENTIONS Ventilatory settings were adjusted to achieve a similar MPRS. MEASUREMENTS AND MAIN RESULTS Mechanical power was normalized to CRS (specific mechanical power or SMP = MPRS/CRS), and SLMP was calculated as the ratio between MPTp and end-expiratory lung volume (SLMP = MPTp/EELV). The strain was defined as the ratio between tidal volume and EELV (strain = Vt/EELV), stress as transpulmonary pressure at the end of inspiration, and atelectrauma as the difference between expiration and inspiration in the nonaerated lung. Although patients had been ventilated with similar MPRS = 23.75 (23-24) J/min and MPTp = 11.6 (10.8-12.8) J/min, SLMP increased linearly with the fall in Pao2/Fio2 (R = -0.83, p = 0.0001). MPRS only correlated positively with VILI-associated mechanisms when normalized to aerated lung size: correlations between SLMP and stress (R = 0.9, R2 = 0.84, p = 0.00004), strain (R = 0.97, R2 = 0.94, p < 0.00001) and atelectrauma (R = 0.82, R2 = 0.70, p = 0.00002), and correlations between SMP and stress (R = 0.86, R2 = 0.75, p = 0.00001), strain (R = 0.68, R2 = 0.47, p = 0.001) and atelectrauma (R = 0.67, R2 = 0.46, p = 0.002). CONCLUSIONS The results suggest that normalizing mechanical power to lung-aerated size or CRS may correlate positively with stress, strain, and atelectrauma.
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Affiliation(s)
- Néstor Pistillo
- Department of Intensive Care, El Cruce, Néstor C. Kirchner Hospital, Buenos Aires, Argentina
| | - Pablo Castelluccio
- Department of Intensive Care, El Cruce, Néstor C. Kirchner Hospital, Buenos Aires, Argentina
| | - Ichiro Suzuki
- Departament of Imaging Diagnosis and Treatment, El Cruce, Néstor C. Kirchner Hospital, Buenos Aires, Argentina
| | - Lina Castiblanco
- Department of Intensive Care, El Cruce, Néstor C. Kirchner Hospital, Buenos Aires, Argentina
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31
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YAN JIE, GU CHANGPING, LIU GE, ZHANG YAQIANG, YANG LI, ZHAO TAO, CAO CUICUI, ZHAO LIANG, WU GUANGHAN, WANG YUELAN. Aerobic Exercise in Male Mice Prevents Ventilator-Induced Lung Injury by Inhibiting Mitochondrial Damage from sirt1 Dysregulation. Med Sci Sports Exerc 2023; 55:1770-1780. [PMID: 37144632 PMCID: PMC10487353 DOI: 10.1249/mss.0000000000003203] [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: 05/06/2023]
Abstract
BACKGROUND Ventilator-induced lung injury (VILI) is a common complication of mechanical ventilation under general anesthesia. Regular aerobic exercise before surgery improves postoperative recovery and reduces postoperative pulmonary complications, but the mechanism driving this protective effect is unclear. METHODS To determine how aerobic exercise prevents VILI, we investigated the effects of exercise and mechanical ventilation on the lungs of male mice and the effects of AMPK stimulation (simulating exercise) and cyclic stretching on human lung microvascular endothelial cells (HLMVEC). Sirtuin 1 (Sirt1) knockdown male mice were generated to explore the regulating mechanisms of sirt1 on mitochondrial function in male mice after mechanical ventilation was explored. Western blot, flow cytometry, live cell imaging, and mitochondrial function evaluations were used to determine the protective effects of aerobic exercise in preventing mitochondrial damage in VILI. RESULTS Mitochondrial function and cell junctions were destroyed by mechanical ventilation in male mice or cyclic stretching in HLMVEC, a model of VILI. However, mitochondrial function and cell junction dysfunction were improved by exercise before mechanical ventilation (male mice) or treatment with AMPK before cyclic stretching (HLMVEC). p66shc, a marker of oxidative stress, was increased, and PINK1, a marker of mitochondrial autophagy, was decreased by mechanical ventilation or cyclic stretching. Sirt1 knockdown increased p66shc and decreased PINK1. Increased sirt1 expression was observed in the exercise and exercise + ventilation groups, suggesting that sirt1 inhibits mitochondrial damage in VILI. CONCLUSIONS Mechanical ventilation induces mitochondrial damage in lung cells and leads to VILI. Regular aerobic exercise before ventilation may prevent VILI by improving mitochondrial function.
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Affiliation(s)
- JIE YAN
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, CHINA
| | - CHANGPING GU
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, CHINA
- Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, Shandong, CHINA
- Department of Anesthesiology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, CHINA
| | - GE LIU
- Department of Anesthesiology, The Second Hospital of Shandong University, Jinan, Shandong, CHINA
| | - YAQIANG ZHANG
- Department of Sports Biomechanics, Beijing Sport University, Beijing, CHINA
| | - LI YANG
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, CHINA
| | - TAO ZHAO
- Department of Anesthesiology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, CHINA
| | - CUICUI CAO
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, CHINA
| | - LIANG ZHAO
- Department of Anesthesiology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, CHINA
| | - GUANGHAN WU
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, CHINA
| | - YUELAN WANG
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, CHINA
- Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, Shandong, CHINA
- Department of Anesthesiology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, CHINA
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32
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Ghiani A, Kneidinger N, Neurohr C, Frank S, Hinske LC, Schneider C, Michel S, Irlbeck M. Mechanical Power Density Predicts Prolonged Ventilation Following Double Lung Transplantation. Transpl Int 2023; 36:11506. [PMID: 37799668 PMCID: PMC10548550 DOI: 10.3389/ti.2023.11506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 09/11/2023] [Indexed: 10/07/2023]
Abstract
Prolonged mechanical ventilation (PMV) after lung transplantation poses several risks, including higher tracheostomy rates and increased in-hospital mortality. Mechanical power (MP) of artificial ventilation unifies the ventilatory variables that determine gas exchange and may be related to allograft function following transplant, affecting ventilator weaning. We retrospectively analyzed consecutive double lung transplant recipients at a national transplant center, ventilated through endotracheal tubes upon ICU admission, excluding those receiving extracorporeal support. MP and derived indexes assessed up to 36 h after transplant were correlated with invasive ventilation duration using Spearman's coefficient, and we conducted receiver operating characteristic (ROC) curve analysis to evaluate the accuracy in predicting PMV (>72 h), expressed as area under the ROC curve (AUROC). PMV occurred in 82 (35%) out of 237 cases. MP was significantly correlated with invasive ventilation duration (Spearman's ρ = 0.252 [95% CI 0.129-0.369], p < 0.01), with power density (MP normalized to lung-thorax compliance) demonstrating the strongest correlation (ρ = 0.452 [0.345-0.548], p < 0.01) and enhancing PMV prediction (AUROC 0.78 [95% CI 0.72-0.83], p < 0.01) compared to MP (AUROC 0.66 [0.60-0.72], p < 0.01). Mechanical power density may help identify patients at risk for PMV after double lung transplantation.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart–Schillerhoehe Lung Clinic GmbH, Robert-Bosch-Hospital GmbH, Stuttgart, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, LMU University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart–Schillerhoehe Lung Clinic GmbH, Robert-Bosch-Hospital GmbH, Stuttgart, Germany
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Sandra Frank
- Department of Anesthesiology, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
| | - Ludwig Christian Hinske
- Department of Anesthesiology, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
- Institute for Digital Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Christian Schneider
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Department of Thoracic Surgery, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
| | - Sebastian Michel
- Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), Munich, Germany
- Clinic of Cardiac Surgery, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, Ludwig-Maximilians-University (LMU) of Munich, Munich, Germany
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Burša F, Oczka D, Jor O, Sklienka P, Frelich M, Stigler J, Vodička V, Ekrtová T, Penhaker M, Máca J. The Impact of Mechanical Energy Assessment on Mechanical Ventilation: A Comprehensive Review and Practical Application. Med Sci Monit 2023; 29:e941287. [PMID: 37669252 PMCID: PMC10492505 DOI: 10.12659/msm.941287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 09/07/2023] Open
Abstract
Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most severe form. The use of excessive ventilation forces can exacerbate the lung condition and lead to ventilator-induced lung injury (VILI); mechanical energy (ME) or power can characterize such forces applied during MV. The ME metric combines all MV parameters affecting the respiratory system (ie, lungs, chest, and airways) into a single value. Besides evaluating the overall ME, this parameter can be also related to patient-specific characteristics, such as lung compliance or patient weight, which can further improve the value of ME for characterizing the aggressiveness of lung ventilation. High ME is associated with poor outcomes and could be used as a prognostic parameter and indicator of the risk of VILI. ME is rarely determined in everyday practice because the calculations are complicated and based on multiple equations. Although low ME does not conclusively prevent the possibility of VILI (eg, due to the lung inhomogeneity and preexisting damage), individualization of MV settings considering ME appears to improve outcomes. This article aims to review the roles of bedside assessment of mechanical power, its relevance in mechanical ventilation, and its associations with treatment outcomes. In addition, we discuss methods for ME determination, aiming to propose the most suitable method for bedside application of the ME concept in everyday practice.
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Affiliation(s)
- Filip Burša
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - David Oczka
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science,VSB – Technical University of Ostrava, Ostrava, Czech Republic
| | - Ondřej Jor
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Peter Sklienka
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Michal Frelich
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Stigler
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Vojtech Vodička
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Tereza Ekrtová
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
| | - Marek Penhaker
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science,VSB – Technical University of Ostrava, Ostrava, Czech Republic
| | - Jan Máca
- Department of Anesthesiology and Intensive Care, University Hospital Ostrava, Ostrava, Czech Republic
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Zheng M. Respiratory Mechanics: Revisiting the Appraisement of Lung Recruitment. Respir Care 2023; 68:1262-1270. [PMID: 37072160 PMCID: PMC10468170 DOI: 10.4187/respcare.10601] [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: 04/20/2023]
Abstract
Mechanical ventilation has long been recognized as the most vital therapy for patients with ARDS. Compared with lung-protective ventilation, debates that involve the open lung strategy, which consists primarily of the lung recruitment maneuver and higher PEEP, have never been resolved. In terms of the beneficial and detrimental effects of this aggressive maneuver, appraisal of lung recruitment is essential for intensivists to make clinical decisions. This review aimed to clarify how to assess the potential for lung recruitment based on respiratory mechanics when using the pressure-volume curve or loop method and end-expiratory lung volume-static compliance of the respiratory system method. However, their limitations related to excessive generalization, accuracy, and identification of cutoff values cannot be omitted. Finally, future studies are warranted to combine these classic methods with newly invented techniques to achieve safer and more effective lung recruitment.
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Affiliation(s)
- Mingjia Zheng
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Wuxing, Huzhou, Zhejiang, People's Republic of China.
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35
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Carvalho EV, Pinto SPS, Gomes EP, Peñuelas Ó, Stohler CG, Arantes GC, Carvalho LL, Oliveira RMF, Martins PN, Reboredo MM, Pinheiro BV. Adherence to protective mechanical ventilation in COVID-19 versus non-COVID-19-associated acute respiratory distress syndrome: Comparison between two prospective cohorts. Med Intensiva 2023; 47:445-453. [PMID: 36813658 DOI: 10.1016/j.medine.2023.01.004] [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] [Received: 11/27/2022] [Revised: 01/02/2023] [Accepted: 01/08/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To compare adherence to protective mechanical ventilation (MV) parameters in patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 with patients with ARDS from other etiologies. DESIGN Multiple prospective cohort study. SETTING Two Brazilian cohorts of ARDS patients were evaluated. One with COVID-19 patients admitted to two Brazilian intensive care units (ICUs) in 2020 and 2021 (C-ARDS, n=282), the other with ARDS-patients from other etiologies admitted to 37 Brazilian ICUs in 2016 (NC-ARDS, n=120). PATIENTS ARDS patients under MV. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Adherence to protective MV (tidal volume ≤8mL/kg PBW; plateau pressure ≤30cmH2O; and driving pressure ≤15cmH2O), adherence to each individual component of the protective MV, and the association between protective MV and mortality. RESULTS Adherence to protective MV was higher in C-ARDS than in NC-ARDS patients (65.8% vs. 50.0%, p=0.005), mainly due to a higher adherence to driving pressure ≤15cmH2O (75.0% vs. 62.4%, p=0.02). Multivariable logistic regression showed that the C-ARDS cohort was independently associated with adherence to protective MV. Among the components of the protective MV, only limiting driving pressure was independently associated with lower ICU mortality. CONCLUSIONS Higher adherence to protective MV in patients with C-ARDS was secondary to higher adherence to limiting driving pressure. Additionally, lower driving pressure was independently associated with lower ICU mortality, which suggests that limiting exposure to driving pressure may improve survival in these patients.
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Affiliation(s)
- E V Carvalho
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - S P S Pinto
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - E P Gomes
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Ó Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain; CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - C G Stohler
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - G C Arantes
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - L L Carvalho
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - R M F Oliveira
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - P N Martins
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - M M Reboredo
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - B V Pinheiro
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil.
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Haudebourg AF, Moncomble E, Lesimple A, Delamaire F, Louis B, Mekontso Dessap A, Mercat A, Richard JC, Beloncle F, Carteaux G. A novel method for assessment of airway opening pressure without the need for low-flow insufflation. Crit Care 2023; 27:273. [PMID: 37420282 PMCID: PMC10329375 DOI: 10.1186/s13054-023-04560-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/04/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Airway opening pressure (AOP) detection and measurement are essential for assessing respiratory mechanics and adapting ventilation. We propose a novel approach for AOP assessment during volume assist control ventilation at a usual constant-flow rate of 60 L/min. OBJECTIVES To validate the conductive pressure (Pcond) method, which compare the Pcond-defined on the airway pressure waveform as the difference between the airway pressure level at which an abrupt change in slope occurs at the beginning of insufflation and PEEP-to resistive pressure for AOP detection and measurement, and to compare its respiratory and hemodynamic tolerance to the standard low-flow insufflation method. METHODS The proof-of-concept of the Pcond method was assessed on mechanical (lung simulator) and physiological (cadavers) bench models. Its diagnostic performance was evaluated in 213 patients, using the standard low-flow insufflation method as a reference. In 45 patients, the respiratory and hemodynamic tolerance of the Pcond method was compared with the standard low-flow method. MEASUREMENTS AND MAIN RESULTS Bench assessments validated the Pcond method proof-of-concept. Sensitivity and specificity of the Pcond method for AOP detection were 93% and 91%, respectively. AOP obtained by Pcond and standard low-flow methods strongly correlated (r = 0.84, p < 0.001). Changes in SpO2 were significantly lower during Pcond than during standard method (p < 0.001). CONCLUSION Determination of Pcond during constant-flow assist control ventilation may permit to easily and safely detect and measure AOP.
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Affiliation(s)
- Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil, France
| | - Elsa Moncomble
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil, France
| | - Arnaud Lesimple
- CNRS, INSERM 1083, MITOVASC, Université d'Angers, Angers, France
- Laboratoire Med2Lab ALMS, Antony, France
| | - Flora Delamaire
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil, France
| | - Bruno Louis
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Alain Mercat
- CNRS, INSERM 1083, MITOVASC, Université d'Angers, Angers, France
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire d'Angers, Vent' Lab, Faculté de Santé, Université d'Angers, Angers, France
| | - Jean-Christophe Richard
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire d'Angers, Vent' Lab, Faculté de Santé, Université d'Angers, Angers, France
- UMR 1066, INSERM, Créteil, France
| | - François Beloncle
- CNRS, INSERM 1083, MITOVASC, Université d'Angers, Angers, France
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier Universitaire d'Angers, Vent' Lab, Faculté de Santé, Université d'Angers, Angers, France
| | - Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil, France.
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France.
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Senturk E, Ugur S, Celik Y, Cukurova Z, Asar S, Cakar N. The power of mechanical ventilation may predict mortality in critically ill patients. Minerva Anestesiol 2023; 89:663-670. [PMID: 37079284 DOI: 10.23736/s0375-9393.23.17080-5] [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: 04/21/2023]
Abstract
BACKGROUND Mechanical power (MP) is the amount of energy transferred from the ventilator to the patient within a unit of time. It has been emphasized in ventilation-induced lung injury (VILI) and mortality. However, its measurement and use in clinical practice are challenging. "Electronic recording systems (ERS)" using mechanical ventilation parameters provided by the ventilator can be helpful to measure and record the MP. The MP (J/minutes) formula is 0.098 x tidal volume x respiratory rate x (Ppeak - ½ ∆P), in which ∆P is the driving pressure and Ppeak is the peak pressure. We aimed to define the association between MP values and ICU mortality, mechanical ventilation days, and intensive care unit length of stay (ICU-LOS). The secondary outcome was to determine the most potent or essential component of power in the equation that has a role in mortality. METHODS This retrospective study was performed in two centers (VKV American Hospital and Bakırköy Sadi Konuk Hospital ICUs) that used ERS (Metavision IMDsoft) between 2014 and 2018. We uploaded the power formula (MP (J/minutes)=0.098×VT×RR×(Ppeak - ½ ∆P) to ERS (METAvision, iMDsoft, and Consult Orion Health) and calculated the MP value by using MV parameters automatically sent from the ventilator. (∆P; driving pressure, VT; tidal volume, RR; respiratory rate and Ppeak; peak pressure). RESULTS A total of 3042 patients were included in the study. The median value of MP was 11.3 J/min. Mortality in MP<11.3 J/min was 35.4%, and 49.1% in MP>11.3J/min.; P<0.001. Mechanical ventilation days and ICU-LOS were also statistically longer in the MVP>11.3 J/min group. CONCLUSIONS The first 24 h MP maybe a predictive value for the ICU patients' prognosis. This implies that MP may be used as a decision-making system to define the clinical approach and as a scoring system to predict patient prognosis.
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Affiliation(s)
- Evren Senturk
- Department of Anesthesiology and Reanimation, Koç University Hospital, Istanbul, Türkiye
| | - Semra Ugur
- Department of Anesthesiology and Reanimation, Koç University Hospital, Istanbul, Türkiye -
| | - Yeliz Celik
- Department of Pulmonology, Koç University Hospital, Istanbul, Türkiye
| | - Zafer Cukurova
- Department of Anesthesiology and Reanimation, Bakirkoy Sadi Konuk Research Hospital, Istanbul, Türkiye
| | - Sinan Asar
- Department of Anesthesiology and Reanimation, Bakirkoy Sadi Konuk Research Hospital, Istanbul, Türkiye
| | - Nahit Cakar
- Department of Anesthesiology and Reanimation, Koç University Hospital, Istanbul, Türkiye
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38
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Taje R, Fabbi E, Sorge R, Elia S, Dauri M, Pompeo E. Adjuvant Transthoracic Negative-Pressure Ventilation in Nonintubated Thoracoscopic Surgery. J Clin Med 2023; 12:4234. [PMID: 37445268 DOI: 10.3390/jcm12134234] [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: 05/22/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND To minimize the risks of barotrauma during nonintubated thoracoscopic-surgery under spontaneous ventilation, we investigated an adjuvant transthoracic negative-pressure ventilation (NPV) method in patients operated on due to severe emphysema or interstitial lung disease. METHODS In this retrospective study, NPV was employed for temporary low oxygen saturation and to achieve end-operative lung re-expansion during nonintubated lung volume reduction surgery (LVRS) for severe emphysema (30 patients, LVRS group) and in the nonintubated wedge resection of undetermined interstitial lung disease (30 patients, wedge-group). The results were compared following 1:1 propensity score matching with equivalent control groups undergoing the same procedures under spontaneous ventilation, with adjuvant positive-pressure ventilation (PPV) performed on-demand through the laryngeal mask. The primary outcomes were changes (preoperative-postoperative value) in the arterial oxygen tension/fraction of the inspired oxygen ratio (ΔPO2/FiO2;) and ΔPaCO2, and lung expansion completeness on a 24 h postoperative chest radiograph (CXR-score, 2: full or 1: incomplete). RESULTS Intergroup comparisons (NPV vs. PPV) showed no differences in demographic and pulmonary function. NPV could be accomplished in all instances with no conversion to general anesthesia with intubation. In the LVRS group, NPV improved ΔPO2/FiO2 (9.3 ± 16 vs. 25.3 ± 30.5, p = 0.027) and ΔPaCO2 (-2.2 ± 3.15 mmHg vs. 0.03 ± 0.18 mmHg, p = 0.008) with no difference in the CXR score, whereas in the wedge group, both ΔPO2/FiO2 (3.1 ± 8.2 vs. 9.9 ± 13.8, p = 0.035) and the CXR score (1.9 ± 0.3 vs. 1.6 ± 0.5, p = 0.04) were better in the NPV subgroup. There was no mortality and no intergroup difference in morbidity. CONCLUSIONS In this retrospective study, NITS with adjuvant transthoracic NPV resulted in better 24 h oxygenation measures than PPV in both the LVRS and wedge groups, and in better lung expansion according to the CXR score in the wedge group.
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Affiliation(s)
- Riccardo Taje
- Department of Thoracic Surgery, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
| | - Eleonora Fabbi
- Department of Anesthesia and Intensive Care, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
| | - Roberto Sorge
- Department of Biostatistics, Tor Vergata University of Rome, 00133 Rome, Italy
| | - Stefano Elia
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100 Campobasso, Italy
| | - Mario Dauri
- Department of Anesthesia and Intensive Care, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
| | - Eugenio Pompeo
- Department of Thoracic Surgery, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
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Dankhara N, Holla I, Ramarao S, Kalikkot Thekkeveedu R. Bronchopulmonary Dysplasia: Pathogenesis and Pathophysiology. J Clin Med 2023; 12:4207. [PMID: 37445242 DOI: 10.3390/jcm12134207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD), also known as chronic lung disease, is the most common respiratory morbidity in preterm infants. "Old" or "classic" BPD, as per the original description, is less common now. "New BPD", which presents with distinct clinical and pathological features, is more frequently observed in the current era of advanced neonatal care, where extremely premature infants are surviving because of medical advancements. The pathogenesis of BPD is complex and multifactorial and involves both genetic and environmental factors. This review provides an overview of the pathology of BPD and discusses the influence of several prenatal and postnatal factors on its pathogenesis, such as maternal factors, genetic susceptibility, ventilator-associated lung injury, oxygen toxicity, sepsis, patent ductus arteriosus (PDA), and nutritional deficiencies. This in-depth review draws on existing literature to explore these factors and their potential contribution to the development of BPD.
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Affiliation(s)
- Nilesh Dankhara
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Ira Holla
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Sumana Ramarao
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
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40
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Tharp WG, Neilson MR, Breidenstein MW, Harned RG, Chatfield SE, Friend AF, Nunez D, Abnet KR, Farhang B, Klick JC, Horn N, Bender SP, Bates JHT, Dixon AE. Effects of obesity, pneumoperitoneum, and body position on mechanical power of intraoperative ventilation: an observational study. J Appl Physiol (1985) 2023; 134:1390-1402. [PMID: 37022962 PMCID: PMC10211461 DOI: 10.1152/japplphysiol.00551.2022] [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: 09/15/2022] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 04/07/2023] Open
Abstract
Mechanical power can describe the complex interaction between the respiratory system and the ventilator and may predict lung injury or pulmonary complications, but the power associated with injury of healthy human lungs is unknown. Body habitus and surgical conditions may alter mechanical power but the effects have not been measured. In a secondary analysis of an observational study of obesity and lung mechanics during robotic laparoscopic surgery, we comprehensively quantified the static elastic, dynamic elastic, and resistive energies comprising mechanical power of ventilation. We stratified by body mass index (BMI) and examined power at four surgical stages: level after intubation, with pneumoperitoneum, in Trendelenburg, and level after releasing the pneumoperitoneum. Esophageal manometry was used to estimate transpulmonary pressures. Mechanical power of ventilation and its bioenergetic components increased over BMI categories. Respiratory system and lung power were nearly doubled in subjects with class 3 obesity compared with lean at all stages. Power dissipated into the respiratory system was increased with class 2 or 3 obesity compared with lean. Increased power of ventilation was associated with decreasing transpulmonary pressures. Body habitus is a prime determinant of increased intraoperative mechanical power. Obesity and surgical conditions increase the energies dissipated into the respiratory system during ventilation. The observed elevations in power may be related to tidal recruitment or atelectasis, and point to specific energetic features of mechanical ventilation of patients with obesity that may be controlled with individualized ventilator settings.NEW & NOTEWORTHY Mechanical power describes the complex interaction between a patient's lungs and the ventilator and may be useful in predicting lung injury. However, its behavior in obesity and during dynamic surgical conditions is not understood. We comprehensively quantified ventilation bioenergetics and effects of body habitus and common surgical conditions. These data show body habitus is a prime determinant of intraoperative mechanical power and provide quantitative context for future translation toward a useful perioperative prognostic measurement.
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Affiliation(s)
- William G Tharp
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Maegan R Neilson
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
| | - Max W Breidenstein
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Ryan G Harned
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Sydney E Chatfield
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
| | - Alexander F Friend
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Denis Nunez
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Kevin R Abnet
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Borzoo Farhang
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - John C Klick
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Nathan Horn
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - S Patrick Bender
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Jason H T Bates
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Anne E Dixon
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, United States
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Lee JE, Kim HY, Lee KW, Kim GS. Second-generation supraglottic airway in laparoscopic donor nephrectomy. Sci Rep 2023; 13:8406. [PMID: 37225750 DOI: 10.1038/s41598-023-34691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Supraglottic airway (SGA) may have advantages over endotracheal tube (ETT) regarding laryngospasm, coughing, sore throat, and hemodynamic changes; however, studies on the use of SGA in laparoscopic donor nephrectomy (LDN) are lacking. Here, we aimed to confirm the safety and feasibility of second-generation SGA in LDN and compare them with those of ETT. Enrolled adult donors (aged > 18 years) who underwent LDN between August 2018 and November 2021 were divided into two groups-ETT vs. SGA. Airway pressure, lung compliance, desaturation, and hypercapnia were recorded during surgery. After propensity score matching for baseline characteristics and surgical duration, 82 and 152 donors were included in the ETT and SGA groups, respectively, and their outcomes were compared. The peak airway pressure was lower in the SGA group than in the ETT group 5 min after pneumoperitoneum. Dynamic lung compliance was higher in the SGA group than in the ETT group during surgery. There were no cases of intraoperative desaturation, hypercapnia, or postoperative aspiration pneumonitis. The use of second-generation SGA, a safe alternative to ETT for LDN, resulted in reduced airway resistance and increased lung compliance, which suggests its benefits for airway management in kidney donors.
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Affiliation(s)
- Ja Eun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Marini JJ, Thornton LT, Rocco PRM, Gattinoni L, Crooke PS. Practical assessment of risk of VILI from ventilating power: a conceptual model. Crit Care 2023; 27:157. [PMID: 37081517 PMCID: PMC10120146 DOI: 10.1186/s13054-023-04406-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
At the bedside, assessing the risk of ventilator-induced lung injury (VILI) requires parameters readily measured by the clinician. For this purpose, driving pressure (DP) and end-inspiratory static 'plateau' pressure ([Formula: see text]) of the tidal cycle are unquestionably useful but lack key information relating to associated volume changes and cumulative strain. 'Mechanical power', a clinical term which incorporates all dissipated ('non-elastic') and conserved ('elastic') energy components of inflation, has drawn considerable interest as a comprehensive 'umbrella' variable that accounts for the influence of ventilating frequency per minute as well as the energy cost per tidal cycle. Yet, like the raw values of DP and [Formula: see text], the absolute levels of energy and power by themselves may not carry sufficiently precise information to guide safe ventilatory practice. In previous work we introduced the concept of 'damaging energy per cycle'. Here we describe how-if only in concept-the bedside clinician might gauge the theoretical hazard of delivered energy using easily observed static circuit pressures ([Formula: see text] and positive end expiratory pressure) and an estimate of the maximally tolerated (threshold) non-dissipated ('elastic') airway pressure that reflects the pressure component applied to the alveolar tissues. Because its core inputs are already in use and familiar in daily practice, the simplified mathematical model we propose here for damaging energy and power may promote deeper comprehension of the key factors in play to improve lung protective ventilation.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA.
| | - Lauren T Thornton
- 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
| | - Luciano Gattinoni
- Department of Anesthesiology, University of Göttingen, Göttingen, Germany
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
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Nurok M, Friedman O, Driver M, Sun N, Kumaresan A, Chen P, Cheng S, Talmor DS, Ebinger J. Mechanically Ventilated Patients With Coronavirus Disease 2019 Had a Higher Chance of In-Hospital Death If Treated With High-Flow Nasal Cannula Oxygen Before Intubation. Anesth Analg 2023; 136:692-698. [PMID: 36730796 PMCID: PMC9990488 DOI: 10.1213/ane.0000000000006211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The impact of high-flow nasal cannula (HFNC) on outcomes of patients with respiratory failure from coronavirus disease 2019 (COVID-19) is unknown. We sought to assess whether exposure to HFNC before intubation was associated with successful extubation and in-hospital mortality compared to patients receiving intubation only. METHODS This single-center retrospective study examined patients with COVID-19-related respiratory failure from March 2020 to March 2021 who required HFNC, intubation, or both. Data were abstracted from the electronic health record. Use and duration of HFNC and intubation were examined' as well as demographics and clinical characteristics. We assessed the association between HFNC before intubation (versus without) and chance of successful extubation and in-hospital death using Cox proportional hazards models adjusting for age, sex, race/ethnicity, obesity, hypertension, diabetes, prior chronic obstructive pulmonary disease or asthma, HCO 3 , CO 2 , oxygen-saturation-to-inspired-oxygen (S:F) ratio, pulse, respiratory rate, temperature, and length of stay before intervention. RESULTS A total of n = 440 patients were identified, of whom 311 (70.7%) received HFNC before intubation, and 129 (29.3%) were intubated without prior use of HFNC. Patients who received HFNC before intubation had a higher chance of in-hospital death (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.06-4.05). No difference was found in the chance of successful extubation between the 2 groups (0.70, 0.41-1.20). CONCLUSIONS Among patients with respiratory failure from COVID-19 requiring mechanical ventilation, patients receiving HFNC before intubation had a higher chance of in-hospital death. Decisions on initial respiratory support modality should weigh the risks of intubation with potential increased mortality associated with HFNC.
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Affiliation(s)
- Michael Nurok
- From the Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Oren Friedman
- Department of Medicine, Intensive Care Unit, Marina del Rey Hospital, Division of Pulmonary & Critical Care Medicine, Cedars-Sinai Health System and Medical Center, Los Angeles, California
| | - Matthew Driver
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nancy Sun
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abirami Kumaresan
- From the Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peter Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Women's Guild Lung Institute, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel S Talmor
- Department of Anesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joseph Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Hoppe K, Khan E, Meybohm P, Riese T. Mechanical power of ventilation and driving pressure: two undervalued parameters for pre extracorporeal membrane oxygenation ventilation and during daily management? Crit Care 2023; 27:111. [PMID: 36915183 PMCID: PMC10010963 DOI: 10.1186/s13054-023-04375-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/19/2023] [Indexed: 03/15/2023] Open
Abstract
The current ARDS guidelines highly recommend lung protective ventilation which include plateau pressure (Pplat < 30 cm H2O), positive end expiratory pressure (PEEP > 5 cm H2O) and tidal volume (Vt of 6 ml/kg) of predicted body weight. In contrast, the ELSO guidelines suggest the evaluation of an indication of veno-venous extracorporeal membrane oxygenation (ECMO) due to hypoxemic or hypercapnic respiratory failure or as bridge to lung transplantation. Finally, these recommendations remain a wide range of scope of interpretation. However, particularly patients with moderate-severe to severe ARDS might benefit from strict adherence to lung protective ventilation strategies. Subsequently, we discuss whether extended physiological ventilation parameter analysis might be relevant for indication of ECMO support and can be implemented during the daily routine evaluation of ARDS patients. Particularly, this viewpoint focus on driving pressure and mechanical power.
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Affiliation(s)
- K Hoppe
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - E Khan
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - P Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - T Riese
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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Tang R, Hu Y, Mei S, Zhou Y, Feng J, Jin T, Dai B, Xing S, Gao Y, Xu Q, He Z. Non-coding RNA alterations in extracellular vesicles from bronchoalveolar lavage fluid contribute to mechanical ventilation-induced pulmonary fibrosis. Front Immunol 2023; 14:1141761. [PMID: 36993978 PMCID: PMC10040560 DOI: 10.3389/fimmu.2023.1141761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 03/18/2023] Open
Abstract
ObjectiveFor respiratory failure patients, mechanical ventilation (MV) is a life-saving therapy to maintain respiratory function. However, MV could also cause damage to pulmonary structures, result in ventilator-induced lung injury (VILI) and eventually progress to mechanical ventilation-induced pulmonary fibrosis (MVPF). Mechanically ventilated patients with MVPF are closely related to increased mortality and poor quality of life in long-term survival. Thus, a thorough understanding of the involved mechanism is necessary.MethodsWe used next-generation sequencing to identify differentially expressed non-coding RNAs (ncRNAs) in BALF EVs which were isolated from Sham and MV mice. Bioinformatics analysis was conducted to identify the engaged ncRNAs and related signaling pathways in the process of MVPF.ResultsWe found 1801 messenger RNAs (mRNA), 53 micro RNAs (miRNA), 273 circular RNAs (circRNA) and 552 long non-coding RNAs (lncRNA) in mice BALF EVs of two groups, which showed significant differential expression. TargetScan predicted that 53 differentially expressed miRNAs targeted 3105 mRNAs. MiRanda revealed that 273 differentially expressed circRNAs were associated with 241 mRNAs while 552 differentially expressed lncRNAs were predicated to target 20528 mRNAs. GO, KEGG pathway analysis and KOG classification showed that these differentially expressed ncRNA-targeted mRNAs were enriched in fibrosis related signaling pathways and biological processes. By taking the intersection of miRNAs target genes, circRNAs target genes and lncRNAs target genes, we found 24 common key genes and 6 downregulated genes were confirmed by qRT-PCR.ConclusionsChanges in BALF-EV ncRNAs may contribute to MVPF. Identification of key target genes involved in the pathogenesis of MVPF could lead to interventions that slow or reverse fibrosis progression.
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Affiliation(s)
- Ri Tang
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue Hu
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuya Mei
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Zhou
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinhua Feng
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Jin
- Shanghai Key Laboratory of Modern Optical System, School of Optical-Electrical and Computer Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Bo Dai
- Shanghai Key Laboratory of Modern Optical System, School of Optical-Electrical and Computer Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Shunpeng Xing
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Gao
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiaoyi Xu
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Qiaoyi Xu, ; Zhengyu He,
| | - Zhengyu He
- Department of Critical Care Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Qiaoyi Xu, ; Zhengyu He,
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Katira BH, Cereda M. Negative Pressure Is the Positive Way to Breathe! Am J Respir Crit Care Med 2023; 207:505-506. [PMID: 36214809 PMCID: PMC10870922 DOI: 10.1164/rccm.202210-1862ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bhushan H Katira
- Department of Pediatrics Washington University in St. Louis St. Louis, Missouri
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School Boston, Massachusetts
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Grassetto A, Pettenuzzo T, Badii F, Carlon R, Sella N, Navalesi P. Flow-controlled ventilation may reduce mechanical power and increase ventilatory efficiency in severe coronavirus disease-19 acute respiratory distress syndrome. Pulmonology 2023; 29:154-156. [PMID: 35864057 PMCID: PMC9186429 DOI: 10.1016/j.pulmoe.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/15/2022] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- A Grassetto
- Anesthesia and Intensive Care, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029 Vittorio Veneto, Italy.
| | - T Pettenuzzo
- Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Via V. Gallucci 13, 35121 Padua, Italy
| | - F Badii
- Anesthesia and Intensive Care, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029 Vittorio Veneto, Italy
| | - R Carlon
- Anesthesia and Intensive Care, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029 Vittorio Veneto, Italy
| | - N Sella
- Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Via V. Gallucci 13, 35121 Padua, Italy
| | - P Navalesi
- Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Via V. Gallucci 13, 35121 Padua, Italy; Department of Medicine, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
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Critical Care and Mechanical Ventilation Practices Surrounding Liver Transplantation in Children: A Multicenter Collaborative. Pediatr Crit Care Med 2023; 24:102-111. [PMID: 36278882 DOI: 10.1097/pcc.0000000000003101] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We aimed to determine which characteristics and management approaches were associated with postoperative invasive mechanical ventilation (IMV) and with a prolonged course of IMV in children post liver transplant as well as describing the utilization of critical care resources. DESIGN Retrospective, multicenter, cohort study of children who underwent an isolated liver transplantation between January 2017 and December 2018. SETTING Twelve U.S., pediatric, liver transplant centers. PATIENTS Three hundred thirty children post liver transplant admitted to the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six patients died in our cohort. The median length of PICU stay was 4.5 days (interquartile range [IQR], 2.9-8.2 d). Most patients were initially monitored with arterial catheters (96%), central venous pressures (95%), and liver ultrasound (93%). Anticoagulation (80%), blood product administration (52.4%), and vasoactive agents (23.0%) were commonly used therapies in the first 7 days. In multivariable logistic regression analysis, age (adjusted odds ratio [aOR] 0.9 [0.86-0.95]), open fascia (aOR 7.0 [95% CI, 2.6-18.9]), large center size (aOR 4.3 [95% CI 2.2-8.3]), and higher Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores (aOR 1.04 [95% CI, 1.01-1.06]) were associated with postoperative IMV. In multivariable logistic regression analysis, postoperative day 0 peak inspiratory pressure (PIP) (aOR 1.2 [95% CI, 1.1-1.3]), large center size (aOR 2.9 [95% CI, 1.6-5.4]), and age (aOR 0.89 [95% CI, 0.85-0.95]) were associated with length of IMV greater than 24 hours. Length of IMV greater than 24 hours was associated with bleeding complications ( p = 0.03), infections ( p = 0.03), graft loss ( p = 0.02), and reoperation ( p = 0.03). CONCLUSIONS Younger age, preoperative hospitalization, large center size, and open fascia are associated with use of IMV, and younger age, large center size, and postoperative day 0 PIP are associated with prolonged IMV on multivariable analysis. Longer IMV is associated with negative outcomes, making it an important clinical marker.
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Liu X, Wang L. Comparison of the effects of different mechanical ventilation modes on the incidence of ventilation-associated pneumonia: a case study of patients undergoing thoracic surgery. Am J Transl Res 2022; 14:8668-8675. [PMID: 36628217 PMCID: PMC9827302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/20/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To investigate the effects of different mechanical ventilation modes on the incidence of ventilator-associated pneumonia (VAP) in patients undergoing thoracic surgery. METHODS From June 2019 to December 2021, the clinical data of 96 patients undergoing thoracic surgery in Cangzhou Central Hospital were retrospectively analyzed. A total of 44 patients who underwent constant flow mode were included in the control group (CG), and 52 patients who underwent auto flow mode were included in the observation group (OG). The respiratory mechanics, hemodynamics, blood gas analysis and serum levels of lung injury markers at different time points were compared between the two groups, and the incidence of VAP was analyzed. RESULTS At 1 hour and 4 hours of ventilation, the peak airway pressure (Ppeak), Pmean mean airway pressure (Pmean) and airway resistance (Raw) of the OG were lower than those of the CG, and the dynamic lung compliance (Cdyn) was higher than that of the CG (P<0.05). There were no statistically significant differences in mean arterial pressure (MAP), heart rate (HR), blood oxygen saturation (SpO2), PH, arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2) between the OG and CG at 1 hour and 4 hours of ventilation respectively (P>0.05). The serum levels of pulmonary surfactant associated protein A (SP-A), human Clara cell protein (CC16) and serum ferritin (SF) in the OG were lower than those in the CG (P<0.05). The incidence of VAP in the OG (3.85%) was lower than that in the CG (15.91%) (P<0.05). CONCLUSION In mechanical ventilation, auto flow mode can reduce the incidence of VAP, improve respiratory mechanics, and reduce lung injury in patients undergoing thoracic surgery, but has no significant effect on hemodynamics and blood gas analysis.
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50
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Driving pressure-guided ventilation improves homogeneity in lung gas distribution for gynecological laparoscopy: a randomized controlled trial. Sci Rep 2022; 12:21687. [PMID: 36522433 PMCID: PMC9755264 DOI: 10.1038/s41598-022-26144-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
To investigate whether driving pressure-guided ventilation could contribute to a more homogeneous distribution in the lung for gynecological laparoscopy. Chinese patients were randomized, after pneumoperitoneum, to receive either positive end expiratory pressure (PEEP) of 5 cm H2O (control group), or individualized PEEP producing the lowest driving pressure (titration group). Ventilation homogeneity is quantified as the global inhomogeneity (GI) index based on electrical impedance tomography, with a lower index implying more homogeneous ventilation. The perioperative arterial oxygenation index and respiratory system mechanics were also recorded. Blood samples were collected for lung injury biomarkers including interleukin-10, neutrophil elastase, and Clara Cell protein-16. A total of 48 patients were included for analysis. We observed a significant increase in the GI index immediately after tracheal extubation compared to preinduction in the control group (p = 0.040) but not in the titration group (p = 0.279). Furthermore, the GI index was obviously lower in the titration group than in the control group [0.390 (0.066) vs 0.460 (0.074), p = 0.0012]. The oxygenation index and respiratory compliance were significantly higher in the titration group than in the control group. No significant differences in biomarkers or hemodynamics were detected between the two groups. Driving pressure-guided PEEP led to more homogeneous ventilation, as well as improved gas exchange and respiratory compliance for patients undergoing gynecological laparoscopy.Trial Registration: ClinicalTrials.gov NCT04374162; first registration on 05/05/2020.
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