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Bastia L, Garberi R, Querci L, Cipolla C, Curto F, Rezoagli E, Fumagalli R, Chieregato A. Dynamic inflation prevents and standardized lung recruitment reverts volume loss associated with percutaneous tracheostomy during volume control ventilation: results from a Neuro-ICU population. J Clin Monit Comput 2024:10.1007/s10877-024-01174-x. [PMID: 38758403 DOI: 10.1007/s10877-024-01174-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: 01/25/2024] [Accepted: 05/02/2024] [Indexed: 05/18/2024]
Abstract
To determine how percutaneous tracheostomy (PT) impacts on respiratory system compliance (Crs) and end-expiratory lung volume (EELV) during volume control ventilation and to test whether a recruitment maneuver (RM) at the end of PT may reverse lung derecruitment. This is a single center, prospective, applied physiology study. 25 patients with acute brain injury who underwent PT were studied. Patients were ventilated in volume control ventilation. Electrical impedance tomography (EIT) monitoring and respiratory mechanics measurements were performed in three steps: (a) baseline, (b) after PT, and (c) after a standardized RM (10 sighs of 30 cmH2O lasting 3 s each within 1 min). End-expiratory lung impedance (EELI) was used as a surrogate of EELV. PT determined a significant EELI loss (mean reduction of 432 arbitrary units p = 0.049) leading to a reduction in Crs (55 ± 13 vs. 62 ± 13 mL/cmH2O; p < 0.001) as compared to baseline. RM was able to revert EELI loss and restore Crs (68 ± 15 vs. 55 ± 13 mL/cmH2O; p < 0.001). In a subgroup of patients (N = 8, 31%), we observed a gradual but progressive increase in EELI. In this subgroup, patients did not experience a decrease of Crs after PT as compared to patients without dynamic inflation. Dynamic inflation did not cause hemodynamic impairment nor raising of intracranial pressure. We propose a novel and explorative hyperinflation risk index (HRI) formula. Volume control ventilation did not prevent the PT-induced lung derecruitment. RM could restore the baseline lung volume and mechanics. Dynamic inflation is common during PT, it can be monitored real-time by EIT and anticipated by HRI. The presence of dynamic inflation during PT may prevent lung derecruitment.
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Affiliation(s)
- Luca Bastia
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Viale Ghirotti 286, Cesena, 47521, Italy.
| | - Roberta Garberi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Lorenzo Querci
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristiana Cipolla
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori Hospital, Monza, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Intensive Care, University of Milano-Bicocca, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Kalchiem-Dekel O, Hossain S, Gauran C, Beattie JA, Husta BC, Lee RP, Chawla M. An evolving role for endobronchial ultrasonography in the intensive care unit. J Thorac Dis 2021; 13:5183-5194. [PMID: 34527358 PMCID: PMC8411164 DOI: 10.21037/jtd-2019-ipicu-09] [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: 02/12/2020] [Accepted: 04/21/2020] [Indexed: 11/06/2022]
Abstract
Endobronchial ultrasound (EBUS) bronchoscopy is an established minimally-invasive modality for visualization, characterization, and guidance of sampling of paratracheal and parabronchial structures and tissues. In the intensive care unit (ICU), rapidly obtaining an accurate diagnosis is paramount to the management of critically ill patients. In some instances, diagnosing and confirming terminal illness in a critically ill patient provides needed closure for patients and their loved ones. Currently available data on feasibility, safety, and yield of EBUS bronchoscopy in critically ill patients is based on single center experiences. These data suggest that in select ICU patients convex and radial probe-EBUS bronchoscopy can serve as useful tools in the evaluation of mediastinal lymphadenopathy, central airway obstruction, pulmonary embolism, and peripheral lung lesions. Barriers to the use of EBUS bronchoscopy in the ICU include: (I) requirement for dedicated equipment, prolonged procedure time, and bronchoscopy team expertise that may not be available; (II) applicability to a limited number of patients and conditions in the ICU; and (III) technical difficulty related to the relatively large outer diameter of the convex probe-EBUS bronchoscope and an increased risk for adverse cardiopulmonary consequences due to intermittent obstruction of the artificial airway. While the prospects for EBUS bronchoscopy in critically ill patients appear promising, judicious patient selection in combination with bronchoscopy team expertise are of utmost importance when considering performance of EBUS bronchoscopy in the ICU setting.
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Affiliation(s)
- Or Kalchiem-Dekel
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Saamia Hossain
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cosmin Gauran
- Department of Anesthesia and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason A Beattie
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bryan C Husta
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert P Lee
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mohit Chawla
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Nakstad ER, Opdahl H, Heyerdahl F, Borchsenius F, Skjønsberg OH. Manual ventilation and open suction procedures contribute to negative pressures in a mechanical lung model. BMJ Open Respir Res 2017; 4:e000176. [PMID: 28725445 PMCID: PMC5501241 DOI: 10.1136/bmjresp-2016-000176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/22/2017] [Accepted: 03/03/2017] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Removal of pulmonary secretions in mechanically ventilated patients usually requires suction with closed catheter systems or flexible bronchoscopes. Manual ventilation is occasionally performed during such procedures if clinicians suspect inadequate ventilation. Suctioning can also be performed with the ventilator entirely disconnected from the endotracheal tube (ETT). The aim of this study was to investigate if these two procedures generate negative airway pressures, which may contribute to atelectasis. METHODS The effects of device insertion and suctioning in ETTs were examined in a mechanical lung model with a pressure transducer inserted distal to ETTs of 9 mm, 8 mm and 7 mm internal diameter (ID). A 16 Fr bronchoscope and 12, 14 and 16 Fr suction catheters were used at two different vacuum levels during manual ventilation and with the ETTs disconnected. RESULTS During manual ventilation with ETTs of 9 mm, 8 mm and 7 mm ID, and bronchoscopic suctioning at moderate suction level, peak pressure (PPEAK) dropped from 23, 22 and 24.5 cm H2O to 16, 16 and 15 cm H2O, respectively. Maximum suction reduced PPEAK to 20, 17 and 11 cm H2O, respectively, and the end-expiratory pressure fell from 5, 5.5 and 4.5 cm H2O to -2, -6 and -17 cm H2O. Suctioning through disconnected ETTs (open suction procedure) gave negative model airway pressures throughout the duration of the procedures. CONCLUSIONS Manual ventilation and open suction procedures induce negative end-expiratory pressure during endotracheal suctioning, which may have clinical implications in patients who need high PEEP (positive end-expiratory pressure).
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Affiliation(s)
- Espen Rostrup Nakstad
- Department of Acute Medicine, Oslo University Hospital, Ullevaal, Norway.,Department of Pulmonary Medicine, Oslo University Hospital, Ullevaal, Norway
| | - Helge Opdahl
- Department of Acute Medicine, Oslo University Hospital, Ullevaal, Norway
| | - Fridtjof Heyerdahl
- Department of Anesthesiology, Oslo University Hospital, Ullevaal, Norway
| | - Fredrik Borchsenius
- Department of Pulmonary Medicine, Oslo University Hospital, Ullevaal, Norway
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Nakstad ER, Opdahl H, Heyerdahl F, Borchsenius F, Skjønsberg OH. Can ventilator settings reduce the negative effects of endotracheal suctioning? Investigations in a mechanical lung model. BMC Anesthesiol 2016; 16:30. [PMID: 27350249 PMCID: PMC4924309 DOI: 10.1186/s12871-016-0196-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 05/13/2016] [Indexed: 11/17/2022] Open
Abstract
Background The insertion of suction devices through endotracheal tubes (ETTs) increases airway resistance and the subsequent suctioning may reduce airway pressures and facilitate atelectasis. The aim of this study was to investigate how airway pressures and tidal volumes change when different combinations of suction equipment and ETT sizes are used, and to what extent unfavorable effects can be ameliorated by choice of ventilator settings. Methods A mechanical ventilator was connected to a lung model by ETTs of 9 mm, 8 mm or 7 mm internal diameter (ID) with a pressure transducer inserted distal to the ETT. The effects of suction procedures with bronchoscope and closed catheter systems were investigated during pressure controlled ventilation (PCV) and volume controlled ventilation (VCV). In each mode, the effects of changes in inspiration:expiration (I:E) ratio, trigger sensitivity and suction pressure were examined. Results The variables that contributed most to negative model airway pressures and loss of tidal volume during suctioning were (in descending order); 1) Small-size ETTs (7–8 mm ID) combined with large diameter suction devices (14–16 Fr); 2) inverse I:E ratio ventilation (in VCV); 3) negative ventilator trigger sensitivity; and 4) strong suction pressure. The pressure changes observed distal to the ETTs were not identical to those detected by the ventilator. Conclusions Negative model airway pressure was induced by suctioning through small-size ETTs. The most extreme pressure and volume changes were ameliorated when conventional ventilator settings were used, such as PCV mode with short inspiration time and a trigger function sensitive to flow changes. Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0196-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Espen R Nakstad
- Department of Acute Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway. .,Department of Pulmonary Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway.
| | - Helge Opdahl
- Department of Acute Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Fridtjof Heyerdahl
- Department of Acute Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Fredrik Borchsenius
- Department of Pulmonary Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Ole H Skjønsberg
- Department of Pulmonary Medicine, Oslo University Hospital, Ullevaal, Oslo, Norway.,University of Oslo, Oslo, Norway
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Vargas M, Sutherasan Y, Antonelli M, Brunetti I, Corcione A, Laffey JG, Putensen C, Servillo G, Pelosi P. Tracheostomy procedures in the intensive care unit: an international survey. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:291. [PMID: 26271742 PMCID: PMC4536803 DOI: 10.1186/s13054-015-1013-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 07/24/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Percutaneous dilatational tracheostomy (PDT) is one of the most frequent procedures performed in the intensive care unit (ICU). PDT may add potential benefit to clinical management of critically ill patients. Despite this, no clinical guidelines are available. We sought to characterize current practice in this international survey. METHODS An international survey, endorsed and peer reviewed by European Society of Intensive Care Medicine (ESICM), was carried out from May to October 2013. The questionnaire was accessible from the ESICM website in the 'survey of the month' section. RESULTS 429 physicians from 59 countries responded to this survey. Single step dilatational tracheostomy was the most used PDT in ICU. Almost 75% of PDT's were performed by intensive care physicians. The main indication for PDT was prolonged mechanical ventilation. Tracheostomies were most frequently performed between 7-15 days after ICU admission. Volume control mechanical ventilation, and a combination of sedation, analgesia, neuromuscular blocking agents and fiberoptic bronchoscopy were used. Surgical tracheostomy was mainly performed in ICU by ENT specialists, and was generally chosen when for patients at increased risk for difficult PDT insertion. Bleeding controlled by compression and stoma infection/inflammation were the most common intra-procedural and late complications, respectively. Informed consent for PDT was obtained in only 60% of cases. CONCLUSIONS This first international picture of current practices in regard to tracheostomy insertion demonstrates considerable geographic variation in practice, suggesting a need for greater standardization of approaches to tracheostomy insertion.
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Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Odonthostomatological and Reproductive Sciences, University of Naples, "Federico II", Naples, Italy.
| | - Yuda Sutherasan
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 RAMA VI road, Bangkok, 10400, Thailand.
| | - Massimo Antonelli
- Department of Intensive Care and Anaesthesiology, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Iole Brunetti
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Largo Rosanna Benzi 8, Genoa, 16131, Italy.
| | | | - John G Laffey
- Department of Anesthesia, Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, Canada.
| | | | - Giuseppe Servillo
- Department of Neurosciences, Odonthostomatological and Reproductive Sciences, University of Naples, "Federico II", Naples, Italy.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Largo Rosanna Benzi 8, Genoa, 16131, Italy.
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Vargas M, Pelosi P, Tessitore G, Aloj F, Brunetti I, Arditi E, Salami D, Kacmarek RM, Servillo G. Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube: a comparison of feasibility, gas exchange, and airway pressures. Chest 2015; 147:1267-1274. [PMID: 25375865 DOI: 10.1378/chest.14-1465] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Gas exchange and airway pressures are markedly altered during percutaneous dilatational tracheostomy (PDT). A double-lumen endotracheal tube (DLET) has been developed for better airway management during PDT. The current study prospectively evaluated the in vivo feasibility, gas exchange, and airway pressures during PDT with DLET compared with a conventional endotracheal tube (ETT). METHODS According to eligibility criteria, patients were divided into a case group (those receiving PDT with DLET) and a control group (those receiving PDT with a conventional ETT). The Ciaglia single-dilator technique was used for PDT in both groups. The primary end point of this study was the feasibility of tracheostomy with DLET. The secondary end points were a comparison of gas exchange, airway pressures, minute volume, and tidal volume before, during, and after PDT performed with DLET and conventional ETT. RESULTS Ten patients meeting the inclusion criteria were assigned to each group. PDTs were performed without difficulties in nine patients in the DLET group and 10 patients in the conventional ETT group. During PDT, gas exchange, airway pressures, and minute ventilation remained more stable in the DLET group and were significantly different from those in the conventional ETT group. CONCLUSIONS PDT with DLET can be performed safely without difficulties limiting the technique. Furthermore, during PDT, the use of the DLET resulted in more stable gas exchange, airway pressures, and ventilation than PDT with a conventional ETT. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01691222; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Maria Vargas
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples "Federico II," Naples, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Gaetano Tessitore
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples "Federico II," Naples, Italy
| | - Fulvio Aloj
- Anesthesia and Intensive Care Unit, IRCCS Neuromed, Pozzilli (IS), Italy
| | - Iole Brunetti
- Intensive Care Unit, IRCCS AOC San Martino IST, Genoa, Italy
| | - Enrico Arditi
- Intensive Care Unit, IRCCS AOC San Martino IST, Genoa, Italy
| | - Dorino Salami
- Intensive Care Unit, IRCCS AOC San Martino IST, Genoa, Italy
| | - Robert M Kacmarek
- Department of Anesthesiology and Critical Care and Department of Respiratory Care, Massachusetts General Hospital, Boston, MA
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples "Federico II," Naples, Anesthesia and Intensive Care Unit, IRCCS Neuromed, Pozzilli (IS), Italy.
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Kuo AS, Philip JH, Edrich T. Airway Ventilation Pressures During Bronchoscopy, Bronchial Blocker, and Double-Lumen Endotracheal Tube Use: An In Vitro Study. J Cardiothorac Vasc Anesth 2014; 28:873-9. [DOI: 10.1053/j.jvca.2013.03.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Indexed: 11/11/2022]
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