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Luecke E, Brunner J, Stegemann-Koniszewski S, Kaasch A, Bauer K, Geginat G, Hachenberg T, Schilling T, Schwarze LL, Schreiber J. [Bacterial load of the surroundings during rigid diagnostic bronchoscopy under high frequency jet-ventilation]. Pneumologie 2024; 78:620-625. [PMID: 38198806 DOI: 10.1055/a-2229-4002] [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: 01/12/2024]
Abstract
BACKGROUND High-frequency jet ventilation (HFJV) is used in pneumological endoscopy for rigid, diagnostic, and therapeutic bronchoscopies. It is unclear to what extent the unobstructed flow of respiratory gas from the patient's lungs causes microbial contamination of the surrounding air. MATERIAL AND METHODS After the start of the HFJV (15 min) in 16 rigid bronchoscopies, airborne pathogen measurements were taken directly at the distal endoscope outlet, at examiner height (40 cm above the endoscope outlet), at a 2 m distance from the endoscope in the room and at the supply air outlet of the examination room using an RCS air sampler. The number and type of pathogens isolated in the air samples were then determined, as well as germs in the bronchoalveolar lavage fluid (BALF) from the patient's lungs. RESULTS An increased bacterial density (136 and 114 CFU/m3) was detected directly at the distal end of the endoscope and at examiner height at a distance of 40 cm, which decreased significantly with increasing distance from the bronchoscope (98 CFU/m3 at a distance of 2 m and 82 CFU/m3 at the supply air outlet). The most frequently detected bacteria were Staphylococcus spp., Micrococcus spp. and Bacillus spp. In the BALF, pathogens could only be cultivated in four of 16 samples, but the same pathogens were detected in the BALF and the ambient air. CONCLUSION When performing a rigid bronchoscopy, in which patients are mechanically ventilated in a controlled manner using an open HFJV system, there is an increased pathogen load in the ambient air and therefore a potential risk for the examiner.
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Affiliation(s)
- Eva Luecke
- Klinik für Pneumologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Juliane Brunner
- Klinik für Pneumologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | | | - Achim Kaasch
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Katja Bauer
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Gernot Geginat
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Thomas Hachenberg
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Thomas Schilling
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Lisa-Lisett Schwarze
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Jens Schreiber
- Klinik für Pneumologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
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2
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Tollman J, Ahmed Z. Ventilating the blast lung: Exploring ventilation strategies in primary blast lung injury. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086221080020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Primary blast lung injury (PBLI) is the most common and fatal of all primary blast injuries. The majority of those with PBLI will require early intubation and mechanical ventilation, and thus, ventilation strategy forms a crucial part of any management plan. Methods: A comprehensive, but not systematic, PubMed and Google Scholar database search identified articles that contribute to our current understanding of ventilation strategies in PBLI for a narrative educational review. Results A PBLI ventilation strategy must strive to minimise all four of ventilator-associated lung injury (VALI), volutrauma, barotrauma and biotrauma. The three main ventilation strategies available are conventional low tidal volume (LTV) ventilation, airway pressure release ventilation (APRV) and high frequency oscillatory ventilation (HFOV). Conventional LTV ventilation together with a variable positive end-expiratory pressure (PEEP) and permissive hypercapnia has demonstrated reduced inflammation and mortality with a greater number of ventilator-free days. APRV has the potential to reduce dynamic strain, PaO2/FiO2 ratios, levels of applied mechanical power and extravascular lung water while encouraging spontaneous breathing. HFOV is able to effectively avoid VALI while curbing inflammation and histological lung injury, though not necessarily mortality. Conclusions: Presently, PBLI should largely be managed with conventional LTV ventilation alongside a variable PEEP and permissive hypercapnia with APRV and HFOV reserved as rescue strategies for where conventional LTV ventilation fails. Clinicians should additionally consider supplementing their strategy with adjunctive therapies such as prone positioning, inhaled nitric oxide and extracorporeal membrane oxygenation that may further reduce mortality and combat severe respiratory and/or cardiac failure.
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Affiliation(s)
- Jaden Tollman
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
- Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham, UK
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3
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Wallace DJ, Sappington P, Tisherman S, Stone M. Republication of “Ultrasonographic Appearance of Lung Sliding in a Patient With a Bronchopleural Fistula on a High-Frequency Oscillator Ventilator”. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2020. [DOI: 10.1177/8756479320924842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The patient with a bronchopleural fistula and acute respiratory distress syndrome can present a therapeutic challenge for the treating clinician. In this case, the authors describe the use of bedside thoracic sonography to show real-time improvement in a pneumothorax after initiation of high-frequency oscillatory ventilation. Sonography may have a role in the evaluation of ventilator strategies in the future, although validation of this application is still needed.
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4
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Sklar MC, Patel BK, Beitler JR, Piraino T, Goligher EC. Optimal Ventilator Strategies in Acute Respiratory Distress Syndrome. Semin Respir Crit Care Med 2019; 40:81-93. [PMID: 31060090 PMCID: PMC7117088 DOI: 10.1055/s-0039-1683896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mechanical ventilation practices in patients with acute respiratory distress syndrome (ARDS) have progressed with a growing understanding of the disease pathophysiology. Paramount to the care of affected patients is the delivery of lung-protective mechanical ventilation which prioritizes tidal volume and plateau pressure limitation. Lung protection can probably be further enhanced by scaling target tidal volumes to the specific respiratory mechanics of individual patients. The best procedure for selecting optimal positive end-expiratory pressure (PEEP) in ARDS remains uncertain; several relevant issues must be considered when selecting PEEP, particularly lung recruitability. Noninvasive ventilation must be used with caution in ARDS as excessively high respiratory drive can further exacerbate lung injury; newer modes of delivery offer promising approaches in hypoxemic respiratory failure. Airway pressure release ventilation offers an alternative approach to maximize lung recruitment and oxygenation, but clinical trials have not demonstrated a survival benefit of this mode over conventional ventilation strategies. Rescue therapy with high-frequency oscillatory ventilation is an important option in refractory hypoxemia. Despite a disappointing lack of benefit (and possible harm) in patients with moderate or severe ARDS, possibly due to lung hyperdistention and right ventricular dysfunction, high-frequency oscillation may improve outcome in patients with very severe hypoxemia.
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Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, New York
| | - Thomas Piraino
- Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Critical Care, Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.,Department of Respiratory Therapy, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Ontario, Canada
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5
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Meyers M, Rodrigues N, Ari A. High-frequency oscillatory ventilation: A narrative review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2019; 55:40-46. [PMID: 31297448 PMCID: PMC6591785 DOI: 10.29390/cjrt-2019-004] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
High-frequency oscillatory ventilation (HFOV) is a lung-protective strategy that can be utilized in the full spectrum of patient populations ranging from neonatal to adults with acute lung injury. HFOV is often utilized as a rescue strategy when conventional mechanical ventilation (CV) has failed. HFOV uses low tidal volumes and constant mean airway pressures in conjunction with high respiratory rates to provide beneficial effects on oxygenation and ventilation, while eliminating the traumatic “inflate–deflate” cycle imposed by CV. Although statistical evidence supporting HFOV is particularly low, potential benefits for its application in many clinical manifestations still remain. High-frequency oscillation is a safe and effective rescue mode of ventilation for the treatment of acute respiratory distress syndrome (ARDS). All patients who have ventilator-induced lung injury (VILI) or are at risk of developing VILI or ARDS would be suitable candidates for HFOV, especially those who have failed conventional mechanical ventilation. This narrative aims to provide a review of HFOV vis-à-vis its indications, contraindications, hazards, parameters to monitoring, patient selection, clinical goals, mechanisms of action, controls for optimizing ventilation and oxygenation, clinical application in ARDS, and a comparison with other modes of mechanical ventilation.
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Affiliation(s)
| | - Nathan Rodrigues
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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6
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Salvage therapies for refractory hypoxemia in ARDS. Respir Med 2018; 141:150-158. [PMID: 30053961 DOI: 10.1016/j.rmed.2018.06.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/15/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
Acute Respiratory Distress Syndrome (ARDS) is a condition of varied etiology characterized by the acute onset (within 1 week of the inciting event) of hypoxemia, reduced lung compliance, diffuse lung inflammation and bilateral opacities on chest imaging attributable to noncardiogenic (increased permeability) pulmonary edema. Although multi-organ failure is the most common cause of death in ARDS, an estimated 10-15% of the deaths in ARDS are caused due to refractory hypoxemia, i.e.- hypoxemia despite lung protective conventional ventilator modes. In these cases, clinicians may resort to other measures with less robust evidence -referred to as "salvage therapies". These include proning, 48 h of paralysis early in the course of ARDS, various recruitment maneuvers, unconventional ventilator modes, inhaled pulmonary vasodilators, and Extracorporeal membrane oxygenation (ECMO). All the salvage therapies described have been associated with improved oxygenation, but with the exception of proning and 48 h of paralysis early in the course of ARDS, none of them have a proven mortality benefit. Based on the current evidence, no salvage therapy has been shown to be superior to the others and each of them is associated with its own risks and benefits. Hence, the order of application of these therapies varies in different institutions and should be applied following a risk-benefit analysis specific to the patient and local experience. This review explores the rationale, evidence, advantages and risks behind each of these strategies.
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Alzahrany M, Banerjee A. Effect of inhaled gas density on the pendelluft-induced lung injury. J Biomech 2016; 49:4039-4047. [PMID: 27839697 DOI: 10.1016/j.jbiomech.2016.10.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/14/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
Helium, sulfur hexafluoride-oxygen, and air were modeled to examine the role of the gas density on the pendelluft-induced lung injury (PILI) under high frequency oscillatory ventilation (HFOV). Large eddy simulation coupled with physiological resistance-compliance boundary conditions was applied to capture pendelluft-induced gas entrapment and mechanical stresses in an image-based human lung model. The flow characteristics were strongly dependent on the inspired gas density. The flow partitioning, globally between the left and right lung and locally between adjacent units branches, was significantly affected by the density of inhaled gas and was more balanced when inspiring lighter gas. The incomplete loops of flow-volume and volume-pressure curves were significantly influenced by the variations of the flow redistribution, resistance, and turbulence associated with the pendelluft mechanism. Inhaling light gas reduced the entrapped gas volume and mechanical stress surrounding carina ridges signifying the important role of inhaled gas properties on PILI. In general, lung ventilation by HFOV with a gas mixture of large amounts of Helium is thought to mitigate ventilator complications.
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Affiliation(s)
- Mohammed Alzahrany
- Department of Mechanical Engineering & Mechanics, Lehigh University, Bethlehem, PA 18015, USA
| | - Arindam Banerjee
- Department of Mechanical Engineering & Mechanics, Lehigh University, Bethlehem, PA 18015, USA.
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8
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High-frequency oscillation ventilation for hypercapnic failure of conventional ventilation in pulmonary acute respiratory distress syndrome. Crit Care 2015; 19:201. [PMID: 25929255 PMCID: PMC4438528 DOI: 10.1186/s13054-015-0935-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/20/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction High-frequency oscillation ventilation (HFOV) is regarded as particularly lung protective. Recently, HFOV has been shown to be not beneficial for acute respiratory distress syndrome (ARDS) patients in general. Due to its special physical effects, it could be beneficial, however, in inhomogeneous ARDS. This study evaluates the effect of HFOV on PaCO2 removal in hypercapnic patients with ARDS of pulmonary origin. Methods Between October 2010 and June 2014 patients with ARDS of pulmonary origin with PaO2/FiO2 ratio >60 mmHg, but respiratory acidosis (pH <7.26) under optimized protective ventilation were switched to HFOV, using moderate airway pressure (adopting the mean airway pressure of the prior ventilation). Data from these patients were analyzed retrospectively; PaCO2 and pH before, 1 h and 24 h after the start of HFOV were compared. Results Twenty-six patients with PaO2/FiO2 ratio 139 ± 49 and respiratory acidosis (PaCO2 68 ± 12 mmHg) were put on HFOV after 17 ± 22 h of conventional ventilation. Mean airway pressure was 19 cm H2O (15 to 28). PaCO2 decreased significantly: after 1 hour the mean difference was −14 ± 10 mmHg; P <0.01 and after 24 hours −17 ± 12 mmHg; P <0.01; n = 24. CO2 clearance improved in all but two patients; in those, extracorporeal lung support was initiated. Oxygenation remained unchanged after 1 h and slightly increased after 24 h. No complications related to HFOV were observed. Twenty-two patients improved and could be weaned from HFOV. Twenty patients (77%) were alive on day 30. Conclusions HFOV could be a useful alternative in patients with ARDS of pulmonary origin with hypercapnic failure of lung-protective conventional ventilation. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0935-4) contains supplementary material, which is available to authorized users.
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9
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Tulman DB, Stawicki SPA, Whitson BA, Gupta SC, Tripathi RS, Firstenberg MS, Hayes D, Xu X, Papadimos TJ. Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies. BMC Anesthesiol 2014; 14:65. [PMID: 25110462 PMCID: PMC4126084 DOI: 10.1186/1471-2253-14-65] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
Background Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently “rescue” a significant proportion of those affected. Discussion Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices. Summary Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.
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Affiliation(s)
- David B Tulman
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA
| | - Stanislaw P A Stawicki
- Department of Surgery, Division of Critical Care, Trauma, and Burn, Wexner Medical Center at The Ohio State University, 410 W 10th Ave, Columbus 43210, OH, USA
| | - Bryan A Whitson
- Department of Surgery, Division of Cardiac Surgery, Wexner Medical Center at The Ohio State University, 410 W 10th Ave, Columbus 43210, OH, USA
| | - Saarik C Gupta
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA ; Northeast Ohio Medical University, 4209 SR 44, PO Box 95, Rootstown 44272, OH, USA
| | - Ravi S Tripathi
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA
| | | | - Don Hayes
- Pulmonary Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus 43205, OH, USA
| | - Xuzhong Xu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical College, 2 Fuxue Road, 32500 Zhejiang, China
| | - Thomas J Papadimos
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA
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Stawicki SP, Swaroop M, Galwankar SC, Papadimos TJ. What's new in critical illness and injury science? State of the art in management of ARDS. Int J Crit Illn Inj Sci 2014; 4:95-7. [PMID: 25024935 PMCID: PMC4093974 DOI: 10.4103/2229-5151.134140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Philadelphia, USA
| | - Mamta Swaroop
- Department of Surgery, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Sagar C Galwankar
- Department of Emergency Medicine, Winter Haven Hospital, University of Florida, Florida, USA
| | - Thomas J Papadimos
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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11
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Arora S, Singh PM, Trikha A. Ventilatory strategies in trauma patients. J Emerg Trauma Shock 2014; 7:25-31. [PMID: 24550626 PMCID: PMC3912646 DOI: 10.4103/0974-2700.125635] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 09/02/2013] [Indexed: 01/21/2023] Open
Abstract
Lung injury in trauma patients can occur because of direct injury to lung or due to secondary effects of injury elsewhere for example fat embolism from a long bone fracture, or due to response to a systemic insult such as; acute respiratory distress syndrome (ARDS) secondary to sepsis or transfusion related lung injury. There are certain special situations like head injury where the primary culprit is not the lung, but the brain and the ventilator strategy is aimed at preserving the brain tissue and the respiratory system takes a second place. The present article aims to delineate the strategies addressing practical problems and challenges faced by intensivists dealing with trauma patients with or without healthy lungs. The lung protective strategies along with newer trends in ventilation are discussed. Ventilatory management for specific organ system trauma are highlighted and their physiological base is presented.
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Affiliation(s)
- Shubhangi Arora
- Department of Anaesthesia, All India Institute of Medical Sciences, Delhi, India
| | - Preet Mohinder Singh
- Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anjan Trikha
- Department of Anaesthesia, All India Institute of Medical Sciences, Delhi, India
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Abstract
Acute respiratory distress syndrome (ARDS) is commonly associated with severe sepsis. While the criteria for diagnosis have evolved since the first description in 1967, the characteristics of hypoxemia, tachypnea, rapidly progressing acute respiratory failure, and poor lung compliance continue. Scoring systems have been developed in an effort to quantify the severity of lung injury, with the most recent being the Berlin Definition. This system attempts to define acute lung injury (ALI) and ARDS with more precision in terms of timing of disease onset, severity of disease, and chest radiograph findings. The number of reported cases of ALI/ARDS per year is lower in pediatric patients vs. adults; however, mortality rates continue to be high. Sepsis-related ARDS has a generally higher disease severity and poorer recovery period from lung injury with an increased mortality rate. ARDS results from an initial insult (direct and/or indirect) which triggers a series of cell-mediated responses leading to damage to the capillary endothelium, alveolar epithelium, and impaired fluid removal from the alveolar space. There is, however, gradual resolution of hypoxemia, lung function, and radiographic abnormalities in survivors of ARDS. Management of ARDS is mainly supportive with specific mechanical ventilation strategies and goal-directed therapies. Prevention of ventilator-induced lung injury (VILI) has been demonstrated to have a positive impact on outcomes in patients with ARDS.
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14
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Turner DA, Rehder KJ, Cheifetz IM. Nontraditional modes of mechanical ventilation: progress or distraction? Expert Rev Respir Med 2012; 6:277-84. [PMID: 22788942 DOI: 10.1586/ers.12.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
As technology continues to develop, a wide range of novel and nontraditional modes of mechanical ventilation have become available for the management of critically ill patients. Proportional assist ventilation, neurally adjusted ventilatory assist and adaptive support ventilation are three novel modes of ventilation, which attempt to optimize patient-ventilator synchrony. Improved interactions between patient and ventilator may be important in improving clinical outcomes. Another important priority for mechanically ventilated patients is lung protection, and nontraditional modes of ventilation that may be implemented to minimize ventilator-associated lung injury include airway pressure release ventilation and high-frequency ventilation. Novel and nontraditional modes of ventilation may represent important tools in the critical care environment; however, continued investigation is needed to determine the overall impact of these various approaches on outcomes for mechanically ventilated patients.
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Affiliation(s)
- David A Turner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Duke University Medical Center, DUMC BOX 3046, Durham, NC 27710, USA.
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15
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Biener I, Czaplik M, Bickenbach J, Rossaint R. [Lung protective ventilation in ARDS]. Med Klin Intensivmed Notfmed 2012; 108:578-83. [PMID: 22907521 DOI: 10.1007/s00063-012-0145-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 06/20/2012] [Accepted: 07/03/2012] [Indexed: 01/08/2023]
Abstract
Mechanical ventilation (MV) is one of the most essential cornerstones of intensive care therapy. Although of pivotal importance for many patients suffering from respiratory insufficiency MV itself may further induce pathophysiological processes due to the mechanical stress exerted on the lungs. Particularly during one of the most distinctive forms of acute respiratory failure, acute respiratory distress syndrome (ARDS), a tremendous impairment of the lungs occurs characterized by heterogeneous damage where normally aerated areas coexist with consolidated and collapsed areas. Although MV is necessary for the treatment of severe hypoxemia it causes damage not only in the lungs but also in other organs due to a secondary inflammatory process in the lungs. To reduce these reactions an evidence-based concept of lung protective ventilation is essential.
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Affiliation(s)
- I Biener
- Klinik für Anästhesiologie, Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland,
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Walkey AJ, Summer R, Ho V, Alkana P. Acute respiratory distress syndrome: epidemiology and management approaches. Clin Epidemiol 2012; 4:159-69. [PMID: 22866017 PMCID: PMC3410685 DOI: 10.2147/clep.s28800] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Acute lung injury and the more severe acute respiratory distress syndrome represent a spectrum of lung disease characterized by the sudden onset of inflammatory pulmonary edema secondary to myriad local or systemic insults. The present article provides a review of current evidence in the epidemiology and treatment of acute lung injury and acute respiratory distress syndrome, with a focus on significant knowledge gaps that may be addressed through epidemiologic methods.
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Affiliation(s)
- Allan J Walkey
- The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
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17
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Sadahiro T, Oda S, Nakamura M, Hirayama Y, Watanabe E, Tateishi Y, Shinozaki K. Trends in and perspectives on extracorporeal membrane oxygenation for severe adult respiratory failure. Gen Thorac Cardiovasc Surg 2012; 60:192-201. [PMID: 22451141 DOI: 10.1007/s11748-011-0868-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Indexed: 10/28/2022]
Abstract
Various approaches such as ventilator management involving lung-protective ventilation, corticosteroids, prone positioning, and nitric oxide have failed to maintain sufficient lung oxygenation or appropriate ventilation competence in very severe acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) has been aggressively introduced for such patients, although in only a few institutions. The clinical usefulness of ECMO in a large-scale multicenter study (CESAR trial, 2009) and continued development/improvement of ECMO devices have facilitated performance of ECMO, with further increase in the number of institutions adopting ECMO therapy. Clinical usefulness of ECMO was documented in many cases of severe ARDS secondary to influenza A (H1N1) 2009 infection. ECMO requires establishment of an appropriate management system to minimize fatal complications (e.g., hemorrhage), which requires a multidisciplinary team. This, in combination with a new technique, interventional lung assist, will further extend the indications for ECMO. ECMO can be expected to gain importance as a respiratory support technique.
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Affiliation(s)
- Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuoku, Chiba, 260-8677, Japan.
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Tripathi RS, Stein EJ, Crestanello JA, Papadimos TJ. High-frequency oscillatory ventilation after cardiac surgery: a treatment for all ages. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:405. [PMID: 22277730 PMCID: PMC3396232 DOI: 10.1186/cc10605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Physiologically relevant application of airway pressure release ventilation. ACTA ACUST UNITED AC 2011; 71:262-3: author reply 263-4. [PMID: 21818036 DOI: 10.1097/ta.0b013e31821b3c72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Gaüzère BA, Bussienne F, Bouchet B, Jabot J, Roussiaux A, Drouet D, Djourhi S, Leauté B, Belcour D, Bossard G, Champion S, Jaffar-Bandjee MC, Belmonte O, Vilain P, Brottet E, Hoang L, Vandroux D. [Severe cases of A(H1N1)v2009 infection in Réunion Island in 2009 and 2010]. ACTA ACUST UNITED AC 2011; 104:97-104. [PMID: 21509522 PMCID: PMC7097782 DOI: 10.1007/s13149-011-0147-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 02/21/2011] [Indexed: 11/21/2022]
Abstract
Dans l’hémisphère sud, La Réunion est la sentinelle des infections survenant préférentiellement au cours de l’hiver austral, susceptibles de gagner quelques mois plus tard l’hémisphère nord, telle l’infection à A(H1N1)v2009. Nous rapportons les caractéristiques des patients admis en 2009 et 2010 dans notre service de réanimation principalement pour détresse respiratoire aiguë, à la suite d’une infection à A(H1N1)v2009. Les données démographiques, cliniques, biologiques, ainsi que les traitements et le devenir des patients admis pour infection virale à A(H1N1)v2009 exclusivement confirmée par RT-PCR ont été recueillis de façon prospective. Au cours des années 2009 et 2010, 25 patients ont répondu aux critères définis d’infection à A(H1N1)v2009. L’âge médian était de 40,4 (±17,4) ans. La plupart d’entre eux (22/25) présentaient des facteurs de comorbidité: pathologies chroniques, surpoids ou obésité, grossesse, trisomie. Les principaux motifs d’admission en réanimation ont été les pneumonies virales avec tableau de syndrome de détresse respiratoire aiguë. Le recours à la ventilation artificielle a été nécessaire chez 22 des 25 patients, avec recours à des méthodes sophistiquées et réservées à quelques centres au niveau national, telles que les techniques d’oxygénation extracorporelle (ECMO) ou ventilation à haute fréquence (HFO). Au cours des deux années, 12 décès (48 %) sont survenus essentiellement dans des tableaux de défaillance multiviscérale. Au cours des hivers et automnes australs 2009 et 2010 et pendant une période de plusieurs semaines, l’infection à A(H1N1) v2009 a entraîné une surcharge d’activité notable dans les services de réanimation de La Réunion. L’échec de la campagne de vaccination, notamment des personnes à risques, a eu pour conséquence la survenue de nouveaux cas graves en 2010, notamment parmi les personnes à risques. Le recueil de ces données peut aider à la planification et à l’anticipation de la prise en charge d’autres épidémies grippales.
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Affiliation(s)
- B-A Gaüzère
- Service De Réanimation Polyvalente, Centre Hospitalier Félix-guyon, Chr Réunion, F-97405, Saint-Denis, France.
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[One case of nosocomial A(H1N1)v2009 influenza in Réunion Island]. BULLETIN DE LA SOCIETE DE PATHOLOGIE EXOTIQUE (1990) 2011; 104:105-7. [PMID: 21451955 DOI: 10.1007/s13149-011-0143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 11/23/2010] [Indexed: 10/18/2022]
Abstract
A 19-year-old patient admitted in an oncology unit for an autograft (Hodgkin disease), developed on day 20 a fatal acute respiratory failure and multiple organ failure due to an infection of the A(H1N1)v2009 virus, which was acquired in the hospital, despite partial preventive measures. At that time, the specific vaccine was not available in Réunion. We discuss the nosocomial origin of the infection. Following the epidemic wave, the vaccination rate of the general population and the hospital employees remains very low.
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Wallace DJ, Sappington P, Tisherman S, Stone M. Ultrasonographic Appearance of Lung Sliding in a Patient With a Bronchopleural Fistula on a High-Frequency Oscillator Ventilator. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2011. [DOI: 10.1177/8756479311400221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The patient with a bronchopleural fistula and acute respiratory distress syndrome can present a therapeutic challenge for the treating clinician. In this case, the authors describe the use of bedside thoracic sonography to show real-time improvement in a pneumothorax after initiation of high-frequency oscillatory ventilation. Sonography may have a role in the evaluation of ventilator strategies in the future, although validation of this application is still needed.
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Scarborough JE, Vaslef SN. Utilisation of high-frequency oscillatory ventilation in blunt thoracic trauma. TRAUMA-ENGLAND 2010. [DOI: 10.1177/1460408610382494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blunt thoracic trauma patients are at high risk of mortality when conventional mechanical ventilation fails to sustain respiratory function.We provide an overview of high-frequency oscillatory ventilation (HFOV) as a potential rescue therapy for such patients.Although few studies have examined the utilisation of HFOV specifically for blunt thoracic trauma, available evidence indicates that this ventilatory strategy may be beneficial when instituted relative early in the management of patients with severe pulmonary contusion or blunt thoracic trauma with superimposed acute respiratory distress syndrome.
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Affiliation(s)
- John E Scarborough
- Section of Trauma and Critical Care, Duke University Medical Center, Durham, North Carolina, USA
| | - Steven N Vaslef
- Section of Trauma and Critical Care, Duke University Medical Center, Durham, North Carolina, USA,
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