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Naendrup JH, Steinke J, Garcia Borrega J, Stoll SE, Michelsen PO, Assion Y, Shimabukuro-Vornhagen A, Eichenauer DA, Kochanek M, Böll B. Airway Pressure Release Ventilation in COVID-19-Associated Acute Respiratory Distress Syndrome-A Multicenter Propensity Score-Matched Analysis. J Intensive Care Med 2024; 39:84-93. [PMID: 37861125 DOI: 10.1177/08850666231207303] [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: 10/21/2023]
Abstract
Background: There are limited and partially contradictory data on the effects of airway pressure release ventilation (APRV) in COVID-19-associated acute respiratory distress syndrome (CARDS). Therefore, we analyzed the clinical outcome, complications, and longitudinal course of ventilation parameters and laboratory values in patients with CARDS, who were mechanically ventilated using APRV. Methods: Respective data from 4 intensive care units (ICUs) were collected and compared to a matched cohort of patients receiving conventional low tidal volume ventilation (LTV). Propensity score matching was performed based on age, sex, blood gas analysis, and APACHE II score at admission, as well as the implementation of prone positioning. Findings: Forty patients with CARDS, who were mechanically ventilated using APRV, and 40 patients receiving LTV were matched. No significant differences were detected for tidal volumes per predicted body weight, peak pressure values, and blood gas analyses on admission, 6 h post admission as well as on day 3 and day 7. Regarding ICU survival, no significant difference was identified between APRV patients (40%) and LTV patients (42%). Median duration of mechanical ventilation and duration of ICU treatment were comparable in both groups. Similar complication rates with respect to ventilator-associated pneumonia, septic shock, thromboembolic events, barotrauma, as well as the necessity for hemodialysis were detected for both groups. Clinical characteristics that were associated with increased mortality in a Cox proportional hazards regression analysis included age (hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.04-1.1; P < .001), severe acute respiratory distress syndrome (HR 2.62, 95% CI 1.02-6.7; P = .046) and the occurrence of septic shock (HR 17.18, 95% CI 2.06-143.2; P = .009), but not the ventilation mode. Interpretation: Intensive care unit survival, duration of mechanical ventilation, and ICU treatment as well as ventilation-associated complication rates were equivalent using APRV compared to conventional LTV in patients with CARDS.
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Affiliation(s)
- Jan-Hendrik Naendrup
- Faculty of Medicine and University Hospital Cologne, First Department of Internal Medicine, University of Cologne, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Jonathan Steinke
- Faculty of Medicine and University Hospital Cologne, First Department of Internal Medicine, University of Cologne, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Jorge Garcia Borrega
- Faculty of Medicine and University Hospital Cologne, First Department of Internal Medicine, University of Cologne, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Sandra Emily Stoll
- Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, University of Cologne, Cologne, Germany
| | - Per Ole Michelsen
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, St. Vinzenz Hospital Cologne, Cologne, Germany
| | - Yannick Assion
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Porz am Rhein Hospital Cologne, Cologne, Germany
| | - Alexander Shimabukuro-Vornhagen
- Faculty of Medicine and University Hospital Cologne, First Department of Internal Medicine, University of Cologne, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Dennis Alexander Eichenauer
- Faculty of Medicine and University Hospital Cologne, First Department of Internal Medicine, University of Cologne, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Matthias Kochanek
- Faculty of Medicine and University Hospital Cologne, First Department of Internal Medicine, University of Cologne, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
| | - Boris Böll
- Faculty of Medicine and University Hospital Cologne, First Department of Internal Medicine, University of Cologne, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO), Cologne, Germany
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2
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Liu PH, Casillas P, Alismail A. Evaluation of ventilatory ratio in airway pressure release ventilation (APRV) in patients with acute respiratory failure: Brief communication. Respir Med 2023; 219:107423. [PMID: 37827292 DOI: 10.1016/j.rmed.2023.107423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Ping-Hui Liu
- Department of Cardiopulmonary Science, Loma Linda University, USA; Division of Respiratory Care, Cincinnati Children's Hospital, USA.
| | - Paul Casillas
- Department of Cardiopulmonary Science, Loma Linda University, USA
| | - Abdullah Alismail
- Department of Cardiopulmonary Science, Loma Linda University, USA; Department of Medicine, Loma Linda University, USA
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3
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Nieman GF, Kaczka DW, Andrews PL, Ghosh A, Al-Khalisy H, Camporota L, Satalin J, Herrmann J, Habashi NM. First Stabilize and then Gradually Recruit: A Paradigm Shift in Protective Mechanical Ventilation for Acute Lung Injury. J Clin Med 2023; 12:4633. [PMID: 37510748 PMCID: PMC10380509 DOI: 10.3390/jcm12144633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is associated with a heterogeneous pattern of injury throughout the lung parenchyma that alters regional alveolar opening and collapse time constants. Such heterogeneity leads to atelectasis and repetitive alveolar collapse and expansion (RACE). The net effect is a progressive loss of lung volume with secondary ventilator-induced lung injury (VILI). Previous concepts of ARDS pathophysiology envisioned a two-compartment system: a small amount of normally aerated lung tissue in the non-dependent regions (termed "baby lung"); and a collapsed and edematous tissue in dependent regions. Based on such compartmentalization, two protective ventilation strategies have been developed: (1) a "protective lung approach" (PLA), designed to reduce overdistension in the remaining aerated compartment using a low tidal volume; and (2) an "open lung approach" (OLA), which first attempts to open the collapsed lung tissue over a short time frame (seconds or minutes) with an initial recruitment maneuver, and then stabilize newly recruited tissue using titrated positive end-expiratory pressure (PEEP). A more recent understanding of ARDS pathophysiology identifies regional alveolar instability and collapse (i.e., hidden micro-atelectasis) in both lung compartments as a primary VILI mechanism. Based on this understanding, we propose an alternative strategy to ventilating the injured lung, which we term a "stabilize lung approach" (SLA). The SLA is designed to immediately stabilize the lung and reduce RACE while gradually reopening collapsed tissue over hours or days. At the core of SLA is time-controlled adaptive ventilation (TCAV), a method to adjust the parameters of the airway pressure release ventilation (APRV) modality. Since the acutely injured lung at any given airway pressure requires more time for alveolar recruitment and less time for alveolar collapse, SLA adjusts inspiratory and expiratory durations and inflation pressure levels. The TCAV method SLA reverses the open first and stabilize second OLA method by: (i) immediately stabilizing lung tissue using a very brief exhalation time (≤0.5 s), so that alveoli simply do not have sufficient time to collapse. The exhalation duration is personalized and adaptive to individual respiratory mechanical properties (i.e., elastic recoil); and (ii) gradually recruiting collapsed lung tissue using an inflate and brake ratchet combined with an extended inspiratory duration (4-6 s) method. Translational animal studies, clinical statistical analysis, and case reports support the use of TCAV as an efficacious lung protective strategy.
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Affiliation(s)
- Gary F. Nieman
- Department of Surgery, Upstate Medical University, Syracuse, NY 13210, USA;
| | - David W. Kaczka
- Departments of Anesthesia, Radiology and Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Penny L. Andrews
- Department of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Auyon Ghosh
- Department of Medicine, Upstate Medical University, Syracuse, NY 13210, USA
| | - Hassan Al-Khalisy
- Brody School of Medicine, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, King’s Partners, St Thomas’ Hospital, London SE1 7EH, UK
| | - Joshua Satalin
- Department of Surgery, Upstate Medical University, Syracuse, NY 13210, USA;
| | - Jacob Herrmann
- Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Nader M. Habashi
- Department of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201, USA
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4
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Cheng J, Wang P, Li L, Kang Y, Zhou Y. Airway Pressure Release Ventilation in Acute Respiratory Failure Due to COVID-19: No Role, We Still Need More Data. Crit Care Med 2022; 50:e813-e814. [PMID: 36394410 PMCID: PMC9668356 DOI: 10.1097/ccm.0000000000005670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jiangli Cheng
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Peng Wang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Li Li
- First People's Hospital of Kashi, Xinjiang 844000, Kashgar, Xinjiang, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Yongfang Zhou
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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Ibarra-Estrada M, Mireles-Cabodevila E, García-Salas Y, Sandoval-Plascencia L, Ortiz-Macías IX, Mijangos-Méndez JC, López-Pulgarín JA, Chávez-Peña Q, Aguirre-Avalos G. The authors reply. Crit Care Med 2022; 50:e794-e795. [PMID: 36227047 PMCID: PMC9555551 DOI: 10.1097/ccm.0000000000005649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, México
- División de Disciplinas Clínicas. Universidad de Guadalajara, Jalisco, México
| | | | - Yessica García-Salas
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, México
- División de Disciplinas Clínicas. Universidad de Guadalajara, Jalisco, México
| | | | - Iris X Ortiz-Macías
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, México
- División de Disciplinas Clínicas. Universidad de Guadalajara, Jalisco, México
| | - Julio C Mijangos-Méndez
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, México
- División de Disciplinas Clínicas. Universidad de Guadalajara, Jalisco, México
| | - José A López-Pulgarín
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, México
- División de Disciplinas Clínicas. Universidad de Guadalajara, Jalisco, México
| | - Quetzalcóatl Chávez-Peña
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, México
- División de Disciplinas Clínicas. Universidad de Guadalajara, Jalisco, México
| | - Guadalupe Aguirre-Avalos
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Guadalajara, México
- División de Disciplinas Clínicas. Universidad de Guadalajara, Jalisco, México
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