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Riddell JR, Jones BJ, Fernandes BM, Law DJ, Cooper JA, Wise MP. Mechanical ventilation variables associated with high pulmonary artery pressures in ARDS patients: a post hoc analysis. Crit Care 2022; 26:396. [PMID: 36544201 PMCID: PMC9773567 DOI: 10.1186/s13054-022-04282-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The relationship between indices of mechanical ventilation and pulmonary artery pressures remains ill-defined in ARDS. As our understanding of mechanical ventilation has progressed, there is now a greater appreciation of the impact of high driving pressures and mechanical power in perpetuating lung injury. However, the relationship between the newer derived indices of mechanical ventilation and pulmonary artery pressure is unclear. We performed a post hoc analysis of the Fluid and Catheters Treatment Trial (FACTT) trial to investigate the associations between mechanical ventilation indices in ARDS patients and the prevalence of pulmonary hypertension. This may help elucidate future clinical targets for more, right ventricular protective, mechanical ventilation strategies. METHODS We performed a post hoc analysis of the FACTT database to identify ARDS patients who had a pulmonary artery catheter (PAC) inserted and pulmonary artery pressure readings recorded. We excluded any patient with a PAC inserted who was spontaneously breathing, as driving pressure and mechanical power are not validated in this cohort. Three independent analyses were performed: a univariate analysis, to assess for associations between mPAP and mechanical ventilation parameters using Pearson correlation coefficients, a multivariate analysis, to assess for independent associations with mPAP using a multiple regression model according to Akaike's information criteria and finally an analysis for nonlinearity, using the best-fitting model according to the Bayesian information criterion (BIC) from linear, quadratic, fractional polynomial and restricted cubic spline models. RESULTS All the ventilation parameters demonstrated a significant correlation with mPAP, except tidal volume (once adjusted for respiratory rate) in the univariate analysis. The multivariate analysis demonstrated that the blood pH level, P/F ratio, PaCO2 level, mean airway pressure and the mechanical power indexed to compliance were independently associated with mPAP. In the final nonlinear analysis, associations did not differ from linearity except for 4 variables for which the fractional polynomial was the best-fitting model. These were mechanical power (p = 0.01 compared to the linear model), respiratory rate (p = 0.04), peak pressure (p = 0.03) and mean airway pressure (p = 0.01). Two nonlinear variables associated with mPAP were assessed in more detail, respiratory rate and mechanical power. Inflexion points at a respiratory rate of 16.8 cycles per minute and a mechanical power of 8.8 J/min were demonstrated. CONCLUSIONS The associations identified between mPAP and mechanical ventilation variables in this analysis would suggest that classical ARDS lung protective strategies, including low tidal volume ventilation and permissive hypercapnia, may negatively impact the management of the subset of ARDS patients with associated right ventricular dysfunction or ACP. Additionally, respiratory rates above 17 cycles per minute show an incremental increase in mPAP. Therefore, increases in tidal volume (within the limitation of driving pressure < 18 cmH20) may represent a more right ventricular protective way to control CO2 and pH.
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Affiliation(s)
- Joseph R. Riddell
- grid.241103.50000 0001 0169 7725Critical Care Department, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Benjamin J. Jones
- grid.241103.50000 0001 0169 7725Critical Care Department, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Bruno M. Fernandes
- grid.241103.50000 0001 0169 7725Critical Care Department, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Daniel J. Law
- grid.241103.50000 0001 0169 7725Critical Care Department, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Jackie A. Cooper
- grid.83440.3b0000000121901201University College London, Gower Street, London, WC1E 6BT UK
| | - Matt P. Wise
- grid.241103.50000 0001 0169 7725Critical Care Department, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
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Honarmand K, Fiorini K, Chakraborty D, Gillett D, Desai K, Martin C, Bosma KJ, Slessarev M, Ball IM, Mele T, LeBlanc D, Elsayed S, Lazo-Langner A, Nicholson MJ, Arntfield R, Basmaji J. Clinical characteristics, multiorgan dysfunction and outcomes of patients with COVID-19: a prospective case series. CMAJ Open 2022; 10:E675-E684. [PMID: 35853662 PMCID: PMC9312996 DOI: 10.9778/cmajo.20210151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Characterizing the multiorgan manifestations and outcomes of patients hospitalized with COVID-19 will inform resource requirements to address the long-term burden of this disease. We conducted a descriptive analysis using prospectively collected data to describe the clinical characteristics and spectrum of organ dysfunction, and in-hospital and longer-term clinical outcomes of patients hospitalized with COVID-19 during the first wave of the pandemic at a Canadian centre. METHODS We conducted a prospective case series involving adult patients (aged ≥ 18 yr) with COVID-19 admitted to 1 of 2 hospitals in London, Ontario, from Mar. 17 to June 18, 2020, during the first wave of the pandemic. We recorded patients' baseline characteristics, physiologic parameters, measures of organ function and therapies administered during hospitalization among patients in the intensive care unit (ICU) and in non-ICU settings, and compared the characteristics of hospital survivors and nonsurvivors. Finally, we recorded follow-up thoracic computed tomography (CT) and echocardiographic findings after hospital discharge. RESULTS We enrolled 100 consecutive patients (47 women) hospitalized with COVID-19, including 32 patients who received ICU care and 68 who received treatment in non-ICU settings. Respiratory sequelae were common: 23.0% received high-flow oxygen by nasal cannula, 9.0% received noninvasive ventilation, 24.0% received invasive mechanical ventilation and 2.0% received venovenous extracorporeal membrane oxygenation. Overall, 9.0% of patients had cerebrovascular events (3.0% ischemic stroke, 6.0% intracranial hemorrhage), and 6.0% had pulmonary embolism. After discharge, 11 of 19 patients had persistent abnormalities on CT thorax, and 6 of 15 had persistent cardiac dysfunction on echocardiography. INTERPRETATION This study provides further evidence that COVID-19 is a multisystem disease involving neurologic, cardiac and thrombotic dysfunction, without evidence of hepatic dysfunction. Patients have persistent organ dysfunction after hospital discharge, underscoring the need for research on long-term outcomes of COVID-19 survivors.
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Affiliation(s)
- Kimia Honarmand
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Kyle Fiorini
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Debarati Chakraborty
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Daniel Gillett
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Karishma Desai
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Claudio Martin
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Karen J Bosma
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Marat Slessarev
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Ian M Ball
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Tina Mele
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Danielle LeBlanc
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Sameer Elsayed
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Alejandro Lazo-Langner
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Mike J Nicholson
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - Robert Arntfield
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont
| | - John Basmaji
- Departments of Medicine (Honarmand, Fiorini, Chakraborty, Gillett, Desai, Martin, Bosma, Slessarev, Ball, Mele, LeBlanc, Lazo-Langner, Nicholson, Arntfield, Basmaji), Medical Biophysics (Slessarev), Microbiology & Immunology and Division of Infectious Diseases (Elsayed), and Epidemiology and Biostatistics (Ball, Lazo-Langner), Western University, London, Ont.
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Mao JY, Li DK, Ding X, Zhang HM, Long Y, Wang XT, Liu DW. Fluctuations of driving pressure during mechanical ventilation indicates elevated central venous pressure and poor outcomes. Pulm Circ 2020; 10:2045894020970363. [PMID: 33282200 PMCID: PMC7691920 DOI: 10.1177/2045894020970363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/11/2020] [Indexed: 12/19/2022] Open
Abstract
Inappropriate mechanical ventilation may induce hemodynamic alterations through cardiopulmonary interactions. The aim of this study was to explore the relationship between airway pressure and central venous pressure during the first 72 h of mechanical ventilation and its relevance to patient outcomes. We conducted a retrospective study of the Department of Critical Care Medicine of Peking Union Medical College Hospital and a secondary analysis of the MIMIC-III clinical database. The relationship between the ranges of driving pressure and central venous pressure during the first 72 h and their associations with prognosis were investigated. Data from 2790 patients were analyzed. Wide range of driving airway pressure (odds ratio, 1.0681; 95% CI, 1.0415-1.0953; p < 0.0001) were independently associated with mortality, ventilator-free time, intensive care unit and hospital length of stay. Furthermore, wide range of driving pressure and elevated central venous pressure exhibited a close correlation. The area under receiver operating characteristic demonstrated that range of driving pressure and central venous pressure were measured at 0.689 (95% CI, 0.670-0.707) and 0.681 (95% CI, 0.662-0.699), respectively. Patients with high ranges of driving pressure and elevated central venous pressure had worse outcomes. Post hoc tests showed significant differences in 28-day survival rates (log-rank (Mantel-Cox), 184.7; p < 0.001). In conclusion, during the first 72 h of mechanical ventilation, patients with hypoxia with fluctuating driving airway pressure have elevated central venous pressure and worse outcomes.
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Affiliation(s)
- Jia-Yu Mao
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Dong-Kai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Ding
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong-Min Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Department of Health Care, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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