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Wang Y, Yu Q, Tian Y, Ren S, Liu L, Wei C, Liu R, Wang J, Li D, Zhu K. Unraveling the impact of nitric oxide, almitrine, and their combination in COVID-19 (at the edge of sepsis) patients: a systematic review. Front Pharmacol 2024; 14:1172447. [PMID: 38318311 PMCID: PMC10839063 DOI: 10.3389/fphar.2023.1172447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 12/27/2023] [Indexed: 02/07/2024] Open
Abstract
Introduction: During the coronavirus disease 2019 (COVID-19) pandemic, a large number of critically ill and severe COVID-19 patients meet the diagnostic criteria for sepsis and even septic shock. The treatments for COVID-19 patients with sepsis are still very limited. For sepsis, improving ventilation is one of the main treatments. Nitric oxide (NO) and almitrine have been reported to improve oxygenation in patients with "classical" sepsis. Here, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of NO, almitrine, and the combination of both for COVID-19 (at the edge of sepsis) patients. Method: A systematic search was performed on Embase, PubMed, the Cochrane Library, the Web of Science, Wanfang Data, and China National Knowledge Infrastructure. Randomized clinical trials, cohort studies, cross-sectional studies, case-control studies, case series, and case reports in COVID-19 patients with suspected or confirmed sepsis were performed. Study characteristics, patient demographics, interventions, and outcomes were extracted from eligible articles. Results: A total of 35 studies representing 1,701 patients met eligibility criteria. Inhaled NO did not affect the mortality (OR 0.96, 95% CI 0.33-2.8, I2 = 81%, very low certainty), hospital length of stay (SMD 0.62, 95% CI 0.04-1.17, I2 = 83%, very low certainty), and intubation needs (OR 0.82, 95% CI 0.34-1.93, I2 = 56%, very low certainty) of patients with COVID-19 (at the edge of sepsis). Meanwhile, almitrine did not affect the mortality (OR 0.44, 95% CI 0.17-1.13, low certainty), hospital length of stay (SMD 0.00, 95% CI -0.29-0.29, low certainty), intubation needs (OR 0.94, 95% CI 0.5-1.79, low certainty), and SAEs (OR 1.16, 95% CI 0.63-2.15, low certainty). Compared with pre-administration, the PaO2/FiO2 of patients with NO (SMD-0.87, 95% CI -1.08-0.66, I2 = 0%, very low certainty), almitrine (SMD-0.73, 95% CI-1.06-0.4, I2 = 1%, very low certainty), and the combination of both (SMD-0.94, 95% CI-1.71-0.16, I2 = 47%, very low certainty) increased significantly. Conclusion: Inhaled NO, almitrine, and the combination of the two drugs improved oxygenation significantly, but did not affect the patients' mortality, hospitalization duration, and intubation needs. Almitrine did not significantly increase the patients' SAEs. Well-designed high-quality studies are needed for establishing a stronger quality of evidence. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=367667, identifier CRD42022367667.
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Affiliation(s)
- Ying Wang
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Qian Yu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
| | - Yuan Tian
- Department of Nutrition and Food Hygiene, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Shiying Ren
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Liping Liu
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Chaojie Wei
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Renli Liu
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Jing Wang
- Department of Pharmacy, Siping Tumor Hospital, Siping, Jilin, China
| | - Dong Li
- Department of Immunology, College of Basic Medical Sciences, Jilin University, Changchun, Jilin, China
| | - Kun Zhu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, Jilin, China
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Yu YY, Ou WF, Wu JJ, Hsu HS, Wu CL, Yang KY, Chan MC. A combination of oxygenation and driving pressure can provide valuable information in predicting the risk of mortality in ARDS patients. PLoS One 2023; 18:e0295261. [PMID: 38091325 PMCID: PMC10718417 DOI: 10.1371/journal.pone.0295261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/19/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a common life-threatening condition in critically ill patients. Itis also an important public health issue because it can cause substantial mortality and health care burden worldwide. The objective of this study was to investigate therisk factors that impact ARDS mortality in a medical center in Taiwan. METHODS This was a single center, observational study thatretrospectively analyzed data from adults in 6 intensive care units (ICUs) at Taichung Veterans General Hospital in Taiwan from 1st October, 2018to30th September, 2019. Patients needing invasive mechanical ventilation and meeting the Berlin definition criteria were included for analysis. RESULTS A total of 1,778 subjects were screened in 6 adult ICUs and 370 patients fulfilled the criteria of ARDS in the first 24 hours of the ICU admission. Among these patients, the prevalenceof ARDS was 20.8% and the overall hospital mortality rate was 42.2%. The mortality rates of mild, moderate and severe ARDS were 35.9%, 43.9% and 46.5%, respectively. In a multivariate logistic regression model, combination of driving pressure (DP) > 14cmH2O and oxygenation (P/F ratio)≤150 was an independent predictor of mortality (OR2.497, 95% CI 1.201-5.191, p = 0.014). Patients with worse oxygenation and a higher driving pressure had the highest hospital mortality rate(p<0.0001). CONCLUSIONS ARDS is common in ICUs and the mortality rate remains high. Combining oxygenation and respiratory mechanics may better predict the outcomes of these ARDS patients.
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Affiliation(s)
- Yu-Yi Yu
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Fan Ou
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jia-Jun Wu
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Thoracic Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chieh-Laing Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Post BaccalaureateMedicine, National Chung Hsing University, Taichung, Taiwan
| | - Kuang-Yao Yang
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Cheng Chan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Post BaccalaureateMedicine, National Chung Hsing University, Taichung, Taiwan
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Marinho SEDS, Paiva DN, Bezerra GMP, Silva TNDS, Lima CRODP, Raposo MCF, Marinho PÉDM. Does the use of a diving mask adapted for non-invasive ventilation in hypoxemic acute respiratory failure in individuals with and without COVID-19 increase the ratio of arterial oxygen partial pressure to fractional inspired oxygen? A randomized clinical trial. Monaldi Arch Chest Dis 2023; 94. [PMID: 37222438 DOI: 10.4081/monaldi.2023.2512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/04/2023] [Indexed: 05/25/2023] Open
Abstract
Non-invasive ventilation (NIV) can be used in acute hypoxemic respiratory failure (AHRF); however, verifying the best interface for its use needs to be evaluated in the COVID-19 pandemic scenario. The objective of this study was to evaluate the behavior of the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio) in patients with AHRF with and without COVID-19 undergoing NIV with the conventional orofacial mask and the adapted diving mask. This is a randomized clinical trial in which patients were allocated into four groups: i) group 1: COVID-19 + adapted mask (n=12); ii) group 2: COVID-19 + conventional orofacial mask (n=12); iii) group 3: non-COVID-19 + adapted mask (n=2); iv) group 4: non-COVID-19 + conventional orofacial mask (n=12). The PaO2/FiO2 ratio was obtained 1, 24, and 48 hours after starting NIV, and the success of NIV was evaluated. This study followed the norms of the Consolidated Standards of Reporting Trials statement and was registered in the Brazilian Registry of Clinical Trials under registration RBR-7xmbgsz. Both the adapted diving mask and the conventional orofacial mask increased the PaO2/FiO2 ratio. The interfaces differed in terms of the PaO2/FiO2 ratio in the first hour [309.66 (11.48) and 275.71 (11.48), respectively] (p=0.042) and 48 hours [365.81 (16.85) and 308.79 (18.86), respectively] (p=0.021). NIV success was 91.7% in groups 1, 2, and 3, and 83.3% in group 4. No adverse effects related to interfaces or NIV were observed. NIV through the conventional orofacial mask interfaces and the adapted diving mask was effective in improving the PaO2/FiO2 ratio; however, the adapted mask presented a better PaO2/FiO2 ratio during use. There was no significant difference between interfaces regarding NIV failure.
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Affiliation(s)
- Sônia Elvira Dos Santos Marinho
- Post-Graduation Program in Physical Therapy, Physical Therapy Department, Federal University of Pernambuco, Recife, Pernambuco.
| | - Dulciane Nunes Paiva
- Department of Physical Education and Health, University of Santa Cruz do Sul, Rio Grande do Sul.
| | | | | | | | | | - Patrícia Érika de Melo Marinho
- Post-Graduation Program in Physical Therapy, Physical Therapy Department, Federal University of Pernambuco, Recife, Pernambuco.
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Prone positioning in COVID-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation. ENFERMERIA INTENSIVA 2023:S2529-9840(23)00018-6. [PMID: 36934077 PMCID: PMC10018443 DOI: 10.1016/j.enfie.2022.09.002] [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: 04/27/2022] [Accepted: 09/13/2022] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. METHODS Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22h [15-24]. The prevalence of adverse events this population was 84.9 %, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin <21mg/dl, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. CONCLUSIONS There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.
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Zheng M. Dead space ventilation-related indices: bedside tools to evaluate the ventilation and perfusion relationship in patients with acute respiratory distress syndrome. Crit Care 2023; 27:46. [PMID: 36732812 PMCID: PMC9894747 DOI: 10.1186/s13054-023-04338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Cumulative evidence has demonstrated that the ventilatory ratio closely correlates with mortality in acute respiratory distress syndrome (ARDS), and a primary feature in coronavirus disease 2019 (COVID-19)-ARDS is increased dead space that has been reported recently. Thus, new attention has been given to this group of dead space ventilation-related indices, such as physiological dead space fraction, ventilatory ratio, and end-tidal-to-arterial PCO2 ratio, which, albeit distinctive, are all global indices with which to assess the relationship between ventilation and perfusion. These parameters have already been applied to positive end expiratory pressure titration, prediction of responses to the prone position and the field of extracorporeal life support for patients suffering from ARDS. Dead space ventilation-related indices remain hampered by several deflects; notwithstanding, for this catastrophic syndrome, they may facilitate better stratifications and identifications of subphenotypes, thereby providing therapy tailored to individual needs.
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Affiliation(s)
- Mingjia Zheng
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, No. 1558, Sanhuan North Road, Wuxing, Huzhou, Zhejiang, People's Republic of China.
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Wang Z, Xia F, Dai H, Chen H, Xie J, Qiu H, Yang Y, Guo F. Early decrease of ventilatory ratio after prone position ventilation may predict successful weaning in patients with acute respiratory distress syndrome: A retrospective cohort study. Front Med (Lausanne) 2022; 9:1057260. [PMID: 36561724 PMCID: PMC9763615 DOI: 10.3389/fmed.2022.1057260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
Background Previous studies usually identified patients who benefit the most from prone positioning by oxygenation improvement. However, inconsistent results have been reported. Physiologically, pulmonary dead space fraction may be more appropriate in evaluating the prone response. As an easily calculated bedside index, ventilatory ratio (VR) correlates well with pulmonary dead space fraction. Hence, we investigated whether the change in VR after prone positioning is associated with weaning outcomes at day 28 and to identify patients who will benefit the most from prone positioning. Materials and methods This retrospective cohort study was performed in a group of mechanically ventilated, non-COVID ARDS patients who received prone positioning in the ICU at Zhongda hospital, Southeast University. The primary outcome was the rate of successful weaning patients at day 28. Arterial blood gas results and corresponding ventilatory parameters on five different time points around the first prone positioning were collected, retrospectively. VR responders were identified by Youden's index. Competing-risk regression models were used to identify the association between the VR change and liberation from mechanical ventilation at day 28. Results One hundred and three ARDS patients receiving prone positioning were included, of whom 53 (51%) successfully weaned from the ventilator at day 28. VR responders were defined as patients showing a decrease in VR of greater than or equal to 0.037 from the baseline to within 4 h after prone. VR responders have significant longer ventilator-free days, higher successful weaning rates and lower mortality compared with non-responders at day 28. And a significant between-group difference exists in the respiratory mechanics improvement after prone (P < 0.05). A linear relationship was also found between VR change and compliance of the respiratory system (Crs) change after prone (r = 0.32, P = 0.025). In the multivariable competing-risk analysis, VR change (sHR 0.57; 95% CI, 0.35-0.92) was independently associated with liberation from mechanical ventilation at day 28. Conclusion Ventilatory ratio decreased more significantly within 4 h after prone positioning in patients with successful weaning at day 28. VR change was independently associated with liberation from mechanical ventilation at day 28.
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Affiliation(s)
- Zhichang Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Feiping Xia
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Huishui Dai
- Department of Critical Care Medicine, Mingguang People’s Hospital, Chuzhou, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China,Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China,*Correspondence: Fengmei Guo,
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Dilken O, Rezoagli E, Yartaş Dumanlı G, Ürkmez S, Demirkıran O, Dikmen Y. Effect of prone positioning on end-expiratory lung volume, strain and oxygenation change over time in COVID-19 acute respiratory distress syndrome: A prospective physiological study. Front Med (Lausanne) 2022; 9:1056766. [PMID: 36530873 PMCID: PMC9755177 DOI: 10.3389/fmed.2022.1056766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/21/2022] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Prone position (PP) is a recommended intervention in severe classical acute respiratory distress syndrome (ARDS). Changes in lung resting volume, respiratory mechanics and gas exchange during a 16-h cycle of PP in COVID-19 ARDS has not been yet elucidated. METHODS Patients with severe COVID-19 ARDS were enrolled between May and September 2021 in a prospective cohort study in a University Teaching Hospital. Lung resting volume was quantitatively assessed by multiple breath nitrogen wash-in/wash-out technique to measure the end-expiratory lung volume (EELV). Timepoints included the following: Baseline, Supine Position (S1); start of PP (P0), and every 4-h (P4; P8; P12) until the end of PP (P16); and Supine Position (S2). Respiratory mechanics and gas exchange were assessed at each timepoint. MEASUREMENTS AND MAIN RESULTS 40 mechanically ventilated patients were included. EELV/predicted body weight (PBW) increased significantly over time. The highest increase was observed at P4. The highest absolute EELV/PBW values were observed at the end of the PP (P16 vs S1; median 33.5 ml/kg [InterQuartileRange, 28.2-38.7] vs 23.4 ml/kg [18.5-26.4], p < 0.001). Strain decreased immediately after PP and remained stable between P4 and P16. PaO2/FiO2 increased during PP reaching the highest level at P12 (P12 vs S1; 163 [138-217] vs 81 [65-97], p < 0.001). EELV/PBW, strain and PaO2/FiO2 decreased at S2 although EELV/PBW and PaO2/FiO2 were still significantly higher as compared to S1. Both absolute values over time and changes of strain and PaO2/FiO2 at P16 and S2 versus S1 were strongly associated with EELV/PBW levels. CONCLUSION In severe COVID-19 ARDS, EELV steadily increased over a 16-h cycle of PP peaking at P16. Strain gradually decreased, and oxygenation improved over time. Changes in strain and oxygenation at the end of PP and back to SP were strongly associated with changes in EELV/PBW. Whether the change in EELV and oxygenation during PP may play a role on outcomes in COVID-ARDS deserves further investigation. CLINICAL TRIAL REGISTRATION [www.ClinicalTrials.gov], identifier [NCT04818164].
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Affiliation(s)
- Olcay Dilken
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, ECMO Center, ASST Monza, San Gerardo University Teaching Hospital, Monza, Italy
| | - Güleren Yartaş Dumanlı
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Seval Ürkmez
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Oktay Demirkıran
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Yalım Dikmen
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Decúbito prono en pacientes COVID-19 con síndrome de distrés respiratorio agudo y ventilación mecánica invasiva. ENFERMERIA INTENSIVA 2022; 34:80-89. [PMID: 36311904 PMCID: PMC9595372 DOI: 10.1016/j.enfi.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022]
Abstract
Objetivos: Identificar eventos adversos secundarios al decúbito prono (DP) en pacientes con COVID-19 con síndrome de distrés respiratorio agudo (SDRA) moderado/severo, analizar los factores de riesgo para el desarrollo de úlceras por presión (UPP) en DP y describir la evolución oximétrica de estos pacientes durante el DP. Método: Estudio descriptivo retrospectivo realizado sobre 63 pacientes ingresados en la UCI de un hospital de segundo nivel, con neumonía por SARS-CoV-2, SDRA moderado/severo, ventilación mecánica invasiva, que precisaron maniobras de DP, durante marzo y abril de 2020. Se usó un muestreo no probabilístico consecutivo y se analizaron las variables seleccionadas a través de una regresión logística. Resultados: Se realizaron un total de 139 sesiones de pronación. La mediana de sesiones fue de 2 [1-3] y la duración de 22 horas [15-24] por sesión. La aparición de eventos adversos ocurrió en un 84,9% de los casos, siendo las fisiológicas (ej. hiper/hipotensión) las más frecuentes. Al comparar pacientes pronados que mantuvieron la integridad cutánea (34 de 63 pacientes, un 54%) versus los que desarrollaron UPP (29 de 63, un 46%), estos últimos presentaron los siguientes factores de riesgo: mayor edad, ser hipertensos, pre-albúmina <21mg/dl, mayor número de sesiones de prono y mayor gravedad al ingreso. Se observó un incremento significativo entre la PaO2/FiO2 previa al DP y en los diferentes cortes temporales durante el prono, además de una caída significativa tras despronar. Conclusiones: Existe una alta incidencia de eventos adversos debidos al DP, siendo los de tipo fisiológico los más frecuentes. La identificación de varios factores de riesgo para el desarrollo de UPP ayudará a prevenir la aparición de estas lesiones durante la pronación. La terapia de DP en pacientes COVID-19 con SDRA moderado/severo ha demostrado una mejora en los parámetros de oxigenación.
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Worku E, Brodie D, Ling RR, Ramanathan K, Combes A, Shekar K. Venovenous extracorporeal CO 2 removal to support ultraprotective ventilation in moderate-severe acute respiratory distress syndrome: A systematic review and meta-analysis of the literature. Perfusion 2022:2676591221096225. [PMID: 35656595 DOI: 10.1177/02676591221096225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO2R in supporting ultra-protective ventilation in moderate-to-severe ARDS. METHODS MEDLINE and EMBASE were interrogated for studies (2000-2021) reporting venovenous ECCO2R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO2R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO2R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. RESULTS Ten studies reporting 421 patients (PaO2:FiO2 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH2O reduction (95%-CI: 3.22-3.91) in driving pressure from baseline (p < .001) and a 1.89 mL/kg (95%-CI: 1.75-2.02, p < .001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO2:FiO2 ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. CONCLUSIONS Venovenous ECCO2R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made.
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Affiliation(s)
- Elliott Worku
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, 12294Columbia University College of Physicians and Surgeons, NY, USA
- Center for Acute Respiratory Failure, 25065New York-Presbyterian Hospital, NY, USA
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiothoracic Intensive Care Unit, 375583National University Heart Centre, National University Hospital, Singapore
| | - Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, 26933Pitié-Salpêtrière Hospital, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, 67567The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane and Bond University, Gold Coast, QLD, Australia
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Protti A, Santini A, Pennati F, Chiurazzi C, Ferrari M, Iapichino GE, Carenzo L, Dalla Corte F, Lanza E, Martinetti N, Aliverti A, Cecconi M. Lung response to prone positioning in mechanically-ventilated patients with COVID-19. Crit Care 2022; 26:127. [PMID: 35526009 PMCID: PMC9076814 DOI: 10.1186/s13054-022-03996-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/23/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Prone positioning improves survival in moderate-to-severe acute respiratory distress syndrome (ARDS) unrelated to the novel coronavirus disease (COVID-19). This benefit is probably mediated by a decrease in alveolar collapse and hyperinflation and a more homogeneous distribution of lung aeration, with fewer harms from mechanical ventilation. In this preliminary physiological study we aimed to verify whether prone positioning causes analogue changes in lung aeration in COVID-19. A positive result would support prone positioning even in this other population. METHODS Fifteen mechanically-ventilated patients with COVID-19 underwent a lung computed tomography in the supine and prone position with a constant positive end-expiratory pressure (PEEP) within three days of endotracheal intubation. Using quantitative analysis, we measured the volume of the non-aerated, poorly-aerated, well-aerated, and over-aerated compartments and the gas-to-tissue ratio of the ten vertical levels of the lung. In addition, we expressed the heterogeneity of lung aeration with the standardized median absolute deviation of the ten vertical gas-to-tissue ratios, with lower values indicating less heterogeneity. RESULTS By the time of the study, PEEP was 12 (10-14) cmH2O and the PaO2:FiO2 107 (84-173) mmHg in the supine position. With prone positioning, the volume of the non-aerated compartment decreased by 82 (26-147) ml, of the poorly-aerated compartment increased by 82 (53-174) ml, of the normally-aerated compartment did not significantly change, and of the over-aerated compartment decreased by 28 (11-186) ml. In eight (53%) patients, the volume of the over-aerated compartment decreased more than the volume of the non-aerated compartment. The gas-to-tissue ratio of the ten vertical levels of the lung decreased by 0.34 (0.25-0.49) ml/g per level in the supine position and by 0.03 (- 0.11 to 0.14) ml/g in the prone position (p < 0.001). The standardized median absolute deviation of the gas-to-tissue ratios of those ten levels decreased in all patients, from 0.55 (0.50-0.71) to 0.20 (0.14-0.27) (p < 0.001). CONCLUSIONS In fifteen patients with COVID-19, prone positioning decreased alveolar collapse, hyperinflation, and homogenized lung aeration. A similar response has been observed in other ARDS, where prone positioning improves outcome. Therefore, our data provide a pathophysiological rationale to support prone positioning even in COVID-19.
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Affiliation(s)
- Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Chiara Chiurazzi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Michele Ferrari
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giacomo E Iapichino
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Dalla Corte
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ezio Lanza
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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11
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Almanza-Hurtado A, Polanco Guerra C, Martínez-Ávila MC, Borré-Naranjo D, Rodríguez-Yanez T, Dueñas-Castell C. Hypercapnia from Physiology to Practice. Int J Clin Pract 2022; 2022:2635616. [PMID: 36225533 PMCID: PMC9525762 DOI: 10.1155/2022/2635616] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/28/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
Acute hypercapnic ventilatory failure is becoming more frequent in critically ill patients. Hypercapnia is the elevation in the partial pressure of carbon dioxide (PaCO2) above 45 mmHg in the bloodstream. The pathophysiological mechanisms of hypercapnia include the decrease in minute volume, an increase in dead space, or an increase in carbon dioxide (CO2) production per sec. They generate a compromise at the cardiovascular, cerebral, metabolic, and respiratory levels with a high burden of morbidity and mortality. It is essential to know the triggers to provide therapy directed at the primary cause and avoid possible complications.
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12
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Friedman E, Franzone J, Ko ER, Corey K, Mock J, Alavian N, Schwartz A, Drummond MB, Suber T, Linstrum K, Bain W, Castiblanco SA, Zak M, Zaeh S, Gupta I, Damarla M, Punjabi NM. Rationale and design of the prone position and respiratory outcomes in non-intubated COVID-19 patients: The "PRONE" study. Contemp Clin Trials 2021; 109:106541. [PMID: 34400361 PMCID: PMC8363159 DOI: 10.1016/j.cct.2021.106541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/10/2023]
Abstract
While benefits of prone position in mechanically-ventilated patients have been well-described, a randomized-control trial to determine the effects of prone positioning in awake, spontaneously-breathing patients with an acute pneumonia has not been previously conducted. Prone Position and Respiratory Outcomes in Non-Intubated COVID-19 PatiEnts: the “PRONE” Study (PRONE) was conducted in non-intubated hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia as defined by respiratory rate ≥ 20/min or an oxyhemoglobin saturation (SpO2) ≤ 93% without supplemental oxygen [1]. The PRONE trial was designed to investigate the effects of prone positioning on need for escalation in respiratory support, as defined by need for transition to a higher acuity level of care, increased fraction of inspired oxygen (FiO2), or the initiation of invasive mechanical ventilation. Secondary objectives were to assess the duration of effect of prone positioning on respiratory parameters such as respiratory rate and SpO2, as well as other outcomes such as time to discharge or transition in level of care.
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Affiliation(s)
- Eugene Friedman
- Duke University, Division of Pulmonary, Allergy, and Critical Care Medicine, DUMC Box 102352, Durham, NC 27710, United States of America
| | - John Franzone
- Duke University, Division of Hospital Medicine, Department of General Internal Medicine, Durham, NC 27710, United States of America
| | - Emily R Ko
- Duke University, Division of Hospital Medicine, Department of General Internal Medicine, Durham, NC 27710, United States of America
| | - Kristin Corey
- Duke University, Division of Pulmonary, Allergy, and Critical Care Medicine, DUMC Box 102352, Durham, NC 27710, United States of America
| | - Jason Mock
- University of North Carolina, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, 130 Mason Farm Road, CB# 7020, 4(th) floor Bioinformatics Bldg, Chapel Hill, NC 27599-7020, United States of America
| | - Naseem Alavian
- University of North Carolina, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, 130 Mason Farm Road, CB# 7020, 4(th) floor Bioinformatics Bldg, Chapel Hill, NC 27599-7020, United States of America
| | - Adam Schwartz
- University of North Carolina, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, 130 Mason Farm Road, CB# 7020, 4(th) floor Bioinformatics Bldg, Chapel Hill, NC 27599-7020, United States of America
| | - M Bradley Drummond
- University of North Carolina, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, 130 Mason Farm Road, CB# 7020, 4(th) floor Bioinformatics Bldg, Chapel Hill, NC 27599-7020, United States of America
| | - Tomeka Suber
- University of Pittsburgh, Division of Pulmonary, Allergy, and Critical Care Medicine, 3459 Fifth Avenue, Montefiore NW628, Pittsburgh, PA 15213, United States of America
| | - Kelsey Linstrum
- University of Pittsburgh, Division of Pulmonary, Allergy, and Critical Care Medicine, 3459 Fifth Avenue, Montefiore NW628, Pittsburgh, PA 15213, United States of America
| | - William Bain
- University of Pittsburgh, Division of Pulmonary, Allergy, and Critical Care Medicine, 3459 Fifth Avenue, Montefiore NW628, Pittsburgh, PA 15213, United States of America
| | - Saramaria Afanador Castiblanco
- University of Miami, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School Of Medicine, 1951 NW 7th Ave, 2nd Floor, Room 2278, Miami, FL 33136, United States of America
| | - Martin Zak
- University of Miami, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School Of Medicine, 1951 NW 7th Ave, 2nd Floor, Room 2278, Miami, FL 33136, United States of America
| | - Sandra Zaeh
- Johns Hopkins University, Division of Pulmonary And Critical Care Medicine, 5501 Hopkins Baview Cr., JHAAC, Room 4A.30, Baltimore, MD 21224, United States of America
| | - Ishaan Gupta
- Johns Hopkins University, Division of Pulmonary And Critical Care Medicine, 5501 Hopkins Baview Cr., JHAAC, Room 4A.30, Baltimore, MD 21224, United States of America
| | - Mahendra Damarla
- Johns Hopkins University, Division of Pulmonary And Critical Care Medicine, 5501 Hopkins Baview Cr., JHAAC, Room 4A.30, Baltimore, MD 21224, United States of America.
| | - Naresh M Punjabi
- University of Miami, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School Of Medicine, 1951 NW 7th Ave, 2nd Floor, Room 2278, Miami, FL 33136, United States of America
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13
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Langer T, Brioni M, Guzzardella A, Carlesso E, Cabrini L, Castelli G, Dalla Corte F, De Robertis E, Favarato M, Forastieri A, Forlini C, Girardis M, Grieco DL, Mirabella L, Noseda V, Previtali P, Protti A, Rona R, Tardini F, Tonetti T, Zannoni F, Antonelli M, Foti G, Ranieri M, Pesenti A, Fumagalli R, Grasselli G. Prone position in intubated, mechanically ventilated patients with COVID-19: a multi-centric study of more than 1000 patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:128. [PMID: 33823862 PMCID: PMC8022297 DOI: 10.1186/s13054-021-03552-2] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023]
Abstract
Background Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave. Methods Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO2/FiO2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position. Results Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO2/FiO2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities;
however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively). Conclusions During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching. Trial registration: clinicaltrials.gov number: NCT04388670 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03552-2.
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Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Matteo Brioni
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Eleonora Carlesso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luca Cabrini
- Ospedale di Circolo e Fondazione Macchi, Università degli studi dell'Insubria, Varese, Italy
| | - Gianpaolo Castelli
- Department of Anesthesiology and Intensive Care, ASST Mantova-Ospedale Carlo Poma, Mantova, Italy
| | | | - Edoardo De Robertis
- Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Martina Favarato
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Andrea Forastieri
- Department of Anesthesia and Intensive Care, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Clarissa Forlini
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | - Lucia Mirabella
- Department of Medical and Surgical Sciences, Intensive Care Unit, University of Foggia, Foggia, Italy
| | - Valentina Noseda
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Paola Previtali
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.,Department of Anaesthesia and Intensive Care, Humanitas Clinical and Research Center-IRCCS, Rozzano, MI, Italy
| | - Roberto Rona
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Francesca Tardini
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Tommaso Tonetti
- Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Fabio Zannoni
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Massimo Antonelli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Sacred Heart Catholic University, Rome, Italy
| | - Giuseppe Foti
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Marco Ranieri
- Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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14
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Dianti J, Slutsky AS, Goligher EC. Validity of Empirical Estimates of the Ratio of Dead Space to Tidal Volume in ARDS. Respir Care 2021; 66:559-565. [PMID: 33082218 PMCID: PMC9993985 DOI: 10.4187/respcare.08246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The ratio of dead space to tidal volume (VD/VT) is a clinically relevant parameter in ARDS; it has been shown to predict mortality, and it determines the extent to which extracorporeal CO2 removal reduces tidal volume (VT) and driving pressure (ΔP). VD/VT can be estimated with volumetric capnography, but empirical formulas using demographic and physiological information have been proposed to estimate VD/VT without the need of additional equipment. It is unknown whether estimated and measured VD/VT produce similar estimates of the predicted effect of extracorporeal CO2 removal on ΔP. METHODS We performed a secondary analysis of data from a previous clinical trial including subjects with ARDS in whom VD/VT and CO2 production ([Formula: see text]) were measured with volumetric capnography. The estimated ratio of dead space to tidal volume (VD,est/VT) was calculated using standard empiric formulas. Agreement between measured and estimated values was evaluated with Bland-Altman analysis. Agreement between the predicted change in ΔP with extracorporeal CO2 removal as computed using the measured ratio of alveolar dead space to tidal volume (VDalv/VT) or estimated VDalv/VT (VDalv,est/VT) was also evaluated. RESULTS VD,est/VT was higher than measured VD/VT, and agreement between them was low (bias 0.05, limits of agreement -0.21 to 0.31). Differences between measured and estimated [Formula: see text] accounted for 57% of the error in VD,est/VT. The predicted reduction in ΔP with extracorporeal CO2 removal computed using VDalv,est/VT was in reasonable agreement with the expected reduction using VDalv/VT (bias -0.7 cm H2O, limits of agreement -1.87 to 0.47 cm H2O). In multivariable regression, measured VD/VT was associated with mortality (odds ratio 1.9, 95% CI 1.2-3.1, P = .01), but VD,est/VT was not (odds ratio 1.2, 95% CI 0.8-1.8, P = .3). CONCLUSIONS VD/VT and VD,est/VT showed low levels of agreement and cannot be used interchangeably in clinical practice. Nevertheless, the predicted decrease in ΔP due to extracorporeal CO2 removal was similar when computed from either estimated or measured VDalv/VT.
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Affiliation(s)
- Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Arthur S Slutsky
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
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15
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Kallet RH. Measured Versus Estimated Dead-Space Ventilation in ARDS: Does It Matter? Perhaps. Respir Care 2021; 66:703-704. [PMID: 33782141 PMCID: PMC9993990 DOI: 10.4187/respcare.08947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Richard H Kallet
- Department of Anesthesia and Perioperative Care, Respiratory Care DivisionUniversity of California, San Francisco at San Francisco General HospitalSan Francisco, California
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16
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Prone Position in Mechanically Ventilated COVID-19 Patients: A Multicenter Study. J Clin Med 2021; 10:jcm10051046. [PMID: 33802479 PMCID: PMC7959453 DOI: 10.3390/jcm10051046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/20/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022] Open
Abstract
Background: The prone position (PP) is increasingly used in mechanically ventilated coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) patients. However, studies investigating the influence of the PP are currently lacking in these patients. This is the first study to investigate the influence of the PP on the oxygenation and decarboxylation in COVID-19 patients. Methods: A prospective bicentric study design was used, and in mechanically ventilated COVID-19 patients, PP was indicated from a partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FIO2) ratio of <200. Patients were left prone for 16 h each. Pressure levels, FIO2, were adjusted to ensure a PaO2 greater than 60 mmHg. Blood gas analyses were performed before (baseline 0.5 h), during (1/2/5.5/9.5/13 h), and after being in the PP (1 h), the circulatory/ventilation parameters were continuously monitored, and lung compliance (LC) was roughly calculated. Responders were defined compared to the baseline value (PaO2/FIO2 ratio increase of ≥15%; partial pressure of carbon dioxide (PaCO2) decrease of ≥2%). Results: 13 patients were included and 36 PP sessions were conducted. Overall, PaO2/FIO2 increased significantly in the PP (p < 0.001). Most PaO2/FIO2 responders (29/36 PP sessions, 77%) were identified 9.5 h after turning prone (14% slow responders), while most PaCO2 responders (15/36 PP sessions, 42%) were identified 13 h after turning prone. A subgroup of patients (interval intubation to PP ≥3 days) showed less PaO2/FIO2 responders (16% vs. 77%). An increase in PaCO2 and minute ventilation in the PP showed a significant negative correlation (p < 0.001). LC (median before the PP = 38 mL/cm H2O; two patients with LC >80 mL/cm H2O) showed a significant positive correlation with the 28 day survival of patients (p = 0.01). Conclusion: The PP significantly improves oxygenation in COVID-19 ARDS patients. The data suggest that they also benefit most from an early PP. A decrease in minute ventilation may result in fewer PaCO2 responders. LC may be a predictive outcome parameter in COVID-19 patients. Trial registration: Retrospectively registered.
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17
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Kallet RH, Lipnick MS. End-Tidal-to-Arterial P CO2 Ratio as Signifier for Physiologic Dead-Space Ratio and Oxygenation Dysfunction in Acute Respiratory Distress Syndrome. Respir Care 2021; 66:263-268. [PMID: 32636278 PMCID: PMC9994218 DOI: 10.4187/respcare.08061] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The ratio of end-tidal CO2 pressure to arterial partial pressure of CO2 ([Formula: see text]) was recently suggested for monitoring pulmonary gas exchange in patients with ARDS associated with COVID-19, yet no evidence was offered supporting that claim. Therefore, we evaluated whether [Formula: see text] might be relevant in assessing ARDS not associated with COVID-19. METHODS We evaluated the correspondence between [Formula: see text] and the ratio of dead space to tidal volume (VD/VT) measured in 561 subjects with ARDS from a previous study in whom [Formula: see text] data were also available. Subjects also were analyzed according to 4 ranges of [Formula: see text] representing increasing illness severity (≥ 0.80, 0.6-0.79, 0.50-0.59, and < 0.50). Correlation was assessed by either Pearson or Spearman tests, grouped comparisons were assessed using either ANOVA or Kruskal-Wallis tests and dichotomous variables assessed by Fisher Exact tests. Normally distributed data are presented as mean and standard deviation(SD) and non-normal data are presented as median and inter-quartile range (IQR). Overall mortality risk was assessed with multivariate logistic regression. Alpha was set at 0.05. RESULTS [Formula: see text] correlated strongly with VD/VT (r = -0.87 [95% CI -0.89 to -0.85], P < .001). Decreasing [Formula: see text] was associated with increased VD/VT and hospital mortality between all groups. In the univariate analysis, for every 0.01 decrease in [Formula: see text], mortality risk increased by ∼1% (odds ratio 0.009, 95% CI 0.003-0.029, P < .001) and maintained a strong independent association with mortality risk when adjusted for other variables (odds ratio 0.19, 95% CI 0.04-0.91, P = .039). [Formula: see text] < 0.50 was characterized by very high mean ± SD value for VD/VT (0.82 ± 0.05, P < .001) and high hospital mortality (70%). CONCLUSIONS Using [Formula: see text] as a surrogate for VD/VT may be a useful and practical measurement for both management and ongoing research into the nature of ARDS.
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Affiliation(s)
- Richard H Kallet
- Department of Anesthesia and Perioperative Care, Respiratory Care Division, University of California, San Francisco at San Francisco General Hospital, San Francisco, California.
| | - Michael S Lipnick
- Department of Anesthesia and Perioperative Care, Critical Care Division, University of California, San Francisco at San Francisco General Hospital, San Francisco, California
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18
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Garfield B, McFadyen C, Briar C, Bleakley C, Vlachou A, Baldwin M, Lees N, Price S, Ledot S, McCabe C, Wort SJ, Patel BV, Price LC. Potential for personalised application of inhaled nitric oxide in COVID-19 pneumonia. Br J Anaesth 2021; 126:e72-e75. [PMID: 33288208 PMCID: PMC7666572 DOI: 10.1016/j.bja.2020.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/06/2020] [Accepted: 11/06/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Benjamin Garfield
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Charlotte Briar
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | | | | | - Melissa Baldwin
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Nick Lees
- Adult Intensive Care Unit, Harefield Hospital, Harefield, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Colm McCabe
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton Hospital, UK
| | - S John Wort
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton Hospital, UK
| | - Brijesh V Patel
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; Anaesthetics, Pain Medicine and Intensive Care, Surgery and Cancer, Imperial College London, UK
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK; National Pulmonary Hypertension Service, Royal Brompton Hospital, UK.
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19
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Jochmans S, Mazerand S, Chelly J, Pourcine F, Sy O, Thieulot-Rolin N, Ellrodt O, Mercier Des Rochettes E, Michaud G, Serbource-Goguel J, Vinsonneau C, Vong LVP, Monchi M. Duration of prone position sessions: a prospective cohort study. Ann Intensive Care 2020; 10:66. [PMID: 32449068 PMCID: PMC7245995 DOI: 10.1186/s13613-020-00683-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 05/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background Prone position (PP) is highly recommended in moderate-to-severe ARDS. However, the optimal duration of PP sessions remains unclear. We searched to evaluate the time required to obtain the maximum physiological effect, and to search for parameters related to patient survival in PP. Methods and results It was a prospective, monocentric, physiological study. We included in the study all prone-positioned patients in our ICU between June 2016 and January 2018. Pulmonary mechanics, data from volumetric capnography and arterial blood gas were recorded before prone positioning, 2 h after proning, before return to a supine position (SP) and 2 h after return to SP. Dynamic parameters were recorded before proning and every 30 min during the session until 24 h. 103 patients (ARDS 95%) were included performing 231 PP sessions with a mean length of 21.5 ± 5 h per session. They presented a significant increase in pH, static compliance and PaO2/FiO2 with a significant decrease in PaCO2, Pplat, phase 3 slope of the volumetric capnography, PetCO2, VD/VT-phy and ΔP. The beneficial physiological effects continued after 16 h of PP and at least up to 24 h in some patients. The evolution of the respiratory parameters during the first session and also during the pooled sessions did not find any predictor of response to PP, whether before, during or 2 h after the return in SP. Conclusions PP sessions should be prolonged at least 24 h and be extended in the event that the PaO2/FiO2 ratio at 24 h remains below 150, especially since no criteria can predict which patient will benefit or not from it. Trial registration The trial has been registered on 28 June 2016 in ClinicalTrials.gov (NCT 02816190) (https://clinicaltrials.gov/ct2/show/NCT02816190?term=propocap&rank=1).
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Affiliation(s)
- Sebastien Jochmans
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France. .,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.
| | - Sandie Mazerand
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Jonathan Chelly
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Franck Pourcine
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Oumar Sy
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Nathalie Thieulot-Rolin
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Olivier Ellrodt
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Emmanuelle Mercier Des Rochettes
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Service de Réanimation Médicale, AP-HP, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Gaël Michaud
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Jean Serbource-Goguel
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Christophe Vinsonneau
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Service de Réanimation, Hôpital de Béthune, 27 rue Delbecque, 62660, Beuvry, France
| | - Ly Van Phach Vong
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Mehran Monchi
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
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20
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Sinha P, Calfee CS, Beitler JR, Soni N, Ho K, Matthay MA, Kallet RH. Physiologic Analysis and Clinical Performance of the Ventilatory Ratio in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2019; 199:333-341. [PMID: 30211618 DOI: 10.1164/rccm.201804-0692oc] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Pulmonary dead space fraction (Vd/Vt) is an independent predictor of mortality in acute respiratory distress syndrome (ARDS). Yet, it is seldom used in practice. The ventilatory ratio is a simple bedside index that can be calculated using routinely measured respiratory variables and is a measure of impaired ventilation. Ventilatory ratio is defined as [minute ventilation (ml/min) × PaCO2 (mm Hg)]/(predicted body weight × 100 × 37.5). OBJECTIVES To determine the relation of ventilatory ratio with Vd/Vt in ARDS. METHODS First, in a single-center, prospective observational study of ARDS, we tested the association of Vd/Vt with ventilatory ratio. With in-hospital mortality as the primary outcome and ventilator-free days as the secondary outcome, we tested the role of ventilatory ratio as an outcome predictor. The findings from this study were further verified in secondary analyses of two NHLBI ARDS Network randomized controlled trials. MEASUREMENTS AND MAIN RESULTS Ventilatory ratio positively correlated with Vd/Vt. Ordinal groups of ventilatory ratio had significantly higher Vd/Vt. Ventilatory ratio was independently associated with increased risk of mortality after adjusting for PaO2/FiO2, and positive end-expiratory pressure (odds ratio, 1.51; P = 0.024) and after adjusting for Acute Physiologic Assessment and Chronic Health Evaluation II score (odds ratio, 1.59; P = 0.04). These findings were further replicated in secondary analyses of two separate NHLBI randomized controlled trials. CONCLUSIONS Ventilatory ratio correlates well with Vd/Vt in ARDS, and higher values at baseline are associated with increased risk of adverse outcomes. These results are promising for the use of ventilatory ratio as a simple bedside index of impaired ventilation in ARDS.
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Affiliation(s)
- Pratik Sinha
- 1 Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine
| | - Carolyn S Calfee
- 1 Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine.,2 Department of Anesthesia, and.,3 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Jeremy R Beitler
- 4 Division of Pulmonary and Critical Care Medicine, University of California, San Diego, San Diego, California
| | - Neil Soni
- 5 Magill Department of Anaesthesia, Intensive Care Medicine and Pain Management, Chelsea and Westminster Hospital, London, United Kingdom; and
| | - Kelly Ho
- 6 Respiratory Care Services, Department of Anesthesia and Perioperative Care, University of California, San Francisco at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Michael A Matthay
- 1 Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine.,2 Department of Anesthesia, and.,3 Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Richard H Kallet
- 6 Respiratory Care Services, Department of Anesthesia and Perioperative Care, University of California, San Francisco at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
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21
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Booker J, Sinha S, Choudhari K, Dawson J, Singh R. Predicting functional recovery after mild traumatic brain injury: the SHEFBIT cohort. Brain Inj 2019; 33:1158-1164. [DOI: 10.1080/02699052.2019.1629626] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- James Booker
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Saurabh Sinha
- Department of Neurosurgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Kishor Choudhari
- Department of Neurosurgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Jeremy Dawson
- Institute of Work Psychology, University of Sheffield Management School, Sheffield, UK
| | - Rajiv Singh
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Osborn Neurorehabilitation Unit, Department of Rehabilitation Medicine, Sheffield Teaching Hospitals, Sheffield, UK
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22
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Basmaciyan L, Bon F, Paradis T, Lapaquette P, Dalle F. " Candida Albicans Interactions With The Host: Crossing The Intestinal Epithelial Barrier". Tissue Barriers 2019; 7:1612661. [PMID: 31189436 PMCID: PMC6619947 DOI: 10.1080/21688370.2019.1612661] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/24/2019] [Accepted: 04/24/2019] [Indexed: 02/08/2023] Open
Abstract
Formerly a commensal organism of the mucosal surfaces of most healthy individuals, Candida albicans is an opportunistic pathogen that causes infections ranging from superficial to the more life-threatening disseminated infections, especially in the ever-growing population of vulnerable patients in the hospital setting. In these situations, the fungus takes advantage of its host following a disturbance in the host defense system and/or the mucosal microbiota. Overwhelming evidence suggests that the gastrointestinal tract is the main source of disseminated C. albicans infections. Major risk factors for disseminated candidiasis include damage to the mucosal intestinal barrier, immune dysfunction, and dysbiosis of the resident microbiota. A better understanding of C. albicans' interaction with the intestinal epithelial barrier will be useful for designing future therapies to avoid systemic candidiasis. In this review, we provide an overview of the current knowledge regarding the mechanisms of pathogenicity that allow the fungus to reach and translocate the gut barrier.
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Affiliation(s)
- Louise Basmaciyan
- Laboratoire de Parasitologie-Mycologie, Plateforme de Biologie Hospitalo-Universitaire Gérard Mack, Dijon France
- UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
| | - Fabienne Bon
- UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
| | - Tracy Paradis
- UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
| | - Pierre Lapaquette
- UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
| | - Frédéric Dalle
- Laboratoire de Parasitologie-Mycologie, Plateforme de Biologie Hospitalo-Universitaire Gérard Mack, Dijon France
- UMR PAM Univ Bourgogne Franche-Comté - AgroSup Dijon - Equipe Vin, Aliment, Microbiologie, Stress, Dijon, France
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23
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Smeijsters KMG, Bijkerk RM, Daniels JMA, van de Ven PM, Girbes ARJ, Heunks LMA, Spijkstra JJ, Tuinman PR. Effect of Bronchoscopy on Gas Exchange and Respiratory Mechanics in Critically Ill Patients With Atelectasis: An Observational Cohort Study. Front Med (Lausanne) 2018; 5:301. [PMID: 30483505 PMCID: PMC6243639 DOI: 10.3389/fmed.2018.00301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/11/2018] [Indexed: 11/29/2022] Open
Abstract
Background: Atelectasis frequently develops in critically ill patients and may result in impaired gas exchange among other complications. The long-term effects of bronchoscopy on gas exchange and the effects on respiratory mechanics are largely unknown. Objective: To evaluate the effect of bronchoscopy on gas exchange and respiratory mechanics in intensive care unit (ICU) patients with atelectasis. Methods: A retrospective, single-center cohort study of patients with clinical indication for bronchoscopy because of atelectasis diagnosed on chest X-ray (CXR). Results: In total, 101 bronchoscopies were performed in 88 ICU patients. Bronchoscopy improved oxygenation (defined as an increase of PaO2/FiO2 ratio > 20 mmHg) and ventilation (defined as a decrease of > 2 mmHg in partial pressure of CO2 in arterial blood) in 76 and 59% of procedures, respectively, for at least 24 h. Patients with a low baseline value of PaO2/FiO2 ratio and a high baseline value of PaCO2 were most likely to benefit from bronchoscopy. In addition, in intubated and pressure control ventilated patients, respiratory mechanics improved after bronchoscopy for up to 24 h. Mild complications, and in particular desaturation between 80 and 90%, were reported in 13% of the patients. Conclusions: In selected critically ill patients with atelectasis, bronchoscopy improves oxygenation, ventilation, and respiratory mechanics for at least 24 h.
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Affiliation(s)
- Kim M G Smeijsters
- Department of Intensive Care, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Anesthesiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ronald M Bijkerk
- Department of Intensive Care, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Anesthesiology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | - Johannes M A Daniels
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Armand R J Girbes
- Department of Intensive Care, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Leo M A Heunks
- Department of Intensive Care, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Jan Jaap Spijkstra
- Department of Intensive Care, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
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24
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Cassarly C, Martin RH, Chimowitz M, Peña EA, Ramakrishnan V, Palesch YY. Treatment effect on ordinal functional outcome using piecewise multistate Markov model with unobservable baseline: an application to the modified Rankin scale. J Biopharm Stat 2018; 29:82-97. [PMID: 29985739 DOI: 10.1080/10543406.2018.1489404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In clinical trials, longitudinally assessed ordinal outcomes are commonly dichotomized and only the final measure is used for primary analysis, partly for ease of clinical interpretation. Dichotomization of the ordinal scale and failure to utilize the repeated measures can reduce statistical power. Additionally, in certain emergent settings, the same measure cannot be assessed at baseline prior to treatment. For such a data set, a piecewise-constant multistate Markov model that incorporates a latent model for the unobserved baseline measure is proposed. These models can be useful in analyzing disease history data and are advantageous in clinical applications where a disease process naturally moves through increasing stages of severity. Two examples are provided using acute stroke clinical trials data. Conclusions drawn in this article are consistent with those from the primary analysis for treatment effect in both of the motivating examples. Use of these models allows for a more refined examination of treatment effect and describes the movement between health states from baseline to follow-up visits which may provide more clinical insight into the treatment effect.
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Affiliation(s)
- Christy Cassarly
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA.,b Department of Otolaryngology-Head & Neck Surgery , Medical University of South Carolina , Charleston , SC , USA
| | - Renee' H Martin
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
| | - Marc Chimowitz
- c Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Edsel A Peña
- d Department of Statistics , University of South Carolina , Columbia , SC , USA
| | - Viswanathan Ramakrishnan
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
| | - Yuko Y Palesch
- a Department of Public Health Sciences , Medical University of South Carolina , Charleston , SC , USA
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25
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Erbatur ME, Sezen ŞC, Bayraktar AC, Arslan M, Kavutçu M, Aydın ME. Effects of dexmedetomidine on renal tissue after lower limb ischemia reperfusion injury in streptozotocin induced diabetic rats. Libyan J Med 2017; 12:1270021. [PMID: 28452604 PMCID: PMC5328322 DOI: 10.1080/19932820.2017.1270021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 12/03/2016] [Indexed: 01/22/2023] Open
Abstract
AIM The aim of this study was to investigate whether dexmedetomidine - administered before ischemia - has protective effects against lower extremity ischemia reperfusion injury that induced by clamping and subsequent declamping of infra-renal abdominal aorta in streptozotocin-induced diabetic rats. MATERIAL AND METHODS After obtaining ethical committee approval, four study groups each containing six rats were created (Control (Group C), diabetes-control (Group DM-C), diabetes I/R (Group DM-I/R), and diabetes-I/R-dexmedetomidine (Group DM-I/R-D). In diabetes groups, single-dose (55 mg/kg) streptozotocin was administered intraperitoneally. Rats with a blood glucose level above 250 mg/dl at the 72nd hour were accepted as diabetic. At the end of four weeks, laparotomy was performed in all rats. Nothing else was done in Group C and DM-C. In Group DM-I/R, ischemia reperfusion was produced via two-hour periods of clamping and subsequent declamping of infra-renal abdominal aorta. In Group DM-I/R-D, 100 μg/kg dexmedetomidine was administered intraperitoneally 30 minutes before ischemia period. At the end of reperfusion, period biochemical and histopathological evaluation of renal tissue specimen were performed. RESULTS Thiobarbituric acid reactive substance (TBARS), Superoxide dismutase (SOD), Nitric oxide synthase (NOS), Catalase (CAT) and Glutathion S transferase (GST) levels were found significantly higher in Group DM-I/R when compared with Group C and Group DM-C. In the dexmedetomidine-treated group, TBARS, NOS, CAT, and GST levels were significantly lower than those measured in the Group D-I/R. In histopathological evaluation, glomerular vacuolization (GV), tubular dilatation (TD), vascular vacuolization and hypertrophy (VVH), tubular cell degeneration and necrosis (TCDN), tubular hyaline cylinder (THC), leucocyte infiltration (LI), and tubular cell spillage (TCS) in Group DM-I/R were significantly increased when compared with the control group. Also, GV, VVH, and THC levels in the dexmedetomidine-treated group (Group DM-I/R-D) were found significantly decreased when compared with the Group DM-I/R. CONCLUSION We found that dexmedetomidine - 100 μg/kg intraperitoneally - administered 30 minutes before ischemia in diabetic rats ameliorates lipid peroxidation, oxidative stress, and I-R-related renal injury. We suggest that dexmedetomidine administration in diabetic rats before I/R has renoprotective effects.
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Affiliation(s)
- Meral Erdal Erbatur
- Department of Anesthesiology and Reanimation, Gazi University, Ankara, Turkey
| | - Şaban Cem Sezen
- Department of Histology and Embryology, Kırıkkale University, Kırıkkale, Turkey
| | | | - Mustafa Arslan
- Department of Anesthesiology and Reanimation, Gazi University, Ankara, Turkey
| | - Mustafa Kavutçu
- Department of Medical Biochemistry, Gazi University, Ankara, Turkey
| | - Muhammed Enes Aydın
- Department of Anesthesiology and Reanimation, Gazi University, Ankara, Turkey
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26
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Barnes T, Zochios V, Parhar K. Re-examining Permissive Hypercapnia in ARDS: A Narrative Review. Chest 2017; 154:185-195. [PMID: 29175086 DOI: 10.1016/j.chest.2017.11.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/20/2017] [Accepted: 11/13/2017] [Indexed: 12/16/2022] Open
Abstract
Lung-protective ventilation (LPV) has become the cornerstone of management in patients with ARDS. A subset of patients is unable to tolerate LPV without significant CO2 elevation. In these patients, permissive hypercapnia is used. Although thought to be benign, it is becoming increasingly evident that elevated CO2 levels have significant physiological effects. In this narrative review, we highlight clinically relevant end-organ effects in both animal models and clinical studies. We also explore the association between elevated CO2, acute cor pulmonale, and ICU mortality. We conclude with a brief review of alternative therapies for CO2 management currently under investigation in patients with moderate to severe ARDS.
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Affiliation(s)
- Tavish Barnes
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Vasileios Zochios
- Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, College of Medical and Dental Sciences, University of Birmingham, Birmingham, England
| | - Ken Parhar
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
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27
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Radermacher P, Maggiore SM, Mercat A. FiftyYears ofResearch inARDS.Gas Exchange in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:964-984. [DOI: 10.1164/rccm.201610-2156so] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Peter Radermacher
- Institute of Anaesthesiological Pathophysiology and Process Engineering, University Medical School, Ulm, Germany
| | - Salvatore Maurizio Maggiore
- Section of Anesthesia, Analgesia, Perioperative, and Intensive Care, Department of Medical, Oral, and Biotechnological Sciences, School of Medicine and Health Sciences, “SS. Annunziata” Hospital, “Gabriele d’Annunzio” University of Chieti-Pescara, Chieti, Italy; and
| | - Alain Mercat
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France
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28
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Kim EH, Preissner M, Carnibella RP, Samarage CR, Bennett E, Diniz MA, Fouras A, Zosky GR, Jones HD. Novel analysis of 4DCT imaging quantifies progressive increases in anatomic dead space during mechanical ventilation in mice. J Appl Physiol (1985) 2017; 123:578-584. [PMID: 28596273 DOI: 10.1152/japplphysiol.00903.2016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 06/02/2017] [Accepted: 06/04/2017] [Indexed: 11/22/2022] Open
Abstract
Increased dead space is an important prognostic marker in early acute respiratory distress syndrome (ARDS) that correlates with mortality. The cause of increased dead space in ARDS has largely been attributed to increased alveolar dead space due to ventilation/perfusion mismatching and shunt. We sought to determine whether anatomic dead space also increases in response to mechanical ventilation. Mice received intratracheal lipopolysaccharide (LPS) or saline and mechanical ventilation (MV). Four-dimensional computed tomography (4DCT) scans were performed at onset of MV and after 5 h of MV. Detailed measurements of airway volumes and lung tidal volumes were performed using image analysis software. The forced oscillation technique was used to obtain measures of airway resistance, tissue damping, and tissue elastance. The ratio of airway volumes to total tidal volume increased significantly in response to 5 h of mechanical ventilation, regardless of LPS exposure, and airways demonstrated significant variation in volumes over the respiratory cycle. These findings were associated with an increase in tissue elastance (decreased lung compliance) but without changes in tidal volumes. Airway volumes increased over time with exposure to mechanical ventilation without a concomitant increase in tidal volumes. These findings suggest that anatomic dead space fraction increases progressively with exposure to positive pressure ventilation and may represent a pathological process.NEW & NOTEWORTHY We demonstrate that anatomic dead space ventilation increases significantly over time in mice in response to mechanical ventilation. The novel functional lung-imaging techniques applied here yield sensitive measures of airway volumes that may have wide applications.
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Affiliation(s)
- Elizabeth H Kim
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Melissa Preissner
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Victoria, Australia
| | | | | | - Ellen Bennett
- School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Marcio A Diniz
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Andreas Fouras
- 4Dx Limited, Melbourne, Victoria, Australia.,Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Graeme R Zosky
- School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Heather D Jones
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, California; .,Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
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29
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Repessé X, Vieillard-Baron A. Hypercapnia during acute respiratory distress syndrome: the tree that hides the forest! J Thorac Dis 2017; 9:1420-1425. [PMID: 28740647 DOI: 10.21037/jtd.2017.05.69] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Xavier Repessé
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, University Hospital Ambroise Paré, Boulogne-Billancourt, France
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, University Hospital Ambroise Paré, Boulogne-Billancourt, France.,Faculty of Medicine Paris Ile-de-France Ouest, University of Versailles Saint-Quentin en Yvelines, Saint-Quentin en Yvelines, France.,INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, Villejuif, France
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Bian W, Chen W, Chao Y, Wang L, Li L, Guan J, Zang X, Zhen J, Sheng B, Zhu X. Application of dead space fraction to titrate optimal positive end-expiratory pressure in an ARDS swine model. Exp Ther Med 2017; 13:1572-1577. [PMID: 28413511 DOI: 10.3892/etm.2017.4117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/05/2016] [Indexed: 11/05/2022] Open
Abstract
This study aimed to apply the dead space fraction [ratio of dead space to tidal volume (VD/VT)] to titrate the optimal positive end-expiratory pressure (PEEP) in a swine model of acute respiratory distress syndrome (ARDS). Twelve swine models of ARDS were constructed. A lung recruitment maneuver was then conducted and the PEEP was set at 20 cm H2O. The PEEP was reduced by 2 cm H2O every 10 min until 0 cm H2O was reached, and VD/VT was measured after each decrement step. VD/VT was measured using single-breath analysis of CO2, and calculated from arterial CO2 partial pressure (PaCO2) and mixed expired CO2 (PeCO2) using the following formula: VD/VT = (PaCO2 - PeCO2)/PaCO2. The optimal PEEP was identified by the lowest VD/VT method. Respiration and hemodynamic parameters were recorded during the periods of pre-injury and injury, and at 4 and 2 cm H2O below and above the optimal PEEP (Po). The optimal PEEP in this study was found to be 13.25±1.36 cm H2O. During the Po period, VD/VT decreased to a lower value (0.44±0.08) compared with that during the injury period (0.68±0.10) (P<0.05), while the intrapulmonary shunt fraction reached its lowest value. In addition, a significant change of dynamic tidal respiratory compliance and oxygenation index was induced by PEEP titration. These results indicate that minimal VD/VT can be used for PEEP titration in ARDS.
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Affiliation(s)
- Weishuai Bian
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Wei Chen
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Yangong Chao
- Department of Critical Care Medicine, The First Affiliated Hospital, Tsing Hua University, Beijing 100016, P.R. China
| | - Lan Wang
- Department of Critical Care Medicine, Dongzhimen Chinese Medical Hospital, Beijing Chinese-Medical University, Beijing 100700, P.R. China
| | - Liming Li
- Department of Critical Care Medicine, The First Affiliated Hospital, Tsing Hua University, Beijing 100016, P.R. China
| | - Jian Guan
- Department of Critical Care Medicine, The First Affiliated Hospital, Tsing Hua University, Beijing 100016, P.R. China
| | - Xuefeng Zang
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Jie Zhen
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Bo Sheng
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, P.R. China
| | - Xi Zhu
- Department of Critical Care Medicine, Third Hospital, Peking University, Beijing 100083, P.R. China
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Buckman SA, Krekel T, Muller AE, Mazuski JE. Ceftazidime-avibactam for the treatment of complicated intra-abdominal infections. Expert Opin Pharmacother 2016; 17:2341-2349. [PMID: 27758148 DOI: 10.1080/14656566.2016.1249847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The treatment of complicated intra-abdominal infections (cIAI) is increasingly challenging due to increased resistance of Gram-negative organisms. These multidrug resistant organisms lead to an increase in morbidity and mortality. This has led to renewed interest in use of older β-lactam antibiotics in combination with newer β-lactamase inhibitors. Ceftazidime-avibactam is one of the newest such combination antibiotics, which has been released for treatment of complicated intra-abdominal infections in combination with metronidazole. Areas covered: In this drug evaluation manuscript cIAI along with the chemistry, pharmacodynamics, pharmacokinetics, metabolism and clinical study results of ceftazidime-avibactam are reviewed. Expert opinion: The role of ceftazidime-avibactam in combination with metronidazole in the treatment of cIAI is still to be defined. Patients with cIAI known to be infected with Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae would be clear candidates for treatment with this agent, as would patients infected with more common types of extended-spectrum β-lactamase producing Gram-negative pathogens if a carbapenem alternative were desired. At present, it is difficult to establish a clear group of patients with cIAI for whom initial empiric therapy with this agent would be warranted.
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Affiliation(s)
- Sara A Buckman
- a Department of Acute and Critical Care Surgery , Washington University School of Medicine , Saint Louis , USA
| | - Tamara Krekel
- b Department of Pharmacy, Infectious Diseases Clinical Pharmacy Specialist , Barnes-Jewish Hospital , Saint Louis , USA
| | - Anouk E Muller
- c Department of Medical Microbiology , Medical Centre Haaglanden-Bronovo , The Hague , The Netherlands
| | - John E Mazuski
- a Department of Acute and Critical Care Surgery , Washington University School of Medicine , Saint Louis , USA
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Verscheure S, Massion PB, Verschuren F, Damas P, Magder S. Volumetric capnography: lessons from the past and current clinical applications. Crit Care 2016; 20:184. [PMID: 27334879 PMCID: PMC4918076 DOI: 10.1186/s13054-016-1377-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Dead space is an important component of ventilation–perfusion abnormalities. Measurement of dead space has diagnostic, prognostic and therapeutic applications. In the intensive care unit (ICU) dead space measurement can be used to guide therapy for patients with acute respiratory distress syndrome (ARDS); in the emergency department it can guide thrombolytic therapy for pulmonary embolism; in peri-operative patients it can indicate the success of recruitment maneuvers. A newly available technique called volumetric capnography (Vcap) allows measurement of physiological and alveolar dead space on a regular basis at the bedside. We discuss the components of dead space, explain important differences between the Bohr and Enghoff approaches, discuss the clinical significance of arterial to end-tidal CO2 gradient and finally summarize potential clinical indications for Vcap measurements in the emergency room, operating room and ICU.
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Affiliation(s)
- Sara Verscheure
- Department of Critical Care Medicine, University of McGill, Montreal, Quebec, Canada.,Department of General Intensive Care, University Hospital of Liege, Liege, Belgium
| | - Paul B Massion
- Department of General Intensive Care, University Hospital of Liege, Liege, Belgium
| | - Franck Verschuren
- Department of Emergency Medicine, Cliniques universitaire Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Liege, Belgium
| | - Sheldon Magder
- Department of Critical Care Medicine, University of McGill, Montreal, Quebec, Canada.
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Xu Y, Deng X, Han Y, Zhou L, He W, Chen S, Nong L, Huang H, Zhang Y, Yu T, Li Y, Liu X. A Multicenter Retrospective Review of Prone Position Ventilation (PPV) in Treatment of Severe Human H7N9 Avian Flu. PLoS One 2015; 10:e0136520. [PMID: 26317621 PMCID: PMC4552847 DOI: 10.1371/journal.pone.0136520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 08/05/2015] [Indexed: 12/26/2022] Open
Abstract
Background Patients with H7N9 avian flu concurrent with severe acute respiratory distress syndrome (ARDS) usually have a poor clinical outcome. Prone position ventilation (PPV) has been shown to improve the prognosis of patients with severe ARDS. This study explored the effects of PPV on the respiratory and circulatory mechanics of H7N9-infected patients with severe ARDS. Methods Individuals admitted to four hospitals designated for H7N9 patients in Guangdong province were treated with PPV, and their clinical data were recorded before and after receiving PPV. Results Six of 20 critically ill patients in the ICU received PPV. After treatment with 35 PPV sessions, the oxygenation index (OI) values of the six patients when measured post-PPV and post-supine position ventilation (SPV) were significantly higher than those measured pre-PPV (P < 0.05).The six patients showed no significant differences in their values for respiratory rate (RR), peak inspiratory pressure (PIP), tidal volume (TV) or arterial partial pressure of carbon dioxide (PaCO2) when compared pre-PPV, post-PPV, and post-SPV. Additionally, there were no significant differences in the mean values for arterial pressure (MAP), cardiac index (CI), central venous pressure (CVP), heart rate (HR), lactic acid (LAC) levels or the doses of norepinephrine (NE) administered when compared pre-PPV, post-PPV, and post-SPV. Conclusion PPV provided improved oxygenation that was sustained after returning to a supine position, and resulted in decreased carbon dioxide retention. PPV can thus serve as an alternative lung protective ventilation strategy for use in patients with H7N9 avian flu concurrent with severe ARDS.
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Affiliation(s)
- Yuanda Xu
- State Key Laboratory of Respiratory Diseases, Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Xilong Deng
- Department of Critical Care Medicine, Guangzhou Eighth People’s Hospital, Guangzhou, 510060, China
| | - Yun Han
- Department of Critical Care Medicine, Fangcun Branch of Guangdong Hospital of Traditional Chinese Medicine, Guangzhou, 510360, China
| | - Lixin Zhou
- Department of Critical Care Medicine, Foshan First People’s Hospital, Foshan, 528000, China
| | - Weiqun He
- State Key Laboratory of Respiratory Diseases, Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Sibei Chen
- State Key Laboratory of Respiratory Diseases, Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Lingbo Nong
- State Key Laboratory of Respiratory Diseases, Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Huang Huang
- Department of Critical Care Medicine, Guangzhou Eighth People’s Hospital, Guangzhou, 510060, China
| | - Yan Zhang
- Department of Critical Care Medicine, Fangcun Branch of Guangdong Hospital of Traditional Chinese Medicine, Guangzhou, 510360, China
| | - Tieou Yu
- Department of Critical Care Medicine, Foshan First People’s Hospital, Foshan, 528000, China
| | - Yimin Li
- State Key Laboratory of Respiratory Diseases, Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- * E-mail: (YL); (XL)
| | - Xiaoqing Liu
- State Key Laboratory of Respiratory Diseases, Department of Critical Care Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
- * E-mail: (YL); (XL)
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Estimating dead-space fraction for secondary analyses of acute respiratory distress syndrome clinical trials. Crit Care Med 2015; 43:1026-35. [PMID: 25738857 DOI: 10.1097/ccm.0000000000000921] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pulmonary dead-space fraction is one of few lung-specific independent predictors of mortality from acute respiratory distress syndrome. However, it is not measured routinely in clinical trials and thus altogether ignored in secondary analyses that shape future research directions and clinical practice. This study sought to validate an estimate of dead-space fraction for use in secondary analyses of clinical trials. DESIGN Analysis of patient-level data pooled from acute respiratory distress syndrome clinical trials. Four approaches to estimate dead-space fraction were evaluated: three required estimating metabolic rate; one estimated dead-space fraction directly. SETTING U.S. academic teaching hospitals. PATIENTS Data from 210 patients across three clinical trials were used to compare performance of estimating equations with measured dead-space fraction. A second cohort of 3,135 patients from six clinical trials without measured dead-space fraction was used to confirm whether estimates independently predicted mortality. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Dead-space fraction estimated using the unadjusted Harris-Benedict equation for energy expenditure was unbiased (mean ± SD Harris-Benedict, 0.59 ± 0.13; measured, 0.60 ± 0.12). This estimate predicted measured dead-space fraction to within ±0.10 in 70% of patients and ±0.20 in 95% of patients. Measured dead-space fraction independently predicted mortality (odds ratio, 1.36 per 0.05 increase in dead-space fraction; 95% CI, 1.10-1.68; p < 0.01). The Harris-Benedict estimate closely approximated this association with mortality in the same cohort (odds ratio, 1.55; 95% CI, 1.21-1.98; p < 0.01) and remained independently predictive of death in the larger Acute Respiratory Distress Syndrome Network cohort. Other estimates predicted measured dead-space fraction or its association with mortality less well. CONCLUSIONS Dead-space fraction should be measured in future acute respiratory distress syndrome clinical trials to facilitate incorporation into secondary analyses. For analyses where dead-space fraction was not measured, the Harris-Benedict estimate can be used to estimate dead-space fraction and adjust for its association with mortality.
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Pfurtscheller K, Ring S, Beran E, Sorantin E, Zobel J, Ganster D, Avian A, Zobel G. Effect of body position on ventilation distribution during PEEP titration in a porcine model of acute lung injury using advanced respiratory monitoring and electrical impedance tomography. Intensive Care Med Exp 2015. [PMID: 26215805 PMCID: PMC4513029 DOI: 10.1186/s40635-014-0038-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Lung failure after acute lung injury remains a challenge in different clinical settings. Various interventions for restoration of gas exchange have been investigated. Recruitment of collapsed alveoli by positive end expiratory pressure (PEEP) titration and optimization of ventilation-perfusion ratio by prone positioning have been extensively described in animal and clinical trials. This animal study was conducted to investigate the effects of PEEP and positioning by means of advanced respiratory monitoring including gas exchange, respiratory mechanics, volumetric capnography and electrical impedance tomography. Methods After induction of acute lung injury by oleic acid and lung lavage, 12 domestic pigs were studied in randomly assigned supine or prone position during a PEEP titration trial with maximal PEEP of 30 mbar. Results Induction of lung injury resulted in significant deterioration of oxygenation [partial pressure of arterial oxygen/inspiratory fraction of oxygen (PaO2/FiO2): p = 0.002] and ventilation [partial pressure of arterial carbon dioxide (PaCO2): p = 0.002] and elevated alveolar dead-space ratios (Valv/Vte: p = 0.003) in both groups. Differences in the prone and the supine group were significant for PaCO2 at incremental PEEP 10 and 20 and at decremental PEEP 20 (20d) and 10 (10d), for PaO2/FiO2 at PEEP 10 and 10d and for alveolar dead space at PEEP 10d. Electrical impedance tomography revealed homogenous ventilation distribution in prone position during PEEP 20, 30 and 20d. Conclusions Prone position leads to improved oxygenation and ventilation parameters in a lung injury model. Respiratory monitoring with measurement of alveolar dead space and electrical impedance tomography may visualize optimized ventilation in a PEEP titration trial.
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Affiliation(s)
- Klaus Pfurtscheller
- Pediatric Intensive Care Unit, University Children's Hospital and Medical University Graz, Auenbruggerplatz 34, 8036, Graz, Austria,
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Kallet RH, Zhuo H, Liu KD, Calfee CS, Matthay MA. The association between physiologic dead-space fraction and mortality in subjects with ARDS enrolled in a prospective multi-center clinical trial. Respir Care 2013; 59:1611-8. [PMID: 24381187 DOI: 10.4187/respcare.02593] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We tested the association between pulmonary dead-space fraction (ratio of dead space to tidal volume [V(D)/V(T)]) and mortality in subjects with ARDS (Berlin definition, P(aO2)/F(IO2) ≤ 300 mm Hg; PEEP ≥ 5 cm H2O) enrolled into a clinical trial incorporating lung-protective ventilation. METHODS We conducted a prospective, multi-center study at medical-surgical ICUs in the United States. A total of 126 ALI subjects with acute lung injury were enrolled into a phase 3 randomized, placebo-controlled study of aerosolized albuterol. V(D)/V(T) and pulmonary mechanics were measured within 4 h of enrollment and repeated daily on study days 1 and 2 in subjects requiring arterial blood gases for clinical management. RESULTS At baseline, non-survivors had a trend toward higher V(D)/V(T) compared with survivors (0.62 ± 0.11 vs 0.56 ± 0.11, respectively, P = .08). Differences in V(D)/V(T) between non-survivors and survivors became significant on study days 1 (0.64 ± 0.12 vs 0.55 ± 0.11, respectively, P = .01) and 2 (0.67 ± 0.12 vs 0.56 ± 0.11, respectively, P = .004). Likewise, the association between VD/VT and mortality was significant on study day 1 (odds ratio per 0.10 change in V(D)/V(T) [95% CI]: 6.84 [1.62-28.84] P = .01; and study day 2: 4.90 [1.28-18.73] P = .02) after adjusting for V(D)/V(T), P(aO2)/F(IO2), oxygenation index, vasopressor use, and the primary risk for ARDS. Using a Cox proportional hazard model, V(D)/V(T) was associated with a trend toward higher mortality (HR = 4.37 [CI 0.99-19.32], P = .052) that became significant when the analysis was adjusted for daily oxygenation index (HR = 1.74 [95% CI 1.12-3.35] P = .04). CONCLUSIONS Markedly elevated V(D)/V(T) (≥ 0.60) in early ARDS is associated with higher mortality. Measuring V(D)/V(T) may be useful in identifying ARDS patients at increased risk of death who are enrolled into a therapeutic trial.
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Affiliation(s)
- Richard H Kallet
- Respiratory Care Services, University of California San Francisco Department of Anesthesia at San Francisco General Hospital
| | - Hanjing Zhuo
- Cardiovascular Research Institute, University of California, San Francisco
| | - Kathleen D Liu
- Department of Nephrology, University of California, San Francisco
| | - Carolyn S Calfee
- Department of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, California
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco
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Kallet RH, Alonso JA, Matthay MA. Quantifying the severity of acute lung injury using dead-space ventilation: should the lung injury score be updated? Respir Care 2012; 57:477-9. [PMID: 22391272 PMCID: PMC3601047 DOI: 10.4187/respcare.01737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Management of acute respiratory failure is an important component of intensive care. In this review, we analyze 21 original research articles published last year in Critical Care in the field of respiratory and critical care medicine. The articles are summarized according to the following topic categories: acute respiratory distress syndrome, mechanical ventilation, adjunctive therapies, and pneumonia.
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Matthay MA, Kallet RH. Prognostic value of pulmonary dead space in patients with the acute respiratory distress syndrome. Crit Care 2011; 15:185. [PMID: 22067424 PMCID: PMC3334730 DOI: 10.1186/cc10346] [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] [Indexed: 11/10/2022] Open
Abstract
A study published in the previous issue of Critical Care demonstrates that measurement of the pulmonary dead-space fraction is superior to hypoxemia as an indicator of a favorable physiologic response to prone positioning in patients with severe acute respiratory distress syndrome. These results add to the growing evidence supporting the clinical and research value of measuring pulmonary dead space in patients with acute respiratory distress syndrome and using this pulmonary physiologic end-point as one indicator of a favorable response to therapy.
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Affiliation(s)
- Michael A Matthay
- Department of Medicine and Cardiovascular Research Institute at University of California, San Francisco, 505 Parnassus Avenue, M-917, San Francisco, CA 94143-0624, USA.
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