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Balzani E, Murgolo F, Pozzi M, Di Mussi R, Bartolomeo N, Simonetti U, Brazzi L, Spadaro S, Bellani G, Grasso S, Fanelli V. Respiratory Drive, Effort, and Lung-Distending Pressure during Transitioning from Controlled to Spontaneous Assisted Ventilation in Patients with ARDS: A Multicenter Prospective Cohort Study. J Clin Med 2024; 13:5227. [PMID: 39274439 PMCID: PMC11396025 DOI: 10.3390/jcm13175227] [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: 07/22/2024] [Revised: 08/22/2024] [Accepted: 08/28/2024] [Indexed: 09/16/2024] Open
Abstract
Objectives: To investigate the impact of patient characteristics and treatment factors on excessive respiratory drive, effort, and lung-distending pressure during transitioning from controlled to spontaneous assisted ventilation in patients with acute respiratory distress syndrome (ARDS). Methods: Multicenter cohort observational study of patients with ARDS at four academic intensive care units. Respiratory drive (P0.1), diaphragm electrical activity (EAdi), inspiratory effort derived from EAdi (∆PmusEAdi) and from occlusion of airway pressure (∆Pocc) (PmusΔPocc), and dynamic transpulmonary driving pressure (ΔPL,dyn) were measured at the first transition to assisted spontaneous breathing. Results: A total of 4171 breaths were analyzed in 48 patients. P0.1 was >3.5 cmH2O in 10%, EAdiPEAK > 15 µV in 29%, ∆PmusEAdi > 15 cmH2O in 28%, and ΔPL,dyn > 15 cmH2O in 60% of the studied breaths. COVID-19 etiology of ARDS was the strongest independent risk factor for a higher proportion of breaths with excessive respiratory drive (RR 3.00 [2.43-3.71], p < 0.0001), inspiratory effort (RR 1.84 [1.58-2.15], p < 0.0001), and transpulmonary driving pressure (RR 1.48 [1.36-1.62], p < 0.0001). The P/F ratio at ICU admission, days of deep sedation, and dose of steroids were additional risk factors for vigorous inspiratory effort. Age and dose of steroids were risk factors for high transpulmonary driving pressure. Days of deep sedation (aHR 1.15 [1.07-1.24], p = 0.0002) and COVID-19 diagnosis (aHR 6.96 [1-48.5], p = 0.05) of ARDS were independently associated with composite outcome of transitioning from light to deep sedation (RASS from 0/-3 to -4/-5) or return to controlled ventilation within 48 h of spontaneous assisted breathing. Conclusions: This study identified that specific patient characteristics, including age, COVID-19-related ARDS, and P/F ratio, along with treatment factors such as the duration of deep sedation and the dosage of steroids, are independently associated with an increased likelihood of assisted breaths reaching potentially harmful thresholds of drive, effort, and lung-distending pressure during the initial transition to spontaneous assisted breathing. It is noteworthy that patients who were subjected to prolonged deep sedation under controlled mechanical ventilation, as well as those with COVID-19, were more susceptible to failing the transition from controlled to assisted breathing.
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Affiliation(s)
- Eleonora Balzani
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Francesco Murgolo
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", 70010 Bari, Italy
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Rossella Di Mussi
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", 70010 Bari, Italy
| | - Nicola Bartolomeo
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, 70121 Bari, Italy
| | - Umberto Simonetti
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, 10126 Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, 10126 Turin, Italy
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Azienda Ospedaliera-Universitaria di Ferrara, 44122 Ferrara, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, 38122 Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, 38122 Trento, Italy
| | - Salvatore Grasso
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", 70010 Bari, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- Department of Anesthesia, Critical Care and Emergency, Città della Salute e della Scienza Hospital, University of Turin, 10126 Turin, Italy
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Marongiu I, Slobod D, Leali M, Spinelli E, Mauri T. Clinical and Experimental Evidence for Patient Self-Inflicted Lung Injury (P-SILI) and Bedside Monitoring. J Clin Med 2024; 13:4018. [PMID: 39064059 PMCID: PMC11278124 DOI: 10.3390/jcm13144018] [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: 06/17/2024] [Revised: 07/01/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Patient self-inflicted lung injury (P-SILI) is a major challenge for the ICU physician: although spontaneous breathing is associated with physiological benefits, in patients with acute respiratory distress syndrome (ARDS), the risk of uncontrolled inspiratory effort leading to additional injury needs to be assessed to avoid delayed intubation and increased mortality. In the present review, we analyze the available clinical and experimental evidence supporting the existence of lung injury caused by uncontrolled high inspiratory effort, we discuss the pathophysiological mechanisms by which increased effort causes P-SILI, and, finally, we consider the measurements and interpretation of bedside physiological measures of increased drive that should alert the clinician. The data presented in this review could help to recognize injurious respiratory patterns that may trigger P-SILI and to prevent it.
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Affiliation(s)
- Ines Marongiu
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, QC H4A 3J1, Canada
| | - Marco Leali
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
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3
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Diao S, Li S, Dong R, Jiang W, Wang C, Chen Y, Wang J, He S, Wang Y, Du B, Weng L. The diaphragmatic electrical activity during spontaneous breathing trial in patients with mechanical ventilation: physiological description and potential clinical utility. BMC Pulm Med 2024; 24:263. [PMID: 38816810 PMCID: PMC11140881 DOI: 10.1186/s12890-024-03077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUNDS Increased respiratory drive has been demonstrated to correlate with weaning failure, which could be quantified by electrical activity of the diaphragm (EAdi). We described the physiological process of EAdi-based parameters during the spontaneous breathing trial (SBT) and evaluated the change of EAdi-based parameters as potential predictors of weaning failure. METHODS We conducted a prospective study in 35 mechanically ventilated patients who underwent a 2-hour SBT. EAdi and ventilatory parameters were continuously measured during the SBT. Diaphragm ultrasound was performed before the SBT and at the 30 min of the SBT. Three EAdi-based parameters were calculated: neuro-ventilatory efficiency, neuro-excursion efficiency and neuro-discharge per min. RESULTS Of the thirty 35 patients studied, 25 patients were defined as SBT success, including 22 patients weaning successfully and 3 patients reintubated. Before the SBT, neuro-excursion efficiency differed significantly between two groups and had the highest predictive value for SBT failure (AUROC 0.875, p < 0.01). Early increases in EAdi were observed in SBT, which are more prominent in SBT failure group. One minute, changes in EAdi and neuro-discharge per min also predicted weaning outcome (AUROCs 0.944 and 0.918, respectively). CONCLUSIONS EAdi-based parameters, especially neuro-excursion efficiency and changes in neuro-discharge per min, may detect impending weaning failure earlier than conventional indices. EAdi monitoring provides physiological insights and a more tailored approach to facilitate successful weaning. Further research should validate these findings and explore the utility of combined EAdi and diaphragm ultrasound assessment in weaning ICU patients from mechanical ventilation. TRIAL REGISTRATION Registered at ClinicalTrials.gov on 20 September 2022 (Identifier: NCT05632822).
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Affiliation(s)
- Shitong Diao
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Run Dong
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Jiang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunyao Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingyi Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuhua He
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yifan Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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Coiffard B, Dianti J, Telias I, Brochard LJ, Slutsky AS, Beck J, Sinderby C, Ferguson ND, Goligher EC. Dyssynchronous diaphragm contractions impair diaphragm function in mechanically ventilated patients. Crit Care 2024; 28:107. [PMID: 38566126 PMCID: PMC10988824 DOI: 10.1186/s13054-024-04894-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Pre-clinical studies suggest that dyssynchronous diaphragm contractions during mechanical ventilation may cause acute diaphragm dysfunction. We aimed to describe the variability in diaphragm contractile loading conditions during mechanical ventilation and to establish whether dyssynchronous diaphragm contractions are associated with the development of impaired diaphragm dysfunction. METHODS In patients receiving invasive mechanical ventilation for pneumonia, septic shock, acute respiratory distress syndrome, or acute brain injury, airway flow and pressure and diaphragm electrical activity (Edi) were recorded hourly around the clock for up to 7 days. Dyssynchronous post-inspiratory diaphragm loading was defined based on the duration of neural inspiration after expiratory cycling of the ventilator. Diaphragm function was assessed on a daily basis by neuromuscular coupling (NMC, the ratio of transdiaphragmatic pressure to diaphragm electrical activity). RESULTS A total of 4508 hourly recordings were collected in 45 patients. Edi was low or absent (≤ 5 µV) in 51% of study hours (median 71 h per patient, interquartile range 39-101 h). Dyssynchronous post-inspiratory loading was present in 13% of study hours (median 7 h per patient, interquartile range 2-22 h). The probability of dyssynchronous post-inspiratory loading was increased with reverse triggering (odds ratio 15, 95% CI 8-35) and premature cycling (odds ratio 8, 95% CI 6-10). The duration and magnitude of dyssynchronous post-inspiratory loading were associated with a progressive decline in diaphragm NMC (p < 0.01 for interaction with time). CONCLUSIONS Dyssynchronous diaphragm contractions may impair diaphragm function during mechanical ventilation. TRIAL REGISTRATION MYOTRAUMA, ClinicalTrials.gov NCT03108118. Registered 04 April 2017 (retrospectively registered).
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Affiliation(s)
- Benjamin Coiffard
- Department of Respiratory Medicine, Aix-Marseille University, APHM, Hôpital Nord, Marseille, France
| | - Jose Dianti
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Irene Telias
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jennifer Beck
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, 585 University Ave., 9-MaRS-9024, Toronto, ON, M5G 2N2, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Ewan C Goligher
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Toronto General Hospital Research Institute, 585 University Ave., 9-MaRS-9024, Toronto, ON, M5G 2N2, Canada.
- Department of Physiology, University of Toronto, Toronto, Canada.
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5
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Poddighe D, Van Hollebeke M, Choudhary YQ, Campos DR, Schaeffer MR, Verbakel JY, Hermans G, Gosselink R, Langer D. Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis. Crit Care 2024; 28:70. [PMID: 38454487 PMCID: PMC10919035 DOI: 10.1186/s13054-024-04823-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION PROSPERO CRD42020209295, October 15, 2020.
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Affiliation(s)
- Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yasir Qaiser Choudhary
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Débora Ribeiro Campos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Prêto, Brazil
| | - Michele R Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, EPI-Centre, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Health and Rehabilitation Sciences, Faculty of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
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Muttini S, Jona Falco J, Cuevas Cairo I, Umbrello M. A High Respiratory Drive Is Associated with Weaning Failure in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome: The Role of the Electrical Activity of the Diaphragm. J Clin Med 2024; 13:1120. [PMID: 38398433 PMCID: PMC10889278 DOI: 10.3390/jcm13041120] [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: 12/21/2023] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Mechanical ventilation is the main supportive treatment of severe cases of COVID-19-associated ARDS (C-ARDS). Weaning failure is common and associated with worse outcomes. We investigated the role of respiratory drive, assessed by monitoring the electrical activity of the diaphragm (EAdi), as a predictor of weaning failure. METHODS Consecutive, mechanically ventilated patients admitted to the ICU for C-ARDS with difficult weaning were enrolled. Blood gas, ventilator, and respiratory mechanic parameters, as well as EAdi, were recorded at the time of placement of EAdi catheter, and then after 1, 2, 3, 7, and 10 days, and compared between patients with weaning success and weaning failure. RESULTS Twenty patients were enrolled: age 66 (60-69); 85% males; PaO2/FiO2 at admission 148 (126-177) mmHg. Thirteen subjects (65%) were classified as having a successful weaning. A younger age (OR(95%CI): 0.02 (0.01-0.11) per year), a higher PaO2/FiO2 ratio (OR(95%CI): 1.10 (1.01-1.21) per mmHg), and a lower EAdi (OR(95%CI): 0.16 (0.08-0.34) per μV) were associated with weaning success. CONCLUSION In critically ill patients with moderate-severe C-ARDS and difficult weaning from mechanical ventilation, a successful weaning was associated with a lower age, a higher oxygenation, and a lower respiratory drive, as assessed at the bedside via EAdi monitoring.
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Affiliation(s)
- Stefano Muttini
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Jacopo Jona Falco
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Ilmari Cuevas Cairo
- Department of Anaesthesia and Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy;
| | - Michele Umbrello
- Department of Intensive care and Anaesthesia, Ospedale Civile di Legnano, ASST Ovest Milanese, 20025 Legnano, Italy
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Yao L, Zhou Z, Yu T, Wang G, Fan Z, Tang Y. The predictive value of neurally adjusted ventilatory assist indexes for the prognosis of patients with severe cerebral hemorrhage. Eur J Med Res 2024; 29:7. [PMID: 38173023 PMCID: PMC10763000 DOI: 10.1186/s40001-023-01601-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE This study assessed the predictive value of electrical activity of the diaphragm (EAdi) and the EAdi-derived monitoring index in the prognosis of patients with severe cerebral hemorrhage. METHODS Ninety patients with severe cerebral hemorrhage were admitted to the Neurosurgery Intensive Care Unit of Yijishan Hospital from April 2019 to June 2021 and were divided into the good prognosis group (Glasgow Outcome Scale [GOS] ≥ 4) and poor prognosis group (GOS ≤ 3). The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to evaluate prediction accuracy. RESULTS EAdi, neuro-ventilatory efficiency (NVE), and neuro-muscular efficiency (NME) in patients with good prognosis were significantly higher than those in patients with poor prognosis (4.707 µV vs 2.80 µV, P < 0.001; 141.85 ml/µV vs 66.01 ml/µV, P = 0.000; 2.57 cm H2O/µV vs 1.37 cm H2O/µV, P = 0.000). The area under the ROC curve for the EAdi score was 0.719, with sensitivity of 69.70% and specificity of 68.42% when EAdi was 3.6 µV. The AUC for NVE score was 0.793, with sensitivity of 75.76% and specificity of 75.44% when the NVE value was 95.32 ml/µV. The AUC for NME score was 0.792, with sensitivity of 69.70% and specificity of 78.95% when the NME value was 2.06 H2O/µV. The 6-month survival time of patients with higher EAdi, NVE, and NME was significantly longer than that of patients with lower EAdi, NVE, and NME CONCLUSION: EAdi, NVE, and NME can be used as indices for predicting the prognosis of patients with severe cerebral hemorrhage. TRIAL REGISTRATION NO ChiCTR1900022861. Registered April 28, 2019, http://www.chictr.org.cn .
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Affiliation(s)
- Lin Yao
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, People's Republic of China
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Wuhu, 241001, People's Republic of China
| | - Zihao Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, People's Republic of China
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Wuhu, 241001, People's Republic of China
| | - Tao Yu
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, People's Republic of China
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Wuhu, 241001, People's Republic of China
| | - Guiliang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, People's Republic of China
| | - Zhen Fan
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, People's Republic of China
| | - Yun Tang
- Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, People's Republic of China.
- The Translational Research Institute for Neurological Disorders of Wannan Medical College, Wuhu, 241001, People's Republic of China.
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Boscolo A, Sella N, Pettenuzzo T, Pistollato E, Calabrese F, Gregori D, Cammarota G, Dres M, Rea F, Navalesi P. Diaphragm Dysfunction Predicts Weaning Outcome after Bilateral Lung Transplant. Anesthesiology 2024; 140:126-136. [PMID: 37552079 DOI: 10.1097/aln.0000000000004729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Diaphragm dysfunction and its effects on outcomes of ventilator weaning have been evaluated in mixed critical care populations using diaphragm thickening fraction (the ratio of the difference between ultrasound diaphragm thickness at end-inspiration and end-expiration to diaphragm thickness at end-expiration) or neuroventilatory efficiency (the ratio of tidal volume and peak electrical activity of the diaphragm). Such data are not available in bilateral-lung transplant recipients. The authors hypothesized that (1) diaphragm dysfunction, as defined by a diaphragm thickening fraction less than 29%, is more likely to occur in difficult weaning; (2) diaphragm thickening fraction and neuroventilatory efficiency predict weaning outcome; and (3) duration of mechanical ventilation before the first spontaneous breathing trial is associated with diaphragm dysfunction. METHODS Adult bilateral-lung transplant patients admitted to the intensive care unit were screened at the time of the first spontaneous breathing trial (pressure-support of 5 cm H2O and 0 positive end-expiratory pressure). At the fifth minute, diaphragm thickening fraction and neuroventilatory efficiency were measured during three respiratory cycles. Weaning was classified as simple, difficult, or prolonged (successful extubation at the first spontaneous breathing trial, within three or after three spontaneous breathing trials, respectively). RESULTS Forty-four subjects were enrolled. Diaphragm dysfunction occurred in 14 subjects (32%), all of whom had difficult weaning (78% of the subgroup of 18 patients experiencing difficult weaning). Both diaphragm thickening fraction (24 [20 to 29] vs. 39 [35 to 45]%) and neuroventilatory efficiency (34 [26 to 45] vs. 55 [43 to 62] ml/µV) were lower in difficult weaning (both P < 0.001). The areas under the receiver operator curve predicting difficult weaning were 0.88 (95% CI, 0.73 to 0.99) for diaphragm thickening fraction and 0.85 (95% CI, 0.71 to 0.95) for neuroventilatory efficiency. The duration of ventilation demonstrated a linear inverse correlation with both diaphragm thickening fraction and neuroventilatory efficiency. CONCLUSIONS Diaphragm dysfunction is common after bilateral-lung transplantation and associated with difficult weaning. In such patients, average values for diaphragm thickening fraction and neuroventilatory efficiency were reduced compared to patients with simple weaning. Both parameters showed similar accuracy for predicting success of ventilator weaning, demonstrating an inverse relationship with duration of ventilation. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Annalisa Boscolo
- Department of Medicine, and Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Tommaso Pettenuzzo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | | | - Fiorella Calabrese
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | | | - Martin Dres
- Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Center, Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Federico Rea
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
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Aljohani H, Russell D, Kim YI, Bassler J, Lowman J. The Neuromechanics of Inspiratory Muscles in Mechanical Ventilation Liberation Success and Failure. Cureus 2024; 16:e51570. [PMID: 38313921 PMCID: PMC10835747 DOI: 10.7759/cureus.51570] [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] [Accepted: 01/03/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Assessing the neuromechanical coupling of inspiratory muscles during mechanical ventilation (MV) could reveal the physiological mechanism of MV failure. This study examined the respiratory neuromechanical characteristics between MV liberation success and failure. METHODS This is an observational prospective study that included patients during their ventilator liberation process. Assessment of surface electromyography (sEMG) of inspiratory muscles, including the diaphragm and extra-diaphragmatic (scalene, sternocleidomastoid, and parasternal) muscles, was performed 15 minutes after the initiation of spontaneous breathing trials. Neuromechanical efficiency of the diaphragm (NMEDia) and extra-diaphragmatic muscles (NMEExtra) were compared in patients who were successfully liberated from MV with those who failed MV liberation within 72 hours after extubation. RESULTS A total of 45 patients were enrolled and 28 were female (67%). The sample median age was 63 (IQR 47, 69) years old. One-third of patients failed MV liberation within 72 hours of their spontaneous breathing trials (SBTs). NMEDia was significantly lower in patients who failed MV liberation with a root mean square of (M 0.27), (IQR 0.21, 0.37) compared with (M 0.371), (IQR 0.3, 0.631) for the success group (p=0.0222). The area under the curve for NMEDia was lower in the failure group (M 0.270), (IQR 0.160, 0.370) and (M 0.485), (IQR 0.280, 0.683) for the success group (p=0.024). However, NMEExtra was not statistically different between the two groups. CONCLUSION Reduced NMEDia is a predictor of MV liberation failure. NMEExtra was not a major contributor to MV liberation outcomes. Further studies should assess the performance of inspiratory muscles NME indices to predict MV liberation outcomes.
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Affiliation(s)
- Hassan Aljohani
- Respiratory Therapy Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Derek Russell
- Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Young-Il Kim
- Preventive Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - John Bassler
- Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| | - John Lowman
- Physical Therapy, University of Alabama at Birmingham, Birmingham, USA
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Zhang R, Xu X, Chen H, Beck J, Sinderby C, Qiu H, Yang Y, Liu L. Predicting extubation in patients with traumatic cervical spinal cord injury using the diaphragm electrical activity during a single maximal maneuver. Ann Intensive Care 2023; 13:122. [PMID: 38055103 DOI: 10.1186/s13613-023-01217-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The unsuccessful extubation in patients with traumatic cervical spinal cord injuries (CSCI) may result from impairment diaphragm function and monitoring of diaphragm electrical activity (EAdi) can be informative in guiding extubation. We aimed to evaluate whether the change of EAdi during a single maximal maneuver can predict extubation outcomes in CSCI patients. METHODS This is a retrospective study of CSCI patients requiring mechanical ventilation in the ICU of a tertiary hospital. A single maximal maneuver was performed by asking each patient to inhale with maximum strength during the first spontaneous breathing trial (SBT). The baseline (during SBT before maximal maneuver), maximum (during the single maximal maneuver), and the increase of EAdi (ΔEAdi, equal to the difference between baseline and maximal) were measured. The primary outcome was extubation success, defined as no reintubation after the first extubation and no tracheostomy before any extubation during the ICU stay. RESULTS Among 107 patients enrolled, 50 (46.7%) were extubated successfully at the first SBT. Baseline EAdi, maximum EAdi, and ΔEAdi were significantly higher, and the rapid shallow breathing index was lower in patients who were extubated successfully than in those who failed. By multivariable logistic analysis, ΔEAdi was independently associated with successful extubation (OR 2.03, 95% CI 1.52-3.17). ΔEAdi demonstrated high diagnostic accuracy in predicting extubation success with an AUROC 0.978 (95% CI 0.941-0.995), and the cut-off value was 7.0 μV. CONCLUSIONS The increase of EAdi from baseline SBT during a single maximal maneuver is associated with successful extubation and can help guide extubation in CSCI patients.
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Affiliation(s)
- Rui Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Xiaoting Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, No. 899 Pinghai Road, Suzhou, 215000, People's Republic of China
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Department of Critical Care, St. Michael's Hospital, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
- Member, Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Department of Critical Care, St. Michael's Hospital, Toronto, Canada
- Member, Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine,, Southeast University, Nanjing, 210009, Jiangsu, China.
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Karthika M, Al Enezi FA, Pillai LV, Arabi YM. Rate of Change of Rapid Shallow Breathing Index and Extubation Outcome in Mechanically Ventilated Patients. Crit Care Res Pract 2023; 2023:9141441. [PMID: 37795474 PMCID: PMC10547562 DOI: 10.1155/2023/9141441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background Rapid shallow breathing index (RSBI) has been widely used as a predictor of extubation outcome in mechanically ventilated patients. We hypothesize that the rate of change of RSBI between the beginning and end of a 120-minute spontaneous breathing trial (SBT) could be a better predictor of extubation outcome than a single RSBI measured at the end of SBT in mechanically ventilated patients. Methodology. In this prospective observational study, we enrolled 193 patients who met the inclusion criteria, of whom 33 patients were unable to tolerate a 120-minute SBT and were excluded from the study. The study population consisted of 160 patients, categorized into three subgroups: patients with normal lung (no reported history of respiratory diseases), patients with airway disease, and patients with parenchymal disease who completed 120 minutes of SBT on low levels of pressure support ventilation. RSBI was obtained from the ventilator display at the 5th and the 120th minutes of SBT. The rate of change of RSBI (RSBI 5-120) was calculated as (RSBI 2-RSBI 1)/RSBI 1 × 100. Receiver-operating characteristic (ROC) curves were plotted for RSBI 5-120 and RSBI 120 in all patients and among the three subgroups (normal group, airway group, and parenchymal group) to compare the superiority of their best thresholds in predicting extubation failure. Results The RSBI 5-120 threshold for extubation failure in the entire patient group was 23% with an overall accuracy of 88% (AUC = 0.933, sensitivity = 91%, and specificity = 86%) and the threshold of RSBI 120 for extubation failure in the entire patient group was 70 breaths/min/L with an overall accuracy of 82% (AUC = 0.899, sensitivity = 85%, and specificity = 81%). In patients in the normal lung group, the threshold of RSBI 5-120 was 22%, with an overall accuracy of 89% (AUC = 0.892, sensitivity = 87.5%, and specificity = 90%), and the RSBI 120 threshold was 70 breaths/min/L, with an overall accuracy of 89% (AUC = 0.956, sensitivity = 88%, and specificity = 90%). The RSBI 5-120 threshold in patients with airway disease was 25% with an accuracy of 86% (AUC = 0.892, sensitivity = 85%, and specificity = 86%) and the threshold of RSBI 120 was 73 breaths/min/L with an accuracy of 83% (AUC = 0.874, sensitivity = 85%, and specificity = 82%). In patients in the parenchymal disease group, the threshold of RSBI 5-120 was 24%, with an accuracy of 90% (AUC = 0.966, sensitivity = 92%, and specificity = 89%) and RSBI 120 threshold was 71 breaths/min/L, which was 88% accurate (AUC = 0.893, sensitivity = 85%, and specificity = 89%). Conclusion The rate of change of RSBI between the 5th and 120th minutes was moderately more accurate than the single value of RSBI measured at the 120th minute in predicting extubation outcome.
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Affiliation(s)
- Manjush Karthika
- Faculty of Medical and Health Sciences, Liwa College, Abu Dhabi, UAE
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
| | - Farhan A. Al Enezi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Lalitha V. Pillai
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
- Department of Critical Care Medicine, Aundh Institute of Medical Sciences, Pune, India
| | - Yaseen M. Arabi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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12
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Al Tayar AS, Abdelshafey EE. Diaphragm Electromyography Versus Ultrasonography in the Prediction of Mechanical Ventilation Liberation Outcome. Respir Care 2022; 67:respcare.09779. [PMID: 35853707 PMCID: PMC9993974 DOI: 10.4187/respcare.09779] [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: 11/05/2022]
Abstract
BACKGROUND ICU-acquired diaphragm paresis occurs in about 25% of patients after prolonged mechanical ventilation. Diaphragm function can be evaluated via several approaches including monitoring of electrical activity of diaphragm (electromyography [EMG]) or ultrasound (US) measurements. We aimed to assess the usefulness of diaphragm EMG indices in predicting liberation outcome in comparison with diaphragm US measurements. METHODS We included consecutive subjects invasively ventilated for > 48 h for acute respiratory failure and who were considered ready to undergo a spontaneous breathing trial (SBT). Exclusion criteria were age < 18 y, pregnancy, tracheostomy, or patients with confirmed neuromuscular diseases. To start the SBT, we set pressure support to 0 cm H2O and PEEP to 5 cm H2O. During the initial 5 min of SBT, mean values of Δ electrical activity of the diaphragm (ΔEAdi) (EAdi peak - EAdi minimal), tidal volume (VT), and breathing frequency were measured. Neuroventilatory efficiency was calculated as VT divided by ΔEAdi. Rapid shallow breathing index was calculated as breathing frequency divided by VT. US examination of the diaphragm and assessment of diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) were recorded 30 min after initiation of SBT. RESULTS Twenty-four subjects were included; DTF predicted weaning failure with area under the curve 0.96 and P value < .001 with sensitivity 100% and specificity 94% for the cutoff value ≤ 15%. DE for the cutoff ≤ 1.56 cm showed sensitivity 75% and specificity 69%, whereas ΔEAdi with cutoff value ≤ 4 μV showed sensitivity 25% and specificity 100%. Neuroventilatory efficiency with cutoff value ≤ 29 mL/μV showed sensitivity 50% and specificity 81%. All 3 parameters showed nonsignificant results with area under the curve 0.73, 0.56, and 0.62 and P values .08, .65, and .34, respectively. CONCLUSIONS Diaphragm EMG indices were inferior to diaphragm ultrasonography in prediction of mechanical ventilation liberation outcome.
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Affiliation(s)
| | - Eslam E Abdelshafey
- Critical Care Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.
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13
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Pozzi M, Rezoagli E, Bronco A, Rabboni F, Grasselli G, Foti G, Bellani G. Accessory and Expiratory Muscles Activation During Spontaneous Breathing Trial: A Physiological Study by Surface Electromyography. Front Med (Lausanne) 2022; 9:814219. [PMID: 35372418 PMCID: PMC8965594 DOI: 10.3389/fmed.2022.814219] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background The physiological and prognostical significance of accessory and expiratory muscles activation is unknown during a spontaneous breathing trial (SBT). We hypothesized that, in patients experiencing weaning failure, accessory and expiratory muscles are activated to cope with an increased respiratory workload. Purpose To describe accessory and expiratory muscle activation non-invasively by surface electromyography (sEMG) during an SBT and to assess differences in electrical activity (EA) of the inspiratory and expiratory muscles in successful vs. failing weaning patients. Methods Intubated patients on mechanical ventilation for more than 48 h undergoing an SBT were enrolled in a medical and surgical third-level ICU of the University Teaching Hospital. Baseline characteristics and physiological variables were recorded in a crossover physiologic prospective clinical study. Results Of 37 critically ill mechanically ventilated patients, 29 (78%) patients successfully passed the SBT. Rapid shallow breathing index (RSBI) was higher in patients who failed SBT compared with the successfully weaned patients at baseline and over time (group-by-time interaction p < 0.001). EA of both the diaphragm (EAdisurf) and of accessory muscles (ACCsurf) was higher in failure patients compared with success (group-by-time interaction p = 0.0174 and p < 0.001, respectively). EA of expiratory muscles (ESPsurf) during SBT increased more in failure than in weaned patients (group-by-time interaction p < 0.0001). Conclusion Non-invasive respiratory muscle monitoring by sEMG was feasible during SBT. Respiratory muscles EA increased during SBT, regardless of SBT outcome, and patients who failed the SBT had a higher increase of all the inspiratory muscles EA compared with the patients who passed the SBT. Recruitment of expiratory muscles—as quantified by sEMG—is associated with SBT failure.
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Affiliation(s)
- Matteo Pozzi
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Alfio Bronco
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Francesca Rabboni
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giuseppe Foti
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
- *Correspondence: Giacomo Bellani
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14
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Gonzales Carazas MM, Gavidia CM, Davila Fernandez R, Vargas Zuñiga JA, Crespo Paiva A, Bocanegra W, Calderon J, Sanchez E, Perales R, Zeña B, Calcina Isique JF, Reategui J, Castañeda B, Casado FL. Biological evaluation of a mechanical ventilator that operates by controlling an automated manual resuscitator. A descriptive study in swine. PLoS One 2022; 17:e0264774. [PMID: 35239740 PMCID: PMC8893637 DOI: 10.1371/journal.pone.0264774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/17/2022] [Indexed: 11/26/2022] Open
Abstract
The Covid-19 outbreak challenged health systems around the world to design and implement cost-effective devices produced locally to meet the increased demand of mechanical ventilators worldwide. This study evaluates the physiological responses of healthy swine maintained under volume- or pressure-controlled mechanical ventilation by a mechanical ventilator implemented to bring life-support by automating a resuscitation bag and closely controlling ventilatory parameters. Physiological parameters were monitored in eight sedated animals (t0) prior to inducing deep anaesthesia, and during the next six hours of mechanical ventilation (t1-7). Hemodynamic conditions were monitored periodically using a portable gas analyser machine (i.e. BEecf, carbonate, SaO2, lactate, pH, PaO2, PaCO2) and a capnometer (i.e. ETCO2). Electrocardiogram, echocardiography and lung ultrasonography were performed to detect in vivo alterations in these vital organs and pathological findings from necropsy were reported. The mechanical ventilator properly controlled physiological levels of blood biochemistry such as oxygenation parameters (PaO2, PaCO2, SaO2, ETCO2), acid-base equilibrium (pH, carbonate, BEecf), and perfusion of tissues (lactate levels). In addition, histopathological analysis showed no evidence of acute tissue damage in lung, heart, liver, kidney, or brain. All animals were able to breathe spontaneously after undergoing mechanical ventilation. These preclinical data, supports the biological safety of the medical device to move forward to further evaluation in clinical studies.
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Affiliation(s)
| | - Cesar Miguel Gavidia
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | | | | | - William Bocanegra
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Joan Calderon
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Evelyn Sanchez
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Rosa Perales
- School of Veterinary Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Brandon Zeña
- Instituto Veterinario de Oftalmologia (IVO), Lima, Peru
| | | | | | - Benjamin Castañeda
- Institute of Omics and Applied Biotechnology, Pontificia Universidad Catolica del Peru, Lima, Peru
- Department of Engineering, Pontificia Universidad Catolica del Peru, Lima, Peru
| | - Fanny L. Casado
- Institute of Omics and Applied Biotechnology, Pontificia Universidad Catolica del Peru, Lima, Peru
- Department of Engineering, Pontificia Universidad Catolica del Peru, Lima, Peru
- * E-mail:
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Diaphragmatic electromyography during a spontaneous breathing trial to predict extubation failure in preterm infants. Pediatr Res 2022; 92:1064-1069. [PMID: 35523885 PMCID: PMC9586868 DOI: 10.1038/s41390-022-02085-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 03/04/2022] [Accepted: 03/26/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Premature attempts at extubation and prolonged episodes of ventilatory support in preterm infants have adverse outcomes. The aim of this study was to determine whether measuring the electrical activity of the diaphragm during a spontaneous breathing trial (SBT) could predict extubation failure in preterm infants. METHODS When infants were ready for extubation, the electrical activity of the diaphragm was measured by transcutaneous electromyography (EMG) before and during a SBT when the infants were on endotracheal continuous positive airway pressure. RESULTS Forty-eight infants were recruited (median (IQR) gestational age of 27.2 (25.6-30.4) weeks). Three infants did not pass the SBT and 13 failed extubation. The amplitude of the EMG increased during the SBT [2.3 (1.5-4.2) versus 3.5 (2.1-5.3) µV; p < 0.001]. In the whole cohort, postmenstrual age (PMA) was the strongest predictor for extubation failure (area under the curve (AUC) 0.77). In infants of gestational age <29 weeks, the percentage change of the EMG predicted extubation failure with an AUC of 0.74 while PMA was not associated with the outcome of extubation. CONCLUSIONS In all preterm infants, PMA was the strongest predictor of extubation failure; in those born <29 weeks of gestation, diaphragmatic electromyography during an SBT was the best predictor of extubation failure. IMPACT Composite assessments of readiness for extubation may be beneficial in the preterm population. Diaphragmatic electromyography measured by surface electrodes is a non-invasive technique to assess the electrical activity of the diaphragm. Postmenstrual age was the strongest predictor of extubation outcome in preterm infants. The change in diaphragmatic activity during a spontaneous breathing trial in extremely prematurely born infants can predict subsequent extubation failure with moderate sensitivity and specificity.
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Wang SY, Liang HW, Lu GS, Jiang ZJ, Zhang BZ, Deng QX, Sun QW, Lin ZM, Chen Q, Yang C, Xu YD, Sang L. Effect of sequential high-flow nasal cannula oxygen therapy and non-invasive positive-pressure ventilation in patients with difficult weaning from mechanical ventilation after extubation on respiratory mechanics. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1251. [PMID: 34532388 PMCID: PMC8421953 DOI: 10.21037/atm-21-3408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022]
Abstract
Background Patients with difficult weaning who undergo mechanical ventilation are more likely to be at risk of reintubation and the sequential use of oxygen therapy after extubation is a concern for clinicians. Therefore, the aim of the present study was to compare the effects of transnasal high-flow nasal cannula (HFNC) oxygen therapy and non-invasive positive-pressure ventilation (NIV) on respiratory mechanics in patients with difficult weaning. Methods The present study was a single-center, retrospective, observational study. Twenty-nine patients with difficult weaning off invasive mechanical ventilation from the Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, from December 2018 to April 2021, were included. Within 48 h after extubation, alternate respiratory support with HFNC and NIV was provided. Relevant indicators were recorded after each support mode had been maintained for at least 60 min. These included esophageal pressure (Pes), gastric pressure (Pga), transdiaphragmatic pressure (Pdi), pressure-time product of Pes (PTPes), pressure-time product of Pga (PTPga), pressure-time product of Pdi (PTPdi), ratio of the PTPdi to the PTPes (PTPdi/PTPes), and ratio of the Pes to the Pdi (Pes/Pdi), diaphragmatic electromyogram (EMGdi), percentage of esophageal pressure coefficient of variation (CVes%),diaphragmatic electromyogram coefficient of variation (CVEMG),inspiratory time (Ti), expiratory time (Te) and respiratory cycle time (Ttot). Results Of the 29 patients included, 22 were males and 7 were females [age: 63.97±15.34 years, Acute Physiological and Chronic Health Estimation II (APACHE II) score: 18.00±5.63]. The CVes% and the Pes/Pdi were significantly higher in patients with NIV than HFNC using 40 L/min, CVes%: 9 (−6, 20) vs. −7 (−23, 6) and Pes/Pdi: 0.17 (−0.1, 0.53), vs. −0.12 (−0.43, 0.08) (P<0.05). The remaining indicators were not statistically different. Conclusions The sequential NIV and HFNC can be tolerated in patients with such difficult weaning off mechanical ventilation after extubation, and more patients tend to choose HFNC subjectively. Compared with HFNC, NIV reduces the work of adjunctive respiratory muscle, but the patient’s Pes dispersion is high when NIV is used, and it is necessary to pay attention to patient–ventilator coordination in clinical practice. We recommend alternating HFNC and NIV during the sequential respiratory therapy after extubation.
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Affiliation(s)
- Shi-Ya Wang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Han-Wen Liang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guang-Sheng Lu
- Department of Critical Care Medicine, First People's Hospital of Zhaoqing, Zhaoqing, China
| | - Zhen-Jie Jiang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bao-Zhu Zhang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiu-Xue Deng
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing-Wen Sun
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhi-Min Lin
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Guangzhou Laboratory, Guangzhou, China
| | - Qiang Chen
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chun Yang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuan-Da Xu
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Guangzhou Laboratory, Guangzhou, China
| | - Ling Sang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Guangzhou Laboratory, Guangzhou, China
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17
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Crulli B, Kawaguchi A, Praud JP, Petrof BJ, Harrington K, Emeriaud G. Evolution of inspiratory muscle function in children during mechanical ventilation. Crit Care 2021; 25:229. [PMID: 34193216 PMCID: PMC8243304 DOI: 10.1186/s13054-021-03647-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no universally accepted method to assess the pressure-generating capacity of inspiratory muscles in children on mechanical ventilation (MV), and no study describing its evolution over time in this population. METHODS In this prospective observational study, we have assessed the function of the inspiratory muscles in children on various modes of MV. During brief airway occlusion maneuvers, we simultaneously recorded airway pressure depression at the endotracheal tube (ΔPaw, force generation) and electrical activity of the diaphragm (EAdi, central respiratory drive) over five consecutive inspiratory efforts. The neuro-mechanical efficiency ratio (NME, ΔPaw/EAdimax) was also computed. The evolution over time of these indices in a group of children in the pediatric intensive care unit (PICU) was primarily described. As a secondary objective, we compared these values to those measured in a group of children in the operating room (OR). RESULTS In the PICU group, although median NMEoccl decreased over time during MV (regression coefficient - 0.016, p = 0.03), maximum ΔPawmax remained unchanged (regression coefficient 0.109, p = 0.50). Median NMEoccl at the first measurement in the PICU group (after 21 h of MV) was significantly lower than at the only measurement in the OR group (1.8 cmH2O/µV, Q1-Q3 1.3-2.4 vs. 3.7 cmH2O/µV, Q1-Q3 3.5-4.2; p = 0.015). Maximum ΔPawmax in the PICU group was, however, not significantly different from the OR group (35.1 cmH2O, Q1-Q3 21-58 vs. 31.3 cmH2O, Q1-Q3 28.5-35.5; p = 0.982). CONCLUSIONS The function of inspiratory muscles can be monitored at the bedside of children on MV using brief airway occlusions. Inspiratory muscle efficiency was significantly lower in critically ill children than in children undergoing elective surgery, and it decreased over time during MV in critically ill children. This suggests that both critical illness and MV may have an impact on inspiratory muscle efficiency.
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Affiliation(s)
- Benjamin Crulli
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Atsushi Kawaguchi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
- Pediatric Intensive Care Unit, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Basil J Petrof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Karen Harrington
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
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18
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Shi ZH, Jonkman AH, Tuinman PR, Chen GQ, Xu M, Yang YL, Heunks LMA, Zhou JX. Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:548. [PMID: 33987246 PMCID: PMC8105847 DOI: 10.21037/atm-20-6407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. METHODS In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. RESULTS In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. CONCLUSIONS In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (No. NCT02863237).
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Affiliation(s)
- Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leo M. A. Heunks
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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19
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Continuous assessment of neuro-ventilatory drive during 12 h of pressure support ventilation in critically ill patients. Crit Care 2020; 24:652. [PMID: 33218354 PMCID: PMC7677450 DOI: 10.1186/s13054-020-03357-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Pressure support ventilation (PSV) should allow spontaneous breathing with a “normal” neuro-ventilatory drive. Low neuro-ventilatory drive puts the patient at risk of diaphragmatic atrophy while high neuro-ventilatory drive may causes dyspnea and patient self-inflicted lung injury. We continuously assessed for 12 h the electrical activity of the diaphragm (EAdi), a close surrogate of neuro-ventilatory drive, during PSV. Our aim was to document the EAdi trend and the occurrence of periods of “Low” and/or “High” neuro-ventilatory drive during clinical application of PSV.
Method In 16 critically ill patients ventilated in the PSV mode for clinical reasons, inspiratory peak EAdi peak (EAdiPEAK), pressure time product of the trans-diaphragmatic pressure per breath and per minute (PTPDI/b and PTPDI/min, respectively), breathing pattern and major asynchronies were continuously monitored for 12 h (from 8 a.m. to 8 p.m.). We identified breaths with “Normal” (EAdiPEAK 5–15 μV), “Low” (EAdiPEAK < 5 μV) and “High” (EAdiPEAK > 15 μV) neuro-ventilatory drive. Results Within all the analyzed breaths (177.117), the neuro-ventilatory drive, as expressed by the EAdiPEAK, was “Low” in 50.116 breath (28%), “Normal” in 88.419 breaths (50%) and “High” in 38.582 breaths (22%). The average times spent in “Low”, “Normal” and “High” class were 1.37, 3.67 and 0.55 h, respectively (p < 0.0001), with wide variations among patients. Eleven patients remained in the “Low” neuro-ventilatory drive class for more than 1 h, median 6.1 [3.9–8.5] h and 6 in the “High” neuro-ventilatory drive class, median 3.4 [2.2–7.8] h. The asynchrony index was significantly higher in the “Low” neuro-ventilatory class, mainly because of a higher number of missed efforts.
Conclusions We observed wide variations in EAdi amplitude and unevenly distributed “Low” and “High” neuro ventilatory drive periods during 12 h of PSV in critically ill patients. Further studies are needed to assess the possible clinical implications of our physiological findings.
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20
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Iwasaki E, Hirata K, Morikawa K, Nozaki M, Mochizuki N, Hirano S, Wada K. Postnatal physiological changes in electrical activity of the diaphragm in extremely preterm infants. Pediatr Pulmonol 2020; 55:1969-1973. [PMID: 32470214 DOI: 10.1002/ppul.24873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES This study aimed to describe postnatal physiological changes in maximum values of peak electrical activity of the diaphragm (Edi) in extremely preterm infants during the preterm period. WORKING HYPOTHESIS The amplitude and frequency of neural sigh are different at each postmenstrual age in extremely preterm infants. STUDY DESIGN A retrospective, observational study. PATIENT-SUBJECT SELECTION Edi values were evaluated in 14 extremely preterm infants with neurally-adjusted ventilatory assist. METHODOLOGY Data of Edi peak and Edi minimum were collected from a ventilator. Edi-sigh was defined as the Edi peak value that was more than twice as large as the median Edi peak at each postmenstrual week in each patient. The frequency of Edi-sigh, and median values of Edi-sigh, Edi peak, and Edi minimum were evaluated at each postmenstrual week. The Jonckheere-Terpstra test was used to analyze the trend between postmenstrual weeks and Edi values. RESULTS From 26 to 35 postmenstrual weeks, the number of Edi-sighs per hour significantly increased as postmenstrual weeks increased (P < .001). Furthermore, the median values of Edi-sigh significantly increased as postmenstrual weeks increased (16.9 µV at 26 weeks to 25.4 µV at 35 weeks, P < .001). There were no significant changes in the median values of Edi peak and Edi minimum at each week. CONCLUSIONS The amplitude and frequency of neural sigh in extremely preterm infants increase with the number of postmenstrual weeks.
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Affiliation(s)
- Eriko Iwasaki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazue Morikawa
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Masatoshi Nozaki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Narutaka Mochizuki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shinya Hirano
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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21
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Yu T, Wu R, Yao L, Wang K, Wang G, Fan Z, Wu N, Fang X. Neurally adjusted ventilatory assist after surgical treatment of intracerebral hemorrhage: a randomized crossover study. J Int Med Res 2020; 48:300060520939837. [PMID: 32720550 PMCID: PMC7388128 DOI: 10.1177/0300060520939837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the neuromechanical efficiency (NME), neuroventilatory efficiency (NVE), and diaphragmatic function effects between pressure support ventilation (PSV) and neutrally adjusted ventilatory assist (NAVA). METHODS Fifteen patients who had undergone surgical treatment of intracerebral hemorrhage were enrolled in this randomized crossover study. The patients were assigned to PSV for the first 24 hours and then to NAVA for the following 24 hours or vice versa. The monitored ventilatory parameters under the two ventilation models were compared. NME, NVE, and diaphragmatic function were compared between the two ventilation models. RESULTS One patient's illness worsened during the study. The study was stopped for this patient, and intact data were obtained from the other 14 patients and analyzed. The monitored tidal volume was significantly higher with PSV than NAVA (487 [443-615] vs. 440 [400-480] mL, respectively). NME, NVE, diaphragmatic function, and the partial pressures of arterial carbon dioxide and oxygen were not significantly different between the two ventilation models. CONCLUSION The tidal volume was lower with NAVA than PSV; however, the patients' selected respiratory pattern during NAVA did not change the NME, NVE, or diaphragmatic function.Clinical trial registration no. ChiCTR1900022861.
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Affiliation(s)
- Tao Yu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Rongrong Wu
- Department of Education, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Lin Yao
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Kui Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Guiliang Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Zhen Fan
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Nianlong Wu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Xinggen Fang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
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22
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Hunt KA, Hunt I, Ali K, Dassios T, Greenough A. Prediction of extubation success using the diaphragmatic electromyograph results in ventilated neonates. J Perinat Med 2020; 48:609-614. [PMID: 32598319 DOI: 10.1515/jpm-2020-0129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022]
Abstract
Objectives Extubation failure is common in infants and associated with complications. Methods A prospective study was undertaken of preterm and term born infants. Diaphragm electromyogram (EMG) was measured transcutaneously for 15-60 min prior to extubation. The EMG results were related to tidal volume (Tve) to calculate the neuroventilatory efficiency (NVE). Receiver operating characteristic curves (ROC) were constructed and areas under the ROCs (AUROC) calculated. Results Seventy-two infants, median gestational age 28 (range 23-42) weeks were included; 15 (21%) failed extubation. Infants successfully extubated were more mature at birth (p=0.001), of greater corrected gestational age (CGA) at extubation (p<0.001) and heavier birth weight (p=0.005) than those who failed extubation. The amplitude and area under the curve of the diaphragm EMG were not significantly different between those who were and were not successfully extubated. Those successfully extubated required a significantly lower inspired oxygen and had higher expiratory tidal volumes (Tve) and NVE. The CGA and Tve had AUROCs of 0.83. A CGA of >29.6 weeks had the highest combined sensitivity (86%) and specificity (80%) in predicting extubation success. Conclusions Although NVE differed significantly between those who did and did not successfully extubate, CGA was the best predictor of extubation success.
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Affiliation(s)
- Katie A Hunt
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ian Hunt
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kamal Ali
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Theodore Dassios
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Asthma UK Centre in Allergic Mechanisms of Asthma, Kings College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas 'NHS Foundation Trust and King's College London, London, UK
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23
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Laghi F, Shaikh H, Littleton SW, Morales D, Jubran A, Tobin MJ. Inhibition of central activation of the diaphragm: a mechanism of weaning failure. J Appl Physiol (1985) 2020; 129:366-376. [PMID: 32673161 PMCID: PMC7473953 DOI: 10.1152/japplphysiol.00856.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
During a T-tube trial following disconnection of mechanical ventilation, patients failing the trial do not develop contractile diaphragmatic fatigue despite increases in inspiratory pressure output. Studies in volunteers, patients, and animals raise the possibility of spinal and supraspinal reflex mechanisms that inhibit central-neural output under loaded conditions. We hypothesized that diaphragmatic recruitment is submaximal at the end of a failed weaning trial despite concurrent respiratory distress. Tidal transdiaphragmatic pressure (ΔPdi) and electrical activity (ΔEAdi) were recorded with esophago-gastric catheters during a T-tube trial in 20 critically ill patients. During the T-tube trial, ∆EAdi was greater in weaning failure patients than in weaning success patients (P = 0.049). Despite increases in ΔPdi, from 18.1 ± 2.5 to 25.9 ± 3.7 cm H2O (P < 0.001), rate of transdiaphragmatic pressure development (from 22.6 ± 3.1 to 37.8 ± 6.7 cm H2O/s; P < 0.0004), and concurrent respiratory distress, ∆EAdi at the end of a failed T-tube trial was half of maximum, signifying inhibition of central neural output to the diaphragm. The increase in ΔPdi in the weaning failure group, while ∆EAdi remained constant, indicates unexpected improvement in diaphragmatic neuromuscular coupling (from 46.7 ± 6.5 to 57.8 ± 8.4 cm H2O/%; P = 0.006). Redistribution of neural output to the respiratory muscles characterized by a progressive increase in rib cage and accessory muscle contribution to tidal breathing and expiratory muscle recruitment contributed to enhanced coupling. In conclusion, diaphragmatic recruitment is submaximal at the end of a failed weaning trial despite concurrent respiratory distress. This finding signifies that reflex inhibition of central neural output to the diaphragm contributes to weaning failure. NEW & NOTEWORTHY Research into pathophysiology of failure to wean from mechanical ventilation has excluded several factors, including contractile fatigue, but the precise mechanism remains unknown. We recorded transdiaphragmatic pressure and diaphragmatic electrical activity in patients undergoing a T-tube trial. Diaphragmatic recruitment was submaximal at the end of a failed trial despite concurrent respiratory distress, signifying that inhibition of central neural output to the diaphragm is an important mechanism of weaning failure.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Stephen W Littleton
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Daniel Morales
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
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24
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Abstract
OBJECTIVES This review discusses the different techniques used at the bedside to assess respiratory muscle function in critically ill children and their clinical applications. DATA SOURCES A scoping review of the medical literature on respiratory muscle function assessment in critically ill children was conducted using the PubMed search engine. STUDY SELECTION We included all scientific, peer-reviewed studies about respiratory muscle function assessment in critically ill children, as well as some key adult studies. DATA EXTRACTION Data extracted included findings or comments about techniques used to assess respiratory muscle function. DATA SYNTHESIS Various promising physiologic techniques are available to assess respiratory muscle function at the bedside of critically ill children throughout the disease process. During the acute phase, this assessment allows a better understanding of the pathophysiological mechanisms of the disease and an optimization of the ventilatory support to increase its effectiveness and limit its potential complications. During the weaning process, these physiologic techniques may help predict extubation success and therefore optimize ventilator weaning. CONCLUSIONS Physiologic techniques are useful to precisely assess respiratory muscle function and to individualize and optimize the management of mechanical ventilation in children. Among all the available techniques, the measurements of esophageal pressure and electrical activity of the diaphragm appear particularly helpful in the era of individualized ventilatory management.
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25
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Spinelli E, Mauri T, Beitler JR, Pesenti A, Brodie D. Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions. Intensive Care Med 2020; 46:606-618. [PMID: 32016537 PMCID: PMC7224136 DOI: 10.1007/s00134-020-05942-6] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Neural respiratory drive, i.e., the activity of respiratory centres controlling breathing, is an overlooked physiologic variable which affects the pathophysiology and the clinical outcome of acute respiratory distress syndrome (ARDS). Spontaneous breathing may offer multiple physiologic benefits in these patients, including decreased need for sedation, preserved diaphragm activity and improved cardiovascular function. However, excessive effort to breathe due to high respiratory drive may lead to patient self-inflicted lung injury (P-SILI), even in the absence of mechanical ventilation. In the present review, we focus on the physiological and clinical implications of control of respiratory drive in ARDS patients. We summarize the main determinants of neural respiratory drive and the mechanisms involved in its potentiation, in health and ARDS. We also describe potential and pitfalls of the available bedside methods for drive assessment and explore classical and more “futuristic” interventions to control drive in ARDS patients.
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Affiliation(s)
- Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Tommaso Mauri
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Via F. Sforza 35, 20122, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Via F. Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Brodie
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
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26
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Mullaguri N, Khan Z, Nattanmai P, Newey CR. Extubating the Neurocritical Care Patient: A Spontaneous Breathing Trial Algorithmic Approach. Neurocrit Care 2019; 28:93-96. [PMID: 28948503 DOI: 10.1007/s12028-017-0398-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delaying extubation in neurologically impaired patients otherwise ready for extubation is a source for significant morbidity, mortality, and costs. There is no consensus to suggest one spontaneous breathing trial (SBT) over another in predicting extubation success. We studied an algorithm using zero pressure support and zero positive end-expiratory pressure (ZEEP) SBT followed by 5-cm H2O pressure support and 5-cm H2O positive end-expiratory pressure (i.e., 5/5) SBT in those who failed ZEEP SBT. METHODS This is a retrospective analysis of intubated patients in a neurosciences intensive care unit. All eligible patients were initially challenged with ZEEP SBT. If failed, a 5/5 SBT was immediately performed. If passed either the ZEEP SBT or the subsequent 5/5 SBT, patients were liberated from mechanical ventilation. RESULTS In total, 108 adult patients were included. The majority of patients were successfully liberated from mechanical ventilation using ZEEP SBT alone (82.4%; p = 0.0007). Fifteen (13.8%) patients failed ZEEP SBT but immediately passed 5/5 SBT (p = 0.0005). One patient (0.93%) required reintubation. We found high sensitivity of this extubation algorithm (100; 95% CI 95.94-100%) but poor specificity (6.67; 95% CI 0.17-31.95%). CONCLUSION This study showed that the majority of patients could be successfully liberated from mechanical ventilation after a ZEEP SBT. In those who failed, a 5/5 SBT increased the successful liberation from mechanical ventilation.
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Affiliation(s)
- Naresh Mullaguri
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA
| | - Zalan Khan
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA
| | - Premkumar Nattanmai
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA
| | - Christopher R Newey
- Department of Neurology, University of Missouri, 5 Hospital Drive CE 540, Columbia, MO, 65211, USA.
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Standardized Unloading of Respiratory Muscles during Neurally Adjusted Ventilatory Assist: A Randomized Crossover Pilot Study. Anesthesiology 2019; 129:769-777. [PMID: 30045094 DOI: 10.1097/aln.0000000000002335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Currently, there is no standardized method to set the support level in neurally adjusted ventilatory assist (NAVA). The primary aim was to explore the feasibility of titrating NAVA to specific diaphragm unloading targets, based on the neuroventilatory efficiency (NVE) index. The secondary outcome was to investigate the effect of reduced diaphragm unloading on distribution of lung ventilation. METHODS This is a randomized crossover study between pressure support and NAVA at different diaphragm unloading at a single neurointensive care unit. Ten adult patients who had started weaning from mechanical ventilation completed the study. Two unloading targets were used: 40 and 60%. The NVE index was used to guide the titration of the assist in NAVA. Electrical impedance tomography data, blood-gas samples, and ventilatory parameters were collected. RESULTS The median unloading was 43% (interquartile range 32, 60) for 40% unloading target and 60% (interquartile range 47, 69) for 60% unloading target. NAVA with 40% unloading led to more dorsal ventilation (center of ventilation at 55% [51, 56]) compared with pressure support (52% [49, 56]; P = 0.019). No differences were found in oxygenation, CO2, and respiratory parameters. The electrical activity of the diaphragm was higher during NAVA with 40% unloading than in pressure support. CONCLUSIONS In this pilot study, NAVA could be titrated to different diaphragm unloading levels based on the NVE index. Less unloading was associated with greater diaphragm activity and improved ventilation of the dependent lung regions.
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Relationship Between Diaphragmatic Electrical Activity and Esophageal Pressure Monitoring in Children. Pediatr Crit Care Med 2019; 20:e319-e325. [PMID: 31107378 DOI: 10.1097/pcc.0000000000001981] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Mechanical ventilation is an essential life support technology, but it is associated with side effects in case of over or under-assistance. The monitoring of respiratory effort may facilitate titration of the support. The gold standard for respiratory effort measurement is based on esophageal pressure monitoring, a technology not commonly available at bedside. Diaphragmatic electrical activity can be routinely monitored in clinical practice and reflects the output of the respiratory centers. We hypothesized that diaphragmatic electrical activity changes accurately reflect changes in mechanical efforts. The objectives of this study were to characterize the relationship between diaphragmatic electrical activity and esophageal pressure. DESIGN Prospective crossover study. SETTING Esophageal pressure and diaphragmatic electrical activity were simultaneously recorded using a specific nasogastric tube in three conditions: in pressure support ventilation and in neurally adjusted ventilatory support in a random order, and then after extubation. PATIENTS Children in the weaning phase of mechanical ventilation. INTERVENTIONS The maximal swing in esophageal pressure and esophageal pressure-time product, maximum diaphragmatic electrical activity, and inspiratory diaphragmatic electrical activity integral were calculated from 100 consecutive breaths. Neuroventilatory efficiency was estimated using the ratio of tidal volume/maximum diaphragmatic electrical activity. MEASUREMENTS AND MAIN RESULTS Sixteen patients, with a median age of 4 months (interquartile range, 0.5-13 mo), and weight 5.8 kg (interquartile range, 4.1-8 kg) were included. A strong linear correlation between maximum diaphragmatic electrical activity and maximal swing in esophageal pressure (r > 0.95), and inspiratory diaphragmatic electrical activity integral and esophageal pressure-time product (r > 0.71) was observed in all ventilatory conditions. This correlation was not modified by the type of ventilatory support. CONCLUSIONS On a short-term basis, diaphragmatic electrical activity changes are strongly correlated with esophageal pressure changes. In clinical practice, diaphragmatic electrical activity monitoring may help to inform on changes in respiratory efforts.
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Tagliabue G, Ji M, Suneby Jagers JV, Zuege DJ, Kortbeek JB, Easton PA. Distinct neural-mechanical efficiency of costal and crural diaphragm during hypercapnia. Respir Physiol Neurobiol 2019; 268:103247. [PMID: 31247325 DOI: 10.1016/j.resp.2019.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/30/2019] [Accepted: 06/23/2019] [Indexed: 11/30/2022]
Abstract
Classic physiology suggests that the two distinct diaphragm segments, costal and crural, are functionally different. It is not known if the two diaphragm muscles share a common neural mechanical activation. We hypothesized that costal and crural diaphragm are recruited differently during hypercapnic stimulated ventilation, and the EMG recordings of the esophageal crural diaphragm segment does not translate to the same level of mechanical shortening for costal and crural segments In 30 spontaneously breathing canines, without confounding anesthetic, we measured directly electrical activity and corresponding mechanical shortening of both the costal and crural diaphragm, at room air and during increasing hypercapnia. During hypercapnic ventilation, the costal diaphragm showed a predominant recruitment over the crural diaphragm. The distinct mechanical contribution of the costal segment was not due to a different level of neural activation between the two muscles as measured by segmental EMG activity. Thus, the two diaphragm segments exhibited a significantly different neural-mechanical relationship.
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Affiliation(s)
- Giovanni Tagliabue
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Michael Ji
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Jenny V Suneby Jagers
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Dan J Zuege
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - John B Kortbeek
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Paul A Easton
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 4N1, Canada.
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Jonkman AH, Jansen D, Gadgil S, Keijzer C, Girbes ARJ, Scheffer GJ, van der Hoeven JG, Tuinman PR, Spoelstra-de Man AME, Sinderby CS, Heunks LMA. Monitoring patient-ventilator breath contribution in the critically ill during neurally adjusted ventilatory assist: reliability and improved algorithms for bedside use. J Appl Physiol (1985) 2019; 127:264-271. [PMID: 31161879 DOI: 10.1152/japplphysiol.00071.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The patient-ventilator breath contribution (PVBC) index estimates the relative contribution of the patient to total tidal volume (Vtinsp) during mechanical ventilation in neurally adjusted ventilator assist mode and has been used to titrate ventilator support. The reliability of this index in ventilated patients is unknown and was investigated in this study. PVBC was calculated by comparing tidal volume (Vtinsp) and diaphragm electrical activity (EAdi) during assisted breaths (Vtinsp/EAdi)assist and during unassisted breaths (Vtinsp/EAdi)no-assist. Vtinsp was normalized to peak EAdi (EAdipeak) using 1) one assisted breath, 2) five consecutive assisted breaths, or 3) five assisted breaths with matching EAdi preceding the unassisted breath (N1PVBC2, X5PVBC2, and PX5VBCEAdi-matching2 , respectively). In addition, PVBC was calculated by comparing only Vtinsp for breaths with matching EAdi (PVBCβ2). Test-retest reliability of the different PVBC calculation methods was evaluated with the intraclass correlation coefficient (ICC) using five repeated PVBC maneuvers performed with a 1-min interval. In total, 125 PVBC maneuvers were analyzed in 25 patients. ICC [95% confidence interval] values were 0.46 [0.23-0.66], 0.51 [0.33-0.70], and 0.42 [0.14-0.69] for N1PVBC2, X5PVBC2, PX5VBCEAdi-matching2 , respectively. Complex waveform analyses showed that insufficient EAdi filtering by the ventilator software affects reliability of PVBC calculation. With our new EAdi-matching techniques reliability improved (PVBCβ2 ICC: 0.78 [0.60-0.90]). We conclude that current techniques to calculate PVBC exhibit low reliability and that our newly developed criteria and estimation of PVBC-using Vtinsp of assisted breaths and unassisted breaths with matching EAdi-improves reliability. This may help implementation of PVBC in clinical practice. NEW & NOTEWORTHY The patient-ventilator breath contribution (PVBC) index estimates the relative contribution of the patient to tidal volume generated by the patient and the mechanical ventilator during mechanical ventilation in neurally adjusted ventilator assist mode. It could be used to titrate ventilator support and thus to limit development of diaphragm dysfunction in intensive care unit patients. Currently available methods for bedside assessment of PVBC are unreliable. Our newly developed criteria and estimation of PVBC largely improve reliability and help to quantify patient contribution to total inspiratory effort.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | - Diana Jansen
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Suvarna Gadgil
- Department of Anesthesiology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | | | - Christer S Sinderby
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto , Toronto, Ontario , Canada
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
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Langer T, Baio S, Chidini G, Marchesi T, Grasselli G, Pesenti A, Calderini E. Severe diaphragmatic dysfunction with preserved activity of accessory respiratory muscles in a critically ill child: a case report of failure of neurally adjusted ventilatory assist (NAVA) and successful support with pressure support ventilation (PSV). BMC Pediatr 2019; 19:155. [PMID: 31101098 PMCID: PMC6524310 DOI: 10.1186/s12887-019-1527-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is an alternative to pressure support ventilation (PSV) potentially improving patient-ventilator interaction. During NAVA, diaphragmatic electrical activity (EAdi) is used to trigger the ventilator and perform a proportional respiratory assistance. We present a case in which the presence of severe bilateral diaphragmatic dysfunction led to a failure of NAVA. On the contrary, the preserved activity of the accessory inspiratory muscles allowed a successful respiratory assistance using PSV. CASE PRESENTATION A 10-year-old girl developed quadriplegia after neurological surgery. Initially, no spontaneous breathing activity was present and volume controlled ventilation was necessary. Two months later spontaneous inspiratory efforts were observed and a maximal negative inspiratory force of - 20 cmH2O was recorded. In addition, a NAVA nasogastric tube was placed. The recorded EAdi signal, despite showing a phasic activity, had a very low amplitude (1-2 μV). Two brief (15 min) breathing trials to compare PSV (pressure support = 8 cmH2O) with NAVA (Gain = 5 cmH2O/μV, inspiratory trigger = 0.3 μV) were performed. On PSV, the patient was well adapted with stable tidal volumes, respiratory rates, minute ventilation, end-tidal and venous carbon dioxide levels. When switched to NAVA, her breathing pattern became irregular and she showed clear sign of increased work of breathing and distress: tidal volume dropped and respiratory rate rose, leading to an increase in total minute ventilation. Nevertheless, end-tidal and venous carbon dioxide rapidly increased (from 49 to 55 mmHg and from 52 to 57 mmHg, respectively). An electromyographic study documented an impairment of the diaphragm with preserved activity of the accessory inspiratory muscles. CONCLUSIONS We document the failure of mechanical assistance performed with NAVA due to bilateral diaphragmatic dysfunction in a critically ill child. The preserved activity of some accessory respiratory muscles allowed to support the patient effectively with pressure support ventilation, i.e. by applying a pneumatic trigger. The present case underlines (i) the importance of the integrity of the respiratory centers, phrenic nerves and diaphragm in order to perform NAVA and (ii) the possible diagnostic role of EAdi monitoring in complex cases of weaning failure.
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Affiliation(s)
- Thomas Langer
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy. .,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy.
| | - Serena Baio
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giovanna Chidini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Tiziana Marchesi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edoardo Calderini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Anestesia e Terapia Intensiva Donna-Bambino, Milan, Italy
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Karagiannidis C, Strassmann S, Schwarz S, Merten M, Fan E, Beck J, Sinderby C, Windisch W. Control of respiratory drive by extracorporeal CO 2 removal in acute exacerbation of COPD breathing on non-invasive NAVA. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:135. [PMID: 31014366 PMCID: PMC6480839 DOI: 10.1186/s13054-019-2404-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/21/2019] [Indexed: 01/19/2023]
Abstract
Background Veno-venous extracorporeal CO2 removal (vv-ECCO2R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. Methods A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. Results Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO2R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO2R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO2R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 μV vs. 56 ± 20 μV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO2 and pH values stable. Edi was the best predictor for vv-ECCO2R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. Conclusions This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO2R and NIV-NAVA. The Edi during vv-ECCO2R weaning was found to be the best predictor of tolerance to removing vv-ECCO2R. Electronic supplementary material The online version of this article (10.1186/s13054-019-2404-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Sarah Schwarz
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Michaela Merten
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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Physiological Effect of Prone Position in Children with Severe Bronchiolitis: A Randomized Cross-Over Study (BRONCHIO-DV). J Pediatr 2019; 205:112-119.e4. [PMID: 30448014 DOI: 10.1016/j.jpeds.2018.09.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation. STUDY DESIGN Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmH2O continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed. RESULTS Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmH2O*s/minute [IQR, 156-282] cmH2O*s/minute vs 353 cmH2O*s/minute [IQR, 249-386 cmH2O*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmH2O/µV [IQR, 0.9-1.3 cmH2O/µV] vs 0.7 cmH2O/µV [IQR, 0.6-1.2 cmH2O/µV], respectively; P = .022). CONCLUSIONS This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population. TRIAL REGISTRATION Clinicaltrials.gov: NCT02602678.
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Stripoli T, Spadaro S, Di Mussi R, Volta CA, Trerotoli P, De Carlo F, Iannuzziello R, Sechi F, Pierucci P, Staffieri F, Bruno F, Camporota L, Grasso S. High-flow oxygen therapy in tracheostomized patients at high risk of weaning failure. Ann Intensive Care 2019; 9:4. [PMID: 30617626 PMCID: PMC6323064 DOI: 10.1186/s13613-019-0482-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/02/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose High-flow oxygen therapy delivered through nasal cannulae improves oxygenation and decreases work of breathing in critically ill patients. Little is known of the physiological effects of high-flow oxygen therapy applied to the tracheostomy cannula (T-HF). In this study, we compared the effects of T-HF or conventional low-flow oxygen therapy (conventional O2) on neuro-ventilatory drive, work of breathing, respiratory rate (RR) and gas exchange, in a mixed population of tracheostomized patients at high risk of weaning failure. Methods This was a single-center, unblinded, cross-over study on fourteen patients. After disconnection from the ventilator, each patient received two 1-h periods of T-HF (T-HF1 and T-HF2) alternated with 1 h of conventional O2. The inspiratory oxygen fraction was titrated to achieve an arterial O2 saturation target of 94–98% (88–92% in COPD patients). We recorded neuro-ventilatory drive (electrical diaphragmatic activity, EAdi), work of breathing (inspiratory muscular pressure–time product per breath and per minute, PTPmusc/b and PTPmusc/min, respectively) respiratory rate and arterial blood gases. Results The EAdipeak remained unchanged (mean ± SD) in the T-HF1, conventional O2 and T-HF2 study periods (8.8 ± 4.3 μV vs 8.9 ± 4.8 μV vs 9.0 ± 4.1 μV, respectively, p = 0.99). Similarly, PTPmusc/b and PTPmusc/min, RR and gas exchange remained unchanged. Conclusions In tracheostomized patients at high risk of weaning failure from mechanical ventilation, T-HF did not improve neuro-ventilatory drive, work of breathing, respiratory rate and gas exchange compared with conventional O2 after disconnection from the ventilator. The present findings might suggest that physiological effects of high-flow therapy through tracheostomy substantially differ from nasal high flow.
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Affiliation(s)
- Tania Stripoli
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Paolo Trerotoli
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy
| | - Francesca De Carlo
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Rachele Iannuzziello
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Fabio Sechi
- Dipartimento di Scienze Chirurgiche e Microchirurgiche, Università degli Studi di Sassari, Sassari, Italy
| | - Paola Pierucci
- Dipartimento di Medicina Respiratoria e del Sonno, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, King's College London, London, UK.,Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy.
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Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization. Crit Care Clin 2018; 34:357-381. [PMID: 29907270 DOI: 10.1016/j.ccc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Affiliation(s)
- Annia Schreiber
- Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili 1, Brescia 25123, Italy
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, Peter Munk Building, 11th Floor Room 192, Toronto, ON M5G 2N2, Canada.
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Naito Y, Shimizu Y, Hatachi T, Inata Y, Moon K, Tachibana K, Takeuchi M. Predicting extubation readiness by monitoring the electrical activity of the diaphragm after prolonged mechanical ventilation: a pediatric case report. JA Clin Rep 2018; 4:76. [PMID: 32026039 PMCID: PMC6967200 DOI: 10.1186/s40981-018-0213-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The intensity of the electrical activity of the diaphragm (Edi) correlates with inspiratory effort. The ratio of tidal volume to the Edi is known as neuroventilatory efficiency (NVE) and is used as an index for ventilation efficiency. Here, we present a case showing that Edi and NVE may be effective parameters to predict successful extubation. CASE PRESENTATION A 6-month-old female infant required prolonged mechanical ventilation after cardiac surgery. Fifty-two days after surgery, her trachea was extubated but required reintubation. Edi monitoring was initiated to assess diaphragm function. The Edi was > 70 mcV just after the reintubation, and her NVE was 1.0 mL/mcV, but gradually decreased. On day 59, her Edi values during the spontaneous breathing trials were 13 mcV with the improvement of NVE (2.5 mL/mcV) and her trachea was extubated without complications. CONCLUSIONS The Edi and NVE were valuable for deciding the extubation readiness in a long-term mechanically ventilated patient.
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Affiliation(s)
- Yusuke Naito
- Department of Anesthesiology, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan.
| | - Yoshiyuki Shimizu
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Takeshi Hatachi
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Yu Inata
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Kazue Moon
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Kazuya Tachibana
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Muneyuki Takeuchi
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
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Jansen D, Jonkman AH, Roesthuis L, Gadgil S, van der Hoeven JG, Scheffer GJJ, Girbes A, Doorduin J, Sinderby CS, Heunks LMA. Estimation of the diaphragm neuromuscular efficiency index in mechanically ventilated critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:238. [PMID: 30261920 PMCID: PMC6161422 DOI: 10.1186/s13054-018-2172-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/28/2018] [Indexed: 12/27/2022]
Abstract
Background Diaphragm dysfunction develops frequently in ventilated intensive care unit (ICU) patients. Both disuse atrophy (ventilator over-assist) and high respiratory muscle effort (ventilator under-assist) seem to be involved. A strong rationale exists to monitor diaphragm effort and titrate support to maintain respiratory muscle activity within physiological limits. Diaphragm electromyography is used to quantify breathing effort and has been correlated with transdiaphragmatic pressure and esophageal pressure. The neuromuscular efficiency index (NME) can be used to estimate inspiratory effort, however its repeatability has not been investigated yet. Our goal is to evaluate NME repeatability during an end-expiratory occlusion (NMEoccl) and its use to estimate the pressure generated by the inspiratory muscles (Pmus). Methods This is a prospective cohort study, performed in a medical-surgical ICU. A total of 31 adult patients were included, all ventilated in neurally adjusted ventilator assist (NAVA) mode with an electrical activity of the diaphragm (EAdi) catheter in situ. At four time points within 72 h five repeated end-expiratory occlusion maneuvers were performed. NMEoccl was calculated by delta airway pressure (ΔPaw)/ΔEAdi and was used to estimate Pmus. The repeatability coefficient (RC) was calculated to investigate the NMEoccl variability. Results A total number of 459 maneuvers were obtained. At time T = 0 mean NMEoccl was 1.22 ± 0.86 cmH2O/μV with a RC of 82.6%. This implies that when NMEoccl is 1.22 cmH2O/μV, it is expected with a probability of 95% that the subsequent measured NMEoccl will be between 2.22 and 0.22 cmH2O/μV. Additional EAdi waveform analysis to correct for non-physiological appearing waveforms, did not improve NMEoccl variability. Selecting three out of five occlusions with the lowest variability reduced the RC to 29.8%. Conclusions Repeated measurements of NMEoccl exhibit high variability, limiting the ability of a single NMEoccl maneuver to estimate neuromuscular efficiency and therefore the pressure generated by the inspiratory muscles based on EAdi. Electronic supplementary material The online version of this article (10.1186/s13054-018-2172-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Diana Jansen
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands
| | - Lisanne Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suvarna Gadgil
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Gert-Jan J Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Armand Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands
| | - Jonne Doorduin
- Department of Neurology, Donders Institute, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christer S Sinderby
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands.
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Respiratory Muscle Effort during Expiration in Successful and Failed Weaning from Mechanical Ventilation. Anesthesiology 2018; 129:490-501. [DOI: 10.1097/aln.0000000000002256] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Respiratory muscle weakness in critically ill patients is associated with difficulty in weaning from mechanical ventilation. Previous studies have mainly focused on inspiratory muscle activity during weaning; expiratory muscle activity is less well understood. The current study describes expiratory muscle activity during weaning, including tonic diaphragm activity. The authors hypothesized that expiratory muscle effort is greater in patients who fail to wean compared to those who wean successfully.
Methods
Twenty adult patients receiving mechanical ventilation (more than 72 h) performed a spontaneous breathing trial. Tidal volume, transdiaphragmatic pressure, diaphragm electrical activity, and diaphragm neuromechanical efficiency were calculated on a breath-by-breath basis. Inspiratory (and expiratory) muscle efforts were calculated as the inspiratory esophageal (and expiratory gastric) pressure–time products, respectively.
Results
Nine patients failed weaning. The contribution of the expiratory muscles to total respiratory muscle effort increased in the “failure” group from 13 ± 9% at onset to 24 ± 10% at the end of the breathing trial (P = 0.047); there was no increase in the “success” group. Diaphragm electrical activity (expressed as the percentage of inspiratory peak) was low at end expiration (failure, 3 ± 2%; success, 4 ± 6%) and equal between groups during the entire expiratory phase (P = 0.407). Diaphragm neuromechanical efficiency was lower in the failure versus success groups (0.38 ± 0.16 vs. 0.71 ± 0.36 cm H2O/μV; P = 0.054).
Conclusions
Weaning failure (vs. success) is associated with increased effort of the expiratory muscles and impaired neuromechanical efficiency of the diaphragm but no difference in tonic activity of the diaphragm.
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Cavalcante JGT, Silva RDE, Souza HCMD, Moraes NHLD. Análise da força muscular expiratória e respiração espontânea de indivíduos em ventilação mecânica: estudo transversal. FISIOTERAPIA E PESQUISA 2018. [DOI: 10.1590/1809-2950/17011525032018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Os músculos da expiração têm funções em todo o ciclo respiratório, mas não são frequentemente avaliados no desmame da ventilação mecânica. Assim, revisões e consensos não mencionam a pressão expiratória máxima (PEmáx) e o treino expiratório. Objetivou-se investigar a relação da força muscular expiratória com a respiração espontânea de indivíduos ventilados mecanicamente. Trata-se de um estudo transversal com participantes de 18 a 79 anos de idade. Foram formados os grupos PEmáx satisfatória (GPES) e PEmáx baixa (GPEB) conforme o ponto de corte de 55cmH2O e comparados a parâmetros de desmame. O GPES (n=9) teve desempenho superior ao do GPEB (n=21) no índice de respiração rápida e superficial (IRRS) (40,6±17,6rpm/L e 75,3±44,1rpm/L, respectivamente; p=0,022) e na frequência respiratória (f) (19,1±6,2rpm e 26,1±9,4rpm; p=0,044). A prevalência de PEmáx satisfatória foi pequena, observada no tamanho dos grupos. Além disso, embora a PEmáx percentual do valor predito tenha sido menor no GPEB, como esperado (67,2±15,4% vs. 45,8±14,7%; p=0,001), a pressão inspiratória máxima percentual não diferiu significantemente (82,4±21,8% vs. 67,8±18,4%; p=0,077). A PEmáx se correlacionou moderadamente com o IRRS (r=-0,406; p=0,026) e com a f (r=-0,426; p=0,017). Conclui-se que a PEmáx≥55cmH2O esteve associada à melhores valores no IRRS e na f, e que a redução da força muscular expiratória foi mais prevalente e severa que a da força muscular inspiratória.
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Baptistella AR, Sarmento FJ, da Silva KR, Baptistella SF, Taglietti M, Zuquello RÁ, Nunes Filho JR. Predictive factors of weaning from mechanical ventilation and extubation outcome: A systematic review. J Crit Care 2018; 48:56-62. [PMID: 30172034 DOI: 10.1016/j.jcrc.2018.08.023] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/06/2018] [Accepted: 08/18/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify, describe and discuss the parameters used to predict weaning from mechanical ventilation and extubation outcomes. METHODS Systematic review of scientific articles using four electronic databases: PubMed, Embase, PEDro and Cochrane Library. Search terms included "weaning", "extubation", "withdrawal" and "discontinuation", combined with "mechanical ventilation" and "predictive factors", "predictive parameters" and "predictors for success". In this study, we included original articles that presented predictive factors for weaning or extubation outcomes in adult patients and not restricted to a single disease. Articles not written in English were excluded. RESULTS A total of 43 articles were included, with a total of 7929 patients and 56 different parameters related to weaning and extubation outcomes. Rapid Shallow Breathing Index (RSBI) was the most common predictor, discussed in 15 studies (2159 patients), followed by Age and Maximum Inspiratory Pressure in seven studies. The other 53 parameters were found in less than six studies. CONCLUSION There are several parameters used to predict weaning and extubation outcomes. RSBI was the most frequently studied and seems to be an important measurement tool in deciding whether to wean/extubate a patient. Furthermore, the results demonstrated that weaning and extubation should be guided by several parameters, and not only to respiratory ones.
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Affiliation(s)
- Antuani Rafael Baptistella
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Programa de Pós-Graduação em Biociências e Saúde/Universidade do Oeste de Santa Catarina, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil.
| | | | | | - Shaline Ferla Baptistella
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Programa de Pós-Graduação em Biociências e Saúde/Universidade do Oeste de Santa Catarina, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil
| | | | | | - João Rogério Nunes Filho
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil
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Di Mussi R, Spadaro S, Stripoli T, Volta CA, Trerotoli P, Pierucci P, Staffieri F, Bruno F, Camporota L, Grasso S. High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:180. [PMID: 30071876 PMCID: PMC6091018 DOI: 10.1186/s13054-018-2107-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The physiological effects of high-flow nasal cannula O2 therapy (HFNC) have been evaluated mainly in patients with hypoxemic respiratory failure. In this study, we compared the effects of HFNC and conventional low-flow O2 therapy on the neuroventilatory drive and work of breathing postextubation in patients with a background of chronic obstructive pulmonary disease (COPD) who had received mechanical ventilation for hypercapnic respiratory failure. METHODS This was a single center, unblinded, cross-over study on 14 postextubation COPD patients who were recovering from an episode of acute hypercapnic respiratory failure of various etiologies. After extubation, each patient received two 1-h periods of HFNC (HFNC1 and HFNC2) alternated with 1 h of conventional low-flow O2 therapy via a face mask. The inspiratory fraction of oxygen was titrated to achieve an arterial O2 saturation target of 88-92%. Gas exchange, breathing pattern, neuroventilatory drive (electrical diaphragmatic activity (EAdi)) and work of breathing (inspiratory trans-diaphragmatic pressure-time product per minute (PTPDI/min)) were recorded. RESULTS EAdi peak increased from a mean (±SD) of 15.4 ± 6.4 to 23.6 ± 10.5 μV switching from HFNC1 to conventional O2, and then returned to 15.2 ± 6.4 μV during HFNC2 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). Similarly, the PTPDI/min increased from 135 ± 60 to 211 ± 70 cmH2O/s/min, and then decreased again during HFNC2 to 132 ± 56 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). CONCLUSIONS In patients with COPD, the application of HFNC postextubation significantly decreased the neuroventilatory drive and work of breathing compared with conventional O2 therapy.
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Affiliation(s)
- Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Tania Stripoli
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Paolo Trerotoli
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy
| | - Paola Pierucci
- Dipartimento di Medicina Respiratoria e del Sonno, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, and Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
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Liu L, Wu AP, Yang Y, Liu SQ, Huang YZ, Xie JF, Pan C, Yang CS, Qiu HB. Effects of Propofol on Respiratory Drive and Patient-ventilator Synchrony during Pressure Support Ventilation in Postoperative Patients: A Prospective Study. Chin Med J (Engl) 2018; 130:1155-1160. [PMID: 28485314 PMCID: PMC5443020 DOI: 10.4103/0366-6999.205864] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Propofol is increasingly used during partial support mechanical ventilation such as pressure support ventilation (PSV) in postoperative patients. However, breathing pattern, respiratory drive, and patient-ventilator synchrony are affected by the sedative used and the sedation depth. The present study aimed to evaluate the physiologic effects of varying depths of propofol sedation on respiratory drive and patient-ventilator synchrony during PSV in postoperative patients. METHODS Eight postoperative patients receiving PSV for <24 h were enrolled. Propofol was administered to achieve and maintain a Ramsay score of 4, and the inspiratory pressure support was titrated to obtain a tidal volume (VT) of 6-8 ml/kg. Then, the propofol dose was reduced to achieve and maintain a Ramsay score of 3 and then 2. At each Ramsay level, the patient underwent 30-min trials of PSV. We measured the electrical activity of the diaphragm, flow, airway pressure, neuro-ventilatory efficiency (NVE), and patient-ventilator synchrony. RESULTS Increasing the depth of sedation reduced the peak and mean electrical activity of the diaphragm, which suggested a decrease in respiratory drive, while VT remained unchanged. The NVE increased with an increase in the depth of sedation. Minute ventilation and inspiratory duty cycle decreased with an increase in the depth of sedation, but this only achieved statistical significance between Ramsay 2 and both Ramsay 4 and 3 (P < 0.05). The ineffective triggering index increased with increasing sedation depth (9.5 ± 4.0%, 6.7 ± 2.0%, and 4.2 ± 2.1% for Ramsay 4, 3, and 2, respectively) and achieved statistical significance between each pair of depth of sedation (P < 0.05). The depth of sedation did not affect gas exchange. CONCLUSIONS Propofol inhibits respiratory drive and deteriorates patient-ventilator synchrony to the extent that varies with the depth of sedation. Propofol has less effect on breathing pattern and has no effect on VT and gas exchange in postoperative patients with PSV.
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Affiliation(s)
- Ling Liu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Ai-Ping Wu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Yi Yang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Song-Qiao Liu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Ying-Zi Huang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Jian-Feng Xie
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Chun Pan
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Cong-Shan Yang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Hai-Bo Qiu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
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Oppersma E, Doorduin J, van der Hoeven JG, Veltink PH, van Hees HWH, Heunks LMA. The effect of metabolic alkalosis on the ventilatory response in healthy subjects. Respir Physiol Neurobiol 2018; 249:47-53. [PMID: 29307724 DOI: 10.1016/j.resp.2018.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/07/2017] [Accepted: 01/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with acute respiratory failure may develop respiratory acidosis. Metabolic compensation by bicarbonate production or retention results in posthypercapnic alkalosis with an increased arterial bicarbonate concentration. The hypothesis of this study was that elevated plasma bicarbonate levels decrease respiratory drive and minute ventilation. METHODS In an intervention study in 10 healthy subjects the ventilatory response using a hypercapnic ventilatory response (HCVR) test was assessed, before and after administration of high dose sodium bicarbonate. Total dose of sodiumbicarbonate was 1000 ml 8.4% in 3 days. RESULTS Plasma bicarbonate increased from 25.2 ± 2.2 to 29.2 ± 1.9 mmol/L. With increasing inspiratory CO2 pressure during the HCVR test, RR, Vt, Pdi, EAdi and VE increased. The clinical ratio ΔVE/ΔPetCO2 remained unchanged, but Pdi, EAdi and VE were significantly lower after bicarbonate administration for similar levels of inspired CO2. CONCLUSION This study demonstrates that in healthy subjects metabolic alkalosis decreases the neural respiratory drive and minute ventilation, as a response to inspiratory CO2.
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Affiliation(s)
- E Oppersma
- MIRA - Institute for Biomedical Technology & Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Doorduin
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G van der Hoeven
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P H Veltink
- MIRA - Institute for Biomedical Technology & Technical Medicine, University of Twente, Enschede, The Netherlands
| | - H W H van Hees
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M A Heunks
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Iyer NP, Dickson J, Ruiz ME, Chatburn R, Beck J, Sinderby C, Rodriguez RJ. Neural breathing pattern in newborn infants pre- and postextubation. Acta Paediatr 2017; 106:1928-1933. [PMID: 28833570 DOI: 10.1111/apa.14040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/29/2017] [Accepted: 08/17/2017] [Indexed: 12/24/2022]
Abstract
AIM To describe the neural breathing pattern before and after extubation in newborn infants. METHODS Prospective, observational study. In infants deemed ready for extubation, the diaphragm electrical activity (EAdi) was continuously recorded from 30 minute before to two hours after extubation. RESULTS Total of 25 neonates underwent 29 extubations; 10 extubations resulted in re-intubation within 72 hours. Postextubation, there was an increase in peak EAdi (EAdi-max) and EAdi-delta (peak minus minimum EAdi) in both groups. The pre- to postextubation change in EAdi-max (8.9-11.1 μv) and EAdi-delta (6-8 μv) was less in the failure group in comparison with the change in EAdi-max (10.2-13.4 μv) and EAdi-delta (6.3-10.6 μv) in the success group, (p = 0.02 and 0.01, respectively). CONCLUSION In our neonatal cohort, extubation failure was associated with a smaller increase in peak and delta EAdi after extubation. If confirmed, these findings indicate an important cause of extubation failure in preterm infants.
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Affiliation(s)
- Narayan P. Iyer
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - John Dickson
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - Michelle E. Ruiz
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - Robert Chatburn
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - Jennifer Beck
- Department of Critical Care; Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Department of Pediatrics; University of Toronto; Toronto ON Canada
| | - Chister Sinderby
- Department of Critical Care; Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Department of Pediatrics; University of Toronto; Toronto ON Canada
- Department of Medicine and Interdepartmental Division of Critical Care Medicine; University of Toronto; Toronto ON Canada
| | - Ricardo J. Rodriguez
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
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Diniz-Silva F, Miethke-Morais A, Alencar AM, Moriya HT, Caruso P, Costa ELV, Ferreira JC. Monitoring the electric activity of the diaphragm during noninvasive positive pressure ventilation: a case report. BMC Pulm Med 2017; 17:91. [PMID: 28623885 PMCID: PMC5473981 DOI: 10.1186/s12890-017-0434-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/08/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In patients with post-extubation respiratory distress, delayed reintubation may worsen clinical outcomes. Objective measures of extubation failure at the bedside are lacking, therefore clinical parameters are currently used to guide the need of reintubation. Electrical activity of the diaphragm (EAdi) provides clinicians with valuable, objective information about respiratory drive and could be used to monitor respiratory effort. CASE PRESENTATION We describe the case of a patient with Chronic Obstructive Pulmonary Disease (COPD), from whom we recorded EAdi during four different ventilatory conditions: 1) invasive mechanical ventilation, 2) spontaneous breathing trial (SBT), 3) unassisted spontaneous breathing, and 4) Noninvasive Positive Pressure Ventilation (NPPV). The patient had been intubated due to an exacerbation of COPD, and after four days of mechanical ventilation, she passed the SBT and was extubated. Clinical signs of respiratory distress were present immediately after extubation, and EAdi increased compared to values obtained during mechanical ventilation. As we started NPPV, EAdi decreased substantially, indicating muscle unloading promoted by NPPV, and we used the EAdi signal to monitor respiratory effort during NPPV. Over the next three days, she was on NPPV for most of the time, with short periods of spontaneous breathing. EAdi remained considerably lower during NPPV than during spontaneous breathing, until the third day, when the difference was no longer clinically significant. She was then weaned from NPPV and discharged from the ICU a few days later. CONCLUSION EAdi monitoring during NPPV provides an objective parameter of respiratory drive and respiratory muscle unloading and may be a useful tool to guide post-extubation ventilatory support. Clinical studies with continuous EAdi monitoring are necessary to clarify the meaning of its absolute values and changes over time.
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Affiliation(s)
- Fabia Diniz-Silva
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Anna Miethke-Morais
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Henrique T. Moriya
- Biomedical Engineering Laboratory, University of São Paulo, São Paulo, Brazil
| | - Pedro Caruso
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo L. V. Costa
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Juliana C. Ferreira
- Pulmonary Division, Heart Institute (InCor) – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW In this review, we discuss the causes for a failed weaning trial and specific diagnostic tests that could be conducted to identify the cause for weaning failure. We briefly highlight treatment strategies that may enhance the chance of weaning success. RECENT FINDINGS Impaired respiratory mechanics, respiratory muscle dysfunction, cardiac dysfunction, cognitive dysfunction, and metabolic disorders are recognized causes for weaning failure. In addition, iatrogenic factors may be at play. Most studies have focused on respiratory muscle dysfunction and cardiac dysfunction. Recent studies demonstrate that both ultrasound and electromyography are valuable tools to evaluate respiratory muscle function in ventilated patients. Sophisticated ultrasound techniques and biomarkers such as B-type natriuretic peptide, are valuable tools to identify cardiac dysfunction as a cause for weaning failure. Once a cause for weaning failure has been identified specific treatment should be instituted. Concerning treatment, both strength training and endurance training should be considered for patients with respiratory muscle weakness. Inotropes and vasodilators should be considered in case of heart failure. SUMMARY Understanding the complex pathophysiology of weaning failure in combination with a systematic diagnostic approach allows identification of the primary cause of weaning failure. This will help the clinician to choose a specific treatment strategy and therefore may fasten liberation from mechanical ventilation.
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Neurally adjusted ventilatory assist feasibility during anaesthesia: A randomised crossover study of two anaesthetics in a large animal model. Eur J Anaesthesiol 2016; 33:283-91. [PMID: 26716863 PMCID: PMC4780484 DOI: 10.1097/eja.0000000000000399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Spontaneous breathing during mechanical ventilation improves gas exchange by redistribution of ventilation to dependent lung regions. Neurally adjusted ventilatory assist (NAVA) supports spontaneous breathing in proportion to the electrical activity of the diaphragm (EAdi). NAVA has never been used in the operating room and no studies have systematically addressed the influence of different anaesthetic drugs on EAdi. OBJECTIVES The aim of this study was to test the feasibility of NAVA under sedation and anaesthesia with two commonly used anaesthetics, sevoflurane and propofol, with and without remifentanil, and to study their effects on EAdi and breathing mechanics. DESIGN A crossover study with factorial design of NAVA during sedation and anaesthesia in pigs. SETTING University basic science laboratory in Uppsala, Sweden, from March 2009 to February 2011. ANIMALS Nine juvenile pigs were used for the experiment. INTERVENTIONS The lungs were ventilated using NAVA while the animals were sedated and anaesthetised with continuous low-dose ketamine combined with sevoflurane and propofol, with and without remifentanil. MAIN OUTCOME MEASURES During the last 5 min of each study period (total eight steps) EAdi, breathing pattern, blood gas analysis, neuromechanical efficiency (NME) and neuroventilatory efficiency (NVE) during NAVA were determined. RESULTS EAdi was preserved and normoventilation was reached with both sevoflurane and propofol during sedation as well as anaesthesia. Tidal volume (Vt) was significantly lower with sevoflurane anaesthesia than with propofol. NME was significantly higher with sevoflurane than with propofol during anaesthesia with and without remifentanil. NVE was significantly higher with sevoflurane than with propofol during sedation and anaesthesia. CONCLUSION NAVA is feasible during ketamine-propofol and ketamine-sevoflurane anaesthesia in pigs. Sevoflurane promotes lower Vt, and affects NME and NVE less than propofol. Our data warrant studies of NAVA in humans undergoing anaesthesia.
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Berger D, Bloechlinger S, von Haehling S, Doehner W, Takala J, Z'Graggen WJ, Schefold JC. Dysfunction of respiratory muscles in critically ill patients on the intensive care unit. J Cachexia Sarcopenia Muscle 2016; 7:403-12. [PMID: 27030815 PMCID: PMC4788634 DOI: 10.1002/jcsm.12108] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 12/18/2015] [Accepted: 01/27/2016] [Indexed: 12/13/2022] Open
Abstract
Muscular weakness and muscle wasting may often be observed in critically ill patients on intensive care units (ICUs) and may present as failure to wean from mechanical ventilation. Importantly, mounting data demonstrate that mechanical ventilation itself may induce progressive dysfunction of the main respiratory muscle, i.e. the diaphragm. The respective condition was termed 'ventilator-induced diaphragmatic dysfunction' (VIDD) and should be distinguished from peripheral muscular weakness as observed in 'ICU-acquired weakness (ICU-AW)'. Interestingly, VIDD and ICU-AW may often be observed in critically ill patients with, e.g. severe sepsis or septic shock, and recent data demonstrate that the pathophysiology of these conditions may overlap. VIDD may mainly be characterized on a histopathological level as disuse muscular atrophy, and data demonstrate increased proteolysis and decreased protein synthesis as important underlying pathomechanisms. However, atrophy alone does not explain the observed loss of muscular force. When, e.g. isolated muscle strips are examined and force is normalized for cross-sectional fibre area, the loss is disproportionally larger than would be expected by atrophy alone. Nevertheless, although the exact molecular pathways for the induction of proteolytic systems remain incompletely understood, data now suggest that VIDD may also be triggered by mechanisms including decreased diaphragmatic blood flow or increased oxidative stress. Here we provide a concise review on the available literature on respiratory muscle weakness and VIDD in the critically ill. Potential underlying pathomechanisms will be discussed before the background of current diagnostic options. Furthermore, we will elucidate and speculate on potential novel future therapeutic avenues.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland; Department of Clinical Cardiology, Inselspital University Hospital of Bern Bern Switzerland
| | - Stephan von Haehling
- Department of Cardiology and Center for Innovative Clinical Trials University of Göttingen Göttingen Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin Charite Universitätsmedizin Berlin Berlin Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery and Dept. of Neurology, Inselspital University Hospital of Bern Bern Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
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Endotoxemia accelerates diaphragm dysfunction in ventilated rabbits. J Surg Res 2016; 206:507-516. [PMID: 27884349 DOI: 10.1016/j.jss.2016.08.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/13/2016] [Accepted: 08/04/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Ventilators may induce diaphragm dysfunction, and most of the septic population who are admitted to the intensive care unit require mechanical ventilation. However, there is no evidence that sepsis accelerates the onset of ventilator-induced diaphragm dysfunction or affects the microcirculation. Our study investigated whether lipopolysaccharide (LPS)-induced endotoxemia accelerated diaphragm dysfunction in ventilated rabbits by evaluating microcirculation, lipid accumulation, and diaphragm contractility. METHODS After anesthesia and tracheostomy, 25 invasively monitored and mechanically ventilated New Zealand white rabbits were randomized to control (n = 5), controlled mechanical ventilation (CMV) (n = 5), pressure support ventilation (PSV; n = 5), CMV or PSV with LPS-induced endotoxemia (CMV-LPS and PSV-LPS, respectively; n = 5 for each). Rabbits were anesthetized and ventilated for 24 h, except the control rabbits (30 min). Diaphragmatic contractility was evaluated using neuromechanical and neuroventilatory efficiency. We evaluated the following at the end of the protocol: (1) diaphragm microcirculation; (2) lipid accumulation; and (3) diaphragm muscular fibers structure. RESULTS Diaphragm contractility, microcirculation, lipid accumulation, and fiber structures were severely compromised in endotoxemic animals after 24 h compared to nonendotoxemic rabbits. Moreover, a slight but significant increase in lipid accumulation was observed in CMV and PSV groups compared with controls (P < 0.05). CONCLUSIONS Endotoxemia accelerates the diaphragm dysfunction process in ventilated rabbits, affects the microcirculation, and results in diaphragmatic lipid accumulation and contractility impairment.
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Di Mussi R, Spadaro S, Mirabella L, Volta CA, Serio G, Staffieri F, Dambrosio M, Cinnella G, Bruno F, Grasso S. Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:1. [PMID: 26728475 PMCID: PMC4700777 DOI: 10.1186/s13054-015-1178-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/19/2015] [Indexed: 12/16/2022]
Abstract
Background Prolonged controlled mechanical ventilation depresses diaphragmatic efficiency. Assisted modes of ventilation should improve it. We assessed the impact of pressure support ventilation versus neurally adjusted ventilator assist on diaphragmatic efficiency. Method Patients previously ventilated with controlled mechanical ventilation for 72 hours or more were randomized to be ventilated for 48 hours with pressure support ventilation (n =12) or neurally adjusted ventilatory assist (n = 13). Neuro-ventilatory efficiency (tidal volume/diaphragmatic electrical activity) and neuro-mechanical efficiency (pressure generated against the occluded airways/diaphragmatic electrical activity) were measured during three spontaneous breathing trials (0, 24 and 48 hours). Breathing pattern, diaphragmatic electrical activity and pressure time product of the diaphragm were assessed every 4 hours. Results In patients randomized to neurally adjusted ventilator assist, neuro-ventilatory efficiency increased from 27 ± 19 ml/μV at baseline to 62 ± 30 ml/μV at 48 hours (p <0.0001) and neuro-mechanical efficiency increased from 1 ± 0.6 to 2.6 ± 1.1 cmH2O/μV (p = 0.033). In patients randomized to pressure support ventilation, these did not change. Electrical activity of the diaphragm, neural inspiratory time, pressure time product of the diaphragm and variability of the breathing pattern were significantly higher in patients ventilated with neurally adjusted ventilatory assist. The asynchrony index was 9.48 [6.38– 21.73] in patients ventilated with pressure support ventilation and 5.39 [3.78– 8.36] in patients ventilated with neurally adjusted ventilatory assist (p = 0.04). Conclusion After prolonged controlled mechanical ventilation, neurally adjusted ventilator assist improves diaphragm efficiency whereas pressure support ventilation does not. Trial registration ClinicalTrials.gov study registration: NCT0247317, 06/11/2015.
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Affiliation(s)
- Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy.
| | - Lucia Mirabella
- Dipartimento di Anestesia e Rianimazione, Università di Foggia, Foggia, Italy.
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy.
| | - Gabriella Serio
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy.
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy.
| | - Michele Dambrosio
- Dipartimento di Anestesia e Rianimazione, Università di Foggia, Foggia, Italy.
| | - Gilda Cinnella
- Dipartimento di Anestesia e Rianimazione, Università di Foggia, Foggia, Italy.
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
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