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Cheng W, Jiang J, Long Y, Yuan S, Sun Y, Zhao Z, He H. Phenotypes of esophageal pressure response to the change of positive end-expiratory pressure in patients with moderate acute respiratory distress syndrome. J Thorac Dis 2024; 16:979-988. [PMID: 38505046 PMCID: PMC10944771 DOI: 10.21037/jtd-23-771] [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] [Received: 05/11/2023] [Accepted: 10/31/2023] [Indexed: 03/21/2024]
Abstract
Background Esophageal pressure (Pes) has been used as a surrogate of pleural pressure (Ppl) to titrate positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. The relationship between Pes and PEEP remains undetermined. Methods A gastric tube with a balloon catheter was inserted to monitor Pes in moderate to severe ARDS patients who underwent invasive mechanical ventilation. To assess the end-expiratory Pes response (ΔPes) to PEEP changes (ΔPEEP), the PEEP level was decreased and increased subsequently (with an average change of 3 cmH2O). The patients underwent the following two series of PEEP adjustment: (I) from PEEP-3 cmH2O to PEEPbaseline; and (II) from PEEPbaseline to PEEP+3 cmH2O. The patients were classified as "PEEP-dependent type" if they had ΔPes ≥30% ΔPEEP and were otherwise classified as "PEEP-independent type" (ΔPes <30% ΔPEEP in any series). Results In total, 54 series of PEEP adjustments were performed in 18 ARDS patients. Of these patients, 12 were classified as PEEP-dependent type, and six were classified as PEEP-independent type. During the PEEP adjustment, end-expiratory Pes changed significantly in the PEEP-dependent patients, who had a Pes of 10.8 (7.9, 12.3), 12.5 (10.5, 14.9), and 14.5 (13.1, 18.3) cmH2O at PEEP-3 cmH2O, PEEPbaseline, and PEEP+3 cmH2O, respectively (median and quartiles; P<0.0001), while end-expiratory transpulmonary pressure (PL) was maintained at an optimal range [-0.1 (-0.7, 0.4), 0.1 (-0.6, 0.5), and 0.3 (-0.3, 0.7) cmH2O, respectively]. In the PEEP-independent patients, the Pes remained unchanged, with a Pes of 15.4 (11.4, 17.8), 15.5 (11.6, 17.8), and 15.4 (11.7, 18.30) cmH2O at each of the three PEEP levels, respectively. Meanwhile, end-expiratory PL significantly improved [from -5.5 (-8.5, -3.4) at PEEP-3 cmH2O to -2.5 (-5.0, -1.6) at PEEPbaseline to -0.5 (-1.8, 0.3) at PEEP+3 cmH2O; P<0.01]. Conclusions Two types of Pes phenotypes were identified according to the ΔPes to ΔPEEP. The underlying mechanisms and implications for clinical practice require further exploration.
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Affiliation(s)
- Wei Cheng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jing Jiang
- Department of Critical Care Medicine, Chongqing General Hospital, Chongqing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yujing Sun
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Emergency Department, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Zhanqi Zhao
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, China
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Yueyi J, Jing T, Lianbing G. A structured narrative review of clinical and experimental studies of the use of different positive end-expiratory pressure levels during thoracic surgery. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:717-731. [PMID: 36181340 PMCID: PMC9629996 DOI: 10.1111/crj.13545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to present a review on the general effects of different positive end-expiratory pressure (PEEP) levels during thoracic surgery by qualitatively categorizing the effects into detrimental, beneficial, and inconclusive. DATA SOURCE Literature search of Pubmed, CNKI, and Wanfang was made to find relative articles about PEEP levels during thoracic surgery. We used the following keywords as one-lung ventilation, PEEP, and thoracic surgery. RESULTS We divide the non-individualized PEEP value into five grades, that is, less than 5, 5, 5-10, 10, and more than 10 cmH2 O, among which 5 cmH2 O is the most commonly used in clinic at present to maintain alveolar dilatation and reduce the shunt fraction and the occurrence of atelectasis, whereas individualized PEEP, adjusted by test titration or imaging method to adapt to patients' personal characteristics, can effectively ameliorate intraoperative oxygenation and obtain optimal pulmonary compliance and better indexes relating to respiratory mechanics. CONCLUSIONS Available data suggest that PEEP might play an important role in one-lung ventilation, the understanding of which will help in exploring a simple and economical method to set the appropriate PEEP level.
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Affiliation(s)
- Jiang Yueyi
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina
| | - Tan Jing
- Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
| | - Gu Lianbing
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina,Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
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Regli A, Ahmadi-Noorbakhsh S, Musk GC, Reese DJ, Herrmann P, Firth MJ, Pillow JJ. Computed tomographic assessment of lung aeration at different positive end-expiratory pressures in a porcine model of intra-abdominal hypertension and lung injury. Intensive Care Med Exp 2021; 9:52. [PMID: 34608559 PMCID: PMC8489364 DOI: 10.1186/s40635-021-00416-5] [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] [Received: 06/13/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background Intra-abdominal hypertension (IAH) is common in critically ill patients and is associated with increased morbidity and mortality. High positive end-expiratory pressures (PEEP) can reverse lung volume and oxygenation decline caused by IAH, but its impact on alveolar overdistension is less clear. We aimed to find a PEEP range that would be high enough to reduce atelectasis, while low enough to minimize alveolar overdistention in the presence of IAH and lung injury. Methods Five anesthetized pigs received standardized anesthesia and mechanical ventilation. Peritoneal insufflation of air was used to generate intra-abdominal pressure of 27 cmH2O. Lung injury was created by intravenous oleic acid. PEEP levels of 5, 12, 17, 22, and 27 cmH2O were applied. We performed computed tomography and measured arterial oxygen levels, respiratory mechanics, and cardiac output 5 min after each new PEEP level. The proportion of overdistended, normally aerated, poorly aerated, and non-aerated atelectatic lung tissue was calculated based on Hounsfield units. Results PEEP decreased the proportion of poorly aerated and atelectatic lung, while increasing normally aerated lung. Overdistension increased with each incremental increase in applied PEEP. “Best PEEP” (respiratory mechanics or oxygenation) was higher than the “optimal CT inflation PEEP range” (difference between lower inflection points of atelectatic and overdistended lung) in healthy and injured lungs. Conclusions Our findings in a large animal model suggest that titrating a PEEP to respiratory mechanics or oxygenation in the presence of IAH is associated with increased alveolar overdistension. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00416-5.
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Affiliation(s)
- Adrian Regli
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch Drive, Murdoch, WA, 6150, Australia. .,Medical School, Division of Emergency Medicine, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia. .,Medical School, The University of Notre Dame Australia, 19 Mouat Street, Fremantle, 6959, Australia. .,School of Human Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia.
| | - Siavash Ahmadi-Noorbakhsh
- School of Human Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia
| | - Gabrielle Christine Musk
- Animal Care Services, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia.,School of Veterinary and Life Sciences, Murdoch University, Nyarrie Drive, Murdoch, 6150, Australia
| | - David Joseph Reese
- VetCT Consultants in Telemedicine PTY LTD, 185-187 High Street, Fremantle, 6160, Australia
| | - Peter Herrmann
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Martin Joseph Firth
- Centre for Applied Statistics, Department of Mathematics and Statistics, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia
| | - J Jane Pillow
- School of Human Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia
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Samimian S, Ashrafi S, Khaleghdoost Mohammadi T, Yeganeh MR, Ashraf A, Hakimi H, Dehghani M. The Correlation between Head of Bed Angle and Intra-Abdominal Pressure of Intubated Patients; a Pre-Post Clinical Trial. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e23. [PMID: 33870210 PMCID: PMC8035694 DOI: 10.22037/aaem.v9i1.1065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION The recommended position for measuring Intra-Abdominal Pressure (IAP) is the supine position. However, patients put in this position are prone to Ventilator-associated pneumonia. This study was done to evaluate the relationship between bed head angle and IAP measurements of intubated patients in the intensive care unit. METHODS In this clinical trial, seventy-six critically ill patients under mechanical ventilation were enrolled. IAP measurement was performed every 8 hours for 24 hours using the KORN method in three different degrees of the head of bed (HOB) elevation (0 ° , 15 ° , and 30 ° ). Bland-Altman analysis was performed to identify the bias and limits of agreement among the three HOBs. According to World Society of the Abdominal Compartment Syndrome (WSACS), we can consider two IAP techniques equivalent if a bias of <1 mmHg and limits of agreement of - 4 to +4 were found between them. Data were analyzed using SPSS statistical software (v. 19), and the significance level was considered as 0.05. RESULTS The prevalence of intra-abdominal hypertension was 18.42%. Mean ± standard deviation (SD) of IAP were 8.44 ± 4.02 mmHg for HOB angle 0°, 9.58 ± 4.52 for HOB angle 15 ° , and 11.10 ± 4.73 for HOB angle 30o (p = 0.0001). The IAP measurement bias between HOB angle 0°and HOB angle 15° was 1.13 mmHg. This bias was 2.66 mmHg between HOB angle 0° and HOB angle 30°. CONCLUSION Elevation of HOB angle from 0 to 30 degree significantly increases IAP. It seems that the measurement of IAP at HOB angle 15° was more reliable than 30°.
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Affiliation(s)
- Sedigheh Samimian
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Sadra Ashrafi
- Student Research Committee, Chronic Kidney Disease Research Center(CKDRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Tahereh Khaleghdoost Mohammadi
- Department of Medical-Surgical Nursing, Shahid Beheshti Faculty of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.,Corresponding author: Tahereh Khaleghdoost Mohammadi; 2nd Floor, Daneshjoo Street, Nursing Department, Shahid Beheshti Faculty of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran, Postal code: 41469 – 39841. , Tel: +98 - 1333555056-8, Mobile Phone Number: +98 – 9111351245, Fax: +98 – 1333550097
| | - Mohammad Reza Yeganeh
- Department of Medical-Surgical Nursing, Shahid Beheshti Faculty of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali Ashraf
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Hamideh Hakimi
- Department of Nursing, Lahijan Branch, Islamic Azad University, Lahijan, Iran
| | - Maryam Dehghani
- Nahavand School of Allied Medical Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
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Kallet RH, Lipnick MS, Burns GD. The Nature of Recruitment and De-Recruitment and Its Implications for Management of ARDS. Respir Care 2021; 66:510-530. [PMID: 33051254 PMCID: PMC9994058 DOI: 10.4187/respcare.08280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recruitment maneuvers in ARDS are used to improve oxygenation and lung mechanics by applying high airway pressures to reopen collapsed or obstructed peripheral airways and alveoli. In the early 1990s, recruitment maneuvers became a central feature of a variant form of lung-protective ventilation known as open-lung ventilation. This strategy is based on the belief that repetitive opening and closing of distal airspaces induces shear injury and therefore contributes both to ventilator-induced lung injury and ARDS-associated mortality. However, the largest multi-center randomized controlled trial of open-lung ventilation in moderate to severe ARDS reported that recruitment maneuver plateau pressures of 50-60 cm H2O were associated with significantly higher mortality compared to traditional lung-protective ventilation. Despite being based on well conducted preclinical and clinical recruitment maneuver studies, the higher mortality associated with the open-lung ventilation strategy requires re-examining the assumptions and conclusions drawn from those previous studies. This narrative review examines the evidence used to design recruitment maneuver strategies. We also review the radiologic, rheologic, and histopathologic evidence regarding the nature of lung injury and the phenomena of recruitment and de-recruitment as it informs our perceptions of recruitment potential in ARDS. Major lung-protective ventilation clinical trial data and other clinical data are also examined to assess the practical necessity of recruitment maneuvers in ARDS and whether a subset of cases might benefit from pursuing recruitment maneuver therapy. Finally, a less a radical approach to recruitment maneuvers is offered that might achieve the goals of recruitment maneuvers with less risk of harm.
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Affiliation(s)
- Richard H Kallet
- Respiratory Care Division, Department of Anesthesia and Perioperative Care, University of California San Francisco at San Francisco General Hospital, San Francisco, California.
| | - Michael S Lipnick
- Critical Care Division, Department of Anesthesia and Perioperative Care, University of California San Francisco at San Francisco General Hospital, San Francisco, California
| | - Gregory D Burns
- Respiratory Care Division, Department of Anesthesia and Perioperative Care, University of California San Francisco at San Francisco General Hospital, San Francisco, California
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Fiedler MO, Simeliunas E, Deutsch BL, Diktanaite D, Harms A, Brune M, Dietrich M, Uhle F, Weigand MA, Kalenka A. Impact of Different Positive End-Expiratory Pressures on Lung Mechanics in the Setting of Moderately Elevated Intra-Abdominal Pressure and Acute Lung Injury in a Porcine Model. J Clin Med 2021; 10:jcm10020306. [PMID: 33467666 PMCID: PMC7830768 DOI: 10.3390/jcm10020306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 12/27/2022] Open
Abstract
The effects of a moderately elevated intra-abdominal pressure (IAP) on lung mechanics in acute respiratory distress syndrome (ARDS) have still not been fully analyzed. Moreover, the optimal positive end-expiratory pressure (PEEP) in elevated IAP and ARDS is unclear. In this paper, 18 pigs under general anesthesia received a double hit lung injury. After saline lung lavage and 2 h of injurious mechanical ventilation to induce an acute lung injury (ALI), an intra-abdominal balloon was filled until an IAP of 10 mmHg was generated. Animals were randomly assigned to one of three groups (group A = PEEP 5, B = PEEP 10 and C = PEEP 15 cmH2O) and ventilated for 6 h. We measured end-expiratory lung volume (EELV) per kg bodyweight, driving pressure (ΔP), transpulmonary pressure (ΔPL), static lung compliance (Cstat), oxygenation (P/F ratio) and cardiac index (CI). In group A, we found increases in ΔP (22 ± 1 vs. 28 ± 2 cmH2O; p = 0.006) and ΔPL (16 ± 1 vs. 22 ± 2 cmH2O; p = 0.007), with no change in EELV/kg (15 ± 1 vs. 14 ± 1 mL/kg) when comparing hours 0 and 6. In group B, there was no change in ΔP (26 ± 2 vs. 25 ± 2 cmH2O), ΔPL (19 ± 2 vs. 18 ± 2 cmH2O), Cstat (21 ± 3 vs. 21 ± 2 cmH2O/mL) or EELV/kg (12 ± 2 vs. 13 ± 3 mL/kg). ΔP and ΔPL were significantly lower after 6 h when comparing between group C and A (21 ± 1 vs. 28 ± 2 cmH2O; p = 0.020) and (14 ± 1 vs. 22 ± 2 cmH2O; p = 0.013)). The EELV/kg increased over time in group C (13 ± 1 vs. 19 ± 2 mL/kg; p = 0.034). The P/F ratio increased in all groups over time. CI decreased in groups B and C. The global lung injury score did not significantly differ between groups (A: 0.25 ± 0.05, B: 0.21 ± 0.02, C: 0.22 ± 0.03). In this model of ALI, elevated IAP, ΔP and ΔPL increased further over time in the group with a PEEP of 5 cmH2O applied over 6 h. This was not the case in the groups with a PEEP of 10 and 15 cmH2O. Although ΔP and ΔPL were significantly lower after 6 hours in group C compared to group A, we could not show significant differences in histological lung injury score.
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Affiliation(s)
- Mascha O. Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany;
- Correspondence:
| | - Emilis Simeliunas
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Department of Anesthesiology, Kantonsspital Lucerne, 6004 Lucerne, Switzerland
| | - B. Luise Deutsch
- Faculty of Medicine, Justus Liebig University, 35392 Giessen, Germany;
| | - Dovile Diktanaite
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Department of Anesthesiology, Kantonsspital Lucerne, 6004 Lucerne, Switzerland
| | - Alexander Harms
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Maik Brune
- Department of Internal Medicine I and Clinical Chemistry, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (E.S.); (D.D.); (M.D.); (F.U.); (M.A.W.)
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany;
| | - Armin Kalenka
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany;
- Department of Anesthesiology and Intensive Care Medicine, Hospital Bergstrasse, 64646 Heppenheim, Germany
- Faculty of Medicine, University of Heidelberg, 69120 Heidelberg, Germany
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Prospective Observational Study to Evaluate the Effect of Different Levels of Positive End-Expiratory Pressure on Lung Mechanics in Patients with and without Acute Respiratory Distress Syndrome. J Clin Med 2020; 9:jcm9082446. [PMID: 32751791 PMCID: PMC7463691 DOI: 10.3390/jcm9082446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background: The optimal level of positive end-expiratory pressure is still under debate. There are scare data examining the association of PEEP with transpulmonary pressure (TPP), end-expiratory lung volume (EELV) and intraabdominal pressure in ventilated patients with and without ARDS. Methods: We analyzed lung mechanics in 3 patient groups: group A, patients with ARDS; group B, obese patients (body mass index (BMI) > 30 kg/m2) and group C, a control group. Three levels of PEEP (5, 10, 15 cm H2O) were used to investigate the consequences for lung mechanics. Results: Fifty patients were included, 22 in group A, 18 in group B (BMI 38 ± 2 kg/m2) and 10 in group C. At baseline, oxygenation showed no differences between the groups. Driving pressure (ΔP) and transpulmonary pressure (ΔPL) was higher in group B than in groups A and C at a PEEP of 5 cm H2O (ΔP A: 15 ± 1, B: 18 ± 1, C: 14 ± 1 cm H2O; ΔPL A: 10 ± 1, B: 13 ± 1, C: 9 ± 0 cm H2O). Peak inspiratory pressure (Pinsp) rose in all groups as PEEP increased, but the resulting driving pressure and transpulmonary pressure were reduced, whereas EELV increased. Conclusion: Measuring EELV or TPP allows a personalized approach to lung-protective ventilation.
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Tonetti T, Cavalli I, Ranieri VM, Mascia L. Respiratory consequences of intra-abdominal hypertension. Minerva Anestesiol 2020; 86:877-883. [DOI: 10.23736/s0375-9393.20.14325-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Fiedler MO, Deutsch BL, Simeliunas E, Diktanaite D, Harms A, Brune M, Uhle F, Weigand M, Brenner T, Kalenka A. Effect of moderate elevated intra-abdominal pressure on lung mechanics and histological lung injury at different positive end-expiratory pressures. PLoS One 2020; 15:e0230830. [PMID: 32294090 PMCID: PMC7159202 DOI: 10.1371/journal.pone.0230830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/09/2020] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Intra-abdominal hypertension (IAH) is a well-known phenomenon in critically ill patients. Effects of a moderately elevated intra-abdominal pressure (IAP) on lung mechanics are still not fully analyzed. Moreover, the optimal positive end-expiratory pressure (PEEP) in elevated IAP is unclear. METHODS We investigated changes in lung mechanics and transformation in histological lung patterns using three different PEEP levels in eighteen deeply anesthetized pigs with an IAP of 10 mmHg. After establishing the intra-abdominal pressure, we randomized the animals into 3 groups. Each of n = 6 (Group A = PEEP 5, B = PEEP 10 and C = PEEP 15 cmH2O). End-expiratory lung volume (EELV/kg body weight (bw)), pulmonary compliance (Cstat), driving pressure (ΔP) and transpulmonary pressure (ΔPL) were measured for 6 hours. Additionally, the histological lung injury score was calculated. RESULTS Comparing hours 0 and 6 in group A, there was a decrease of EELV/kg (27±2 vs. 16±1 ml/kg; p<0.05) and of Cstat (42±2 vs. 27±1 ml/cmH2O; p<0.05) and an increase of ΔP (11±0 vs. 17±1 cmH2O; p<0.05) and ΔPL (6±0 vs. 10±1 cmH2O; p<0.05). In group B, there was no significant change in EELV/kg (27±3 vs. 24±3 ml/kg), but a decrease in Cstat (42±3 vs. 32±1 ml/cmH20; p<0.05) and an increase in ΔP (11±1 vs. 15±1 cmH2O; p<0.05) and ΔPL (5±1 vs. 7±0 cmH2O; p<0.05). In group C, there were no significant changes in EELV/kg (27±2 vs. 29±3 ml/kg), ΔP (10±1 vs. 12±1 cmH2O) and ΔPL (5±1 vs. 7±1 cmH2O), but a significant decrease of Cstat (43±1 vs. 37±1 ml/cmH2O; p<0.05). Histological lung injury score was lowest in group B. CONCLUSIONS A moderate elevated IAP of 10 mmHg leads to relevant changes in lung mechanics during mechanical ventilation. In our study, a PEEP of 10 cmH2O was associated with a lower lung injury score and was able to overcome the IAP induced alterations of EELV.
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Affiliation(s)
- Mascha O. Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Emilis Simeliunas
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dovile Diktanaite
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Harms
- Heidelberg University Hospital, Institute of Pathology, Heidelberg, Germany
| | - Maik Brune
- Department of Internal Medicine I and Clinical Chemistry, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Armin Kalenka
- Department of Anesthesiology and Intensive Care Medicine, Hospital Bergstrasse, Heppenheim, Germany
- Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
- * E-mail:
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Transpulmonary thermodilution detects rapid and reversible increases in lung water induced by positive end-expiratory pressure in acute respiratory distress syndrome. Ann Intensive Care 2020; 10:28. [PMID: 32124129 PMCID: PMC7052093 DOI: 10.1186/s13613-020-0644-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/21/2020] [Indexed: 01/22/2023] Open
Abstract
PURPOSE It has been suggested that, by recruiting lung regions and enlarging the distribution volume of the cold indicator, increasing the positive end-expiratory pressure (PEEP) may lead to an artefactual overestimation of extravascular lung water (EVLW) by transpulmonary thermodilution (TPTD). METHODS In 60 ARDS patients, we measured EVLW (PiCCO2 device) at a PEEP level set to reach a plateau pressure of 30 cmH2O (HighPEEPstart) and 15 and 45 min after decreasing PEEP to 5 cmH2O (LowPEEP15' and LowPEEP45', respectively). Then, we increased PEEP back to the baseline level (HighPEEPend). Between HighPEEPstart and LowPEEP15', we estimated the degree of lung derecruitment either by measuring changes in the compliance of the respiratory system (Crs) in the whole population, or by measuring the lung derecruited volume in 30 patients. We defined patients with a large derecruitment from the other ones as patients in whom the Crs changes and the measured derecruited volume were larger than the median of these variables observed in the whole population. RESULTS Reducing PEEP from HighPEEPstart (14 ± 2 cmH2O) to LowPEEP15' significantly decreased EVLW from 20 ± 4 to 18 ± 4 mL/kg, central venous pressure (CVP) from 15 ± 4 to 12 ± 4 mmHg, the arterial oxygen tension over inspired oxygen fraction (PaO2/FiO2) ratio from 184 ± 76 to 150 ± 69 mmHg and lung volume by 144 [68-420] mL. The EVLW decrease was similar in "large derecruiters" and the other patients. When PEEP was re-increased to HighPEEPend, CVP, PaO2/FiO2 and EVLW significantly re-increased. At linear mixed effect model, EVLW changes were significantly determined only by changes in PEEP and CVP (p < 0.001 and p = 0.03, respectively, n = 60). When the same analysis was performed by estimating recruitment according to lung volume changes (n = 30), CVP remained significantly associated to the changes in EVLW (p < 0.001). CONCLUSIONS In ARDS patients, changing the PEEP level induced parallel, small and reversible changes in EVLW. These changes were not due to an artefact of the TPTD technique and were likely due to the PEEP-induced changes in CVP, which is the backward pressure of the lung lymphatic drainage. Trial registration ID RCB: 2015-A01654-45. Registered 23 October 2015.
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Respiratory Mechanics, Lung Recruitability, and Gas Exchange in Pulmonary and Extrapulmonary Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:792-799. [PMID: 30908313 DOI: 10.1097/ccm.0000000000003715] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Acute respiratory distress syndrome is a clinical syndrome characterized by a refractory hypoxemia due to an inflammatory and high permeability pulmonary edema secondary to direct or indirect lung insult (pulmonary and extrapulmonary form). Aim of this study was to evaluate in a large database of acute respiratory distress syndrome patients, the pulmonary versus extrapulmonary form in terms of respiratory mechanics, lung recruitment, gas exchange, and positive end-expiratory pressure response. DESIGN A secondary analysis of previously published data. PATIENTS One-hundred eighty-one sedated and paralyzed acute respiratory distress syndrome patients (age 60 yr [46-72 yr], body mass index 25 kg/m [22-28 kg/m], and PaO2/FIO2 184 ± 66). INTERVENTIONS Lung CT scan performed at 5 and 45 cm H2O. Two levels of positive end-expiratory pressure (5 and 15 cm H2O) were randomly applied. MEASUREMENTS AND MAIN RESULTS Ninety-seven and 84 patients had a pulmonary and extrapulmonary acute respiratory distress syndrome. The median time from intensive care admission to the CT scan and respiratory mechanics analysis was 4 days (interquartile range, 2-6). At both positive end-expiratory pressure levels, pulmonary acute respiratory distress syndrome presented a significantly lower PaO2/FIO2 and higher physiologic dead space compared with extrapulmonary acute respiratory distress syndrome. The lung and chest wall elastance were similar between groups. The intra-abdominal pressure was significantly higher in extrapulmonary compared with pulmonary acute respiratory distress syndrome (10 mm Hg [7-12 mm Hg] vs 7 mm Hg [5-8 mm Hg]). The lung weight and lung recruitability were significantly higher in pulmonary acute respiratory distress syndrome (1,534 g [1,286-1,835 g] vs 1,342 g [1,090-1,507 g] and 16% [9-25%] vs 9% [5-14%]). CONCLUSIONS In the early stage, pulmonary acute respiratory distress syndrome is characterized by a greater impairment of gas exchange and higher lung recruitability. The recognition of the origin of acute respiratory distress syndrome is important for a more customized ventilatory management.
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Regli A, Pelosi P, Malbrain MLNG. Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know. Ann Intensive Care 2019; 9:52. [PMID: 31025221 PMCID: PMC6484068 DOI: 10.1186/s13613-019-0522-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/04/2019] [Indexed: 12/16/2022] Open
Abstract
The incidence of intra-abdominal hypertension (IAH) is high and still underappreciated by critical care physicians throughout the world. One in four to one in three patients will have IAH on admission, while one out of two will develop IAH within the first week of Intensive Care Unit stay. IAH is associated with high morbidity and mortality. Although considerable progress has been made over the past decades, some important questions remain regarding the optimal ventilation management in patients with IAH. An important first step is to measure intra-abdominal pressure (IAP). If IAH (IAP > 12 mmHg) is present, medical therapies should be initiated to reduce IAP as small reductions in intra-abdominal volume can significantly reduce IAP and airway pressures. Protective lung ventilation with low tidal volumes in patients with respiratory failure and IAH is important. Abdominal-thoracic pressure transmission is around 50%. In patients with IAH, higher positive end-expiratory pressure (PEEP) levels are often required to avoid alveolar collapse but the optimal PEEP in these patients is still unknown. During recruitment manoeuvres, higher opening pressures may be required while closely monitoring oxygenation and the haemodynamic response. During lung-protective ventilation, whilst keeping driving pressures within safe limits, higher plateau pressures than normally considered might be acceptable. Monitoring of the respiratory function and adapting the ventilatory settings during anaesthesia and critical care are of great importance. This review will focus on how to deal with the respiratory derangements in critically ill patients with IAH.
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Affiliation(s)
- Adrian Regli
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch Drive, Murdoch, WA 6152 Australia
- Medical School, Division of Emergency Medicine, The University of Western Australia, Sterling Highway, Crawley, Perth, WA 6009 Australia
- Medical School, The Notre Dame University, Henry Road, Fremantle, Perth, WA 6959 Australia
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Manu L. N. G. Malbrain
- Intensive Care Unit, University Hospital Brussels (UZB), Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Iyer D, Hunt L, Frost SA, Aneman A. Daily intra-abdominal pressure, Sequential Organ Failure Score and fluid balance predict duration of mechanical ventilation. Acta Anaesthesiol Scand 2018; 62:1421-1427. [PMID: 29974932 DOI: 10.1111/aas.13211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 06/07/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Elevated intra-abdominal pressure (IAP) is a common occurrence in mechanically ventilated patients in the intensive care unit (ICU). This study was undertaken to determine the relationship between IAP, pulmonary compliance and the duration of mechanical ventilation. METHODS A prospective study of 220 consecutively enrolled mechanically ventilated patients admitted to a mixed surgical-medical ICU in a tertiary referral hospital. The IAP was measured at least twice daily, benchmarked against consensus guidelines. Dynamic pulmonary compliance was calculated together with admission Acute Physiology and Chronic Health Evaluation (APACHE III) score and daily Sequential Organ Failure Assessment (SOFA) score. RESULTS No relationship between highest IAP for the day and pulmonary compliance (P = 0.61) was found. For each 5 mm Hg increase in IAP, the risk of remaining intubated increased 19% (HR = 1.19, 95% CI: 0.98-1.44); for each standard deviation increase in SOFA score (3.7 points), the risk of remaining intubated increased by 14% (HR = 1.14, 95% CI: 0.98-1.33); and for each 1 L increase in fluid balance, the risk of remaining intubated increased by 11% (HR = 1.11, 95% CI: 1.04-1.19). A nomogram was developed to predict the probability of extubation based on daily highest IAP for the day, SOFA score and fluid balance. CONCLUSION IAPs did not correlate with pulmonary compliance in critically ill patients. Increased IAP was associated with a longer duration of mechanical ventilation. A nomogram integrating daily IAP, SOFA score and fluid balance may be used to predict the duration of mechanical ventilation.
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Affiliation(s)
- Dushyant Iyer
- Department of Intensive Care Liverpool Hospital Sydney Australia
- South Western Sydney Clinical School University of New South Wales Sydney Australia
| | - Leanne Hunt
- Department of Intensive Care Liverpool Hospital Sydney Australia
- Western Sydney University Sydney New South Wales Australia
- Centre for Applied Nursing Research Ingham Institute of Applied Medical Research Sydney Australia
| | - Steven A. Frost
- Department of Intensive Care Liverpool Hospital Sydney Australia
- South Western Sydney Clinical School University of New South Wales Sydney Australia
- Western Sydney University Sydney New South Wales Australia
- Centre for Applied Nursing Research Ingham Institute of Applied Medical Research Sydney Australia
| | - Anders Aneman
- Department of Intensive Care Liverpool Hospital Sydney Australia
- South Western Sydney Clinical School University of New South Wales Sydney Australia
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Krebs J, Pelosi P, Rocco PRM, Hagmann M, Luecke T. Positive end-expiratory pressure titrated according to respiratory system mechanics or to ARDSNetwork table did not guarantee positive end-expiratory transpulmonary pressure in acute respiratory distress syndrome. J Crit Care 2018; 48:433-442. [PMID: 30336419 DOI: 10.1016/j.jcrc.2018.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Pulmonary recruitment and positive end-expiratory pressure (PEEP) titrated according to minimal static elastance of the respiratory system (PEEPEstat,RS) compared to PEEP set according to the ARDSNetwork table (PEEPARDSNetwork) as a strategy to prevent ventilator-associated lung injury (VALI) in patients with acute respiratory distress syndrome (ARDS) increases mortality. Alternatively, avoiding negative end-expiratory transpulmonary pressure has been discussed as superior PEEP titration strategy. Therefore, we tested whether PEEPEstat,RS or PEEPARDSNetwork prevent negative end-expiratory transpulmonary pressure in ARDS patients. MATERIAL AND METHODS Thirteen patients with moderate to severe ARDS were studied at PEEPARDSNetwork versus PEEPEstat,RS. Patients were then grouped post hoc according to the end-expiratory transpulmonary pressure (positive or negative). RESULTS 7 out of 13 patients showed negative end-expiratory transpulmonary pressures (Ptp-) with both strategies (PEEPARDSNetwork: - 5.4 ± 3.5 vs. 2.2 ± 3.7 cm H2O, p = .005; PEEPEstat,RS: - 3.6 ± 1.5 vs. 3.5 ± 3.3 cm H2O, p < .001). Ptp- was associated with higher intra-abdominal pressure and lower end-expiratory lung volume with both PEEP strategies. CONCLUSIONS In patients with moderate-to-severe ARDS, PEEP titrated according to the minimal static elastance of the respiratory system or according to the ARDSNetwork table did not prevent negative end-expiratory transpulmonary pressure.
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Affiliation(s)
- Joerg Krebs
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, 21941-902 Rio de Janeiro, RJ, Brazil
| | - Michael Hagmann
- Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany.
| | - Thomas Luecke
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany.
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The prophylactic effect of different levels of positive endexpiratory pressure on the incidence rate of atelectasis after cardiac surgery: A Randomized Controlled Trial. Med J Islam Repub Iran 2018; 32:20. [PMID: 30159271 PMCID: PMC6108254 DOI: 10.14196/mjiri.32.20] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 01/12/2023] Open
Abstract
Background: The use of positive end-expiratory pressure (PEEP) can have an important role as one of the ways to prevent and treat atelectasis, but it seems that there is still no consensus about its beneficial level. The aim of this study was to determine the effect of different levels of PEEP on the incidence of atelectasis after heart surgery.
Methods: This is a double-blind randomized controlled trial that was adopted from a research project recorded in the Iranian Registry of Clinical Trials. This paper is the result of a research project undertaken at Fatemeh Zahra Hospital (Mazandaran Heart Center) in 2015. 180 patients underwent open heart surgery were selected and were divided randomly into three groups: control, PEEP=8, and PEEP=10 (60 in each group). The patients in the two PEEP8 and PEEP10 intervention groups separately received 8 cm H2O and 10 cm H2O PEEP, respectively, 30 minutes after admission to the ICU for 4 hours and then received 5 cm H2O PEEP until extubation. Atelectasis was examined two hours after the extubation and on the third day after surgery.
Results: The incidence rates of atelectasis two hours after extubation on the first day of surgery were 22 (36.7%), 20 (33.3%) and 10 (16.7%) patients in the control, PEEP8 and PEEP10 groups, respectively. The differences were statistically significant among the three groups (p=0.035). The incidence rates of atelectasis on the third day after surgery were 39 (65%), 36 (60%) and 21 (35%) patients in the control, PEEP8 and PEEP10 groups, respectively. The differences were also statistically significant among the three groups (p=0.003).
Conclusion: The use of 10 cm H2O PEEP can lead to a reduction in the incidence of atelectasis, intubation time at the ICU and length of ICU and hospital stay. Given that this level of PEEP is effective, this method is recommended to be used in postoperative care of patients.
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Regli A, De Keulenaer BL, Palermo A, van Heerden PV. Positive end-expiratory pressure adjusted for intra-abdominal pressure - A pilot study. J Crit Care 2017; 43:390-394. [PMID: 29054769 DOI: 10.1016/j.jcrc.2017.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 09/29/2017] [Accepted: 10/13/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Intra-abdominal hypertension (IAH) is associated with impaired respiratory function. Animal data suggest that positive end-expiratory pressure (PEEP) levels adjusted to intra-abdominal pressure (IAP) levels may counteract IAH-induced respiratory dysfunction. In this pilot study, our aim was to assess whether PEEP adjusted for IAP can be applied safely in patients with IAH. MATERIALS AND METHODS We included patients on mechanical ventilation and with IAH. Patients were excluded with severe cardiovascular dysfunction or severe hypoxemia or if the patient was in imminent danger of dying. Following a recruitment manoeuvre, the following PEEP levels were randomly applied: PEEP of 5cmH2O (baseline), PEEP=50% of IAP, and PEEP=100% of IAP. After a 30min equilibration period we measured arterial blood gases and cardio-respiratory parameters. RESULTS Fifteen patients were enrolled. Six (41%) patients did not tolerate PEEP=100% IAP due to hypoxemia, hypotension or endotracheal cuff leak. PaO2/FiO2 ratios were 234 (68), 271 (99), and 329 (107) respectively. The differences were significant (p=0.009) only between baseline and PEEP=100% IAP. CONCLUSIONS PEEP=100% of IAP was not well-tolerated and only marginally improved oxygenation in ventilated patients with IAH.
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Affiliation(s)
- Adrian Regli
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia; Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia; School of Medicine and Pharmacology, The University of Western Australia, Sterling Highway, Crawley, (Perth) WA 6009, Australia; Medical School, The Notre Dame University, Henry Road, Fremantle, WA 6160, Australia.
| | - Bart Leon De Keulenaer
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia; Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia; School of Surgery, The University of Western Australia, Sterling Highway, Crawley, (Perth) WA 6009, Australia.
| | - Annamaria Palermo
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle, WA 6160, Australia; Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, WA 6150, Australia.
| | - Peter Vernon van Heerden
- School of Medicine and Pharmacology, The University of Western Australia, Sterling Highway, Crawley, (Perth) WA 6009, Australia; General Intensive Care Unit, Hadassah University Hospital, Kiryat Hadassah, Jerusalem 91120, Israel.
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Muturi A, Ndaguatha P, Ojuka D, Kibet A. Prevalence and predictors of intra-abdominal hypertension and compartment syndrome in surgical patients in critical care units at Kenyatta National Hospital. BMC Emerg Med 2017; 17:10. [PMID: 28330440 PMCID: PMC5363018 DOI: 10.1186/s12873-017-0120-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 03/04/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Intra-abdominal hypertension (IAH) affects almost every organ sytem.If it is not detected early and corrected, mortality would be high. The prevalence of IAH and abdominal compartment syndrome (ACS) at Kenyatta National Hospital (KNH) critical care units is not known. The aim of this sudy was to determine the prevalence and factors associated with development of IAH/ACS among critically ill surgical patients. METHODS This was a cross sectional descriptive study involving surgical patients in critical care units at KNH, carried out from March 2015 to October 2015. One hundred and thirteen critically ill and ventilated patients 13 years or older were recruited into the study. Krohn's intravesical method was used to measure intra- abdominal pressure (IAP). Measurements were done at first contact, then at 12 and 24 h. Additional parameters recorded included: laboratory tests such as serum bilirubin and total blood count as well as clinical parameters such as urine output, vital signs and peak airway pressure, among others. Frequency, means and standard deviation were used to describe the data. Categorical variables e.g. age, were analysed using Chi square test and continous variables using student 't' test and Mann Whitney test as appropriate RESULT: A total of 113 consecutive surgical patients admitted to the critical care units were recruited. Of our study population, 71.7% (by IAP max) and 67.3% (by IAP mean) had IAH. Abdominal compartment syndrome (ACS) developed in 4.4% of the population. The following factors were significant determinants of risk of IAH : amount of IV fluids over 24 h (3949.6 vs 2931.1, p = 0.003, adjusted OR 1.0 [1.0-1.002]), haemoglobin values at admission (9.9 vs 12.0, p = <0.012, adjusted OR 0.6 [0.4-0.9]), peak airway pressure (28.4 vs 17.3; p = 0.018, adjusted OR 1.6 [1.1-2.4]) and synchronised intermittent mandatory ventilation (SIMV) (60 vs 32; p = 0.041, adjusted OR 1.4 [0.78-2.04]). Of those who had IAH; age, amount of iv fluids over 24 h, fluid balance and ventilator mode were significant determinants of risk of progression to ACS . CONCLUSION The prevalence of intraabdominal hypertension and abdominal compartment syndrome at KNH is high. Clinical parameters pertaining to fluids administration and ventilator mode are siginificant determinants.
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Affiliation(s)
- A. Muturi
- University of Nairobi, P. O Box 14523–00800, Nairobi, Kenya
| | - P. Ndaguatha
- Department of Surgery, University of Nairobi, P. O Box 30197, Nairobi, 00100 Kenya
| | - Daniel Ojuka
- Department of Surgery, University of Nairobi, P. O Box 30197, Nairobi, 00100 Kenya
| | - A. Kibet
- Department of Anaesthesia and Critical Care, Kenyatta National Hospital, P. O. Box 20723-00202 Nairobi, Kenya
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Regli A, De Keulenaer BL, Singh B, Hockings LE, Noffsinger B, van Heerden PV. The respiratory pressure-abdominal volume curve in a porcine model. Intensive Care Med Exp 2017; 5:11. [PMID: 28243924 PMCID: PMC5328886 DOI: 10.1186/s40635-017-0124-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/17/2017] [Indexed: 12/02/2022] Open
Abstract
Background Increasing intra-abdominal volume (IAV) can lead to intra-abdominal hypertension (IAH) or abdominal compartment syndrome. Both are associated with raised morbidity and mortality. IAH can increase airway pressures and impair ventilation. The relationship between increasing IAV and airway pressures is not known. We therefore assessed the effect of increasing IAV on airway and intra-abdominal pressures (IAP). Methods Seven pigs (41.4 +/−8.5 kg) received standardized anesthesia and mechanical ventilation. A latex balloon inserted in the peritoneal cavity was inflated in 1-L increments until IAP exceeded 40 cmH2O. Peak airway pressure (pPAW), respiratory compliance, and IAP (bladder pressure) were measured. Abdominal compliance was calculated. Different equations were tested that best described the measured pressure-volume curves. Results An exponential equation best described the measured pressure-volume curves. Raising IAV increased pPAW and IAP in an exponential manner. Increases in IAP were associated with parallel increases in pPAW with an approximate 40% transmission of IAP to pPAW. The higher the IAP, the greater IAV effected pPAW and IAP. Conclusions The exponential nature of the effect of IAV on pPAW and IAP implies that, in the presence of high grades of IAH, small reductions in IAV can lead to significant reductions in airway and abdominal pressures. Conversely, in the presence of normal IAP levels, large increases in IAV may not affect airway and abdominal pressures. Electronic supplementary material The online version of this article (doi:10.1186/s40635-017-0124-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrian Regli
- Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch (Perth), WA, 6150, Australia. .,Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth), WA, 6009, Australia. .,School of Medicine and Pharmacology, The University of Western Australia, Sterling Highway, Crawley (Perth), WA, 6009, Australia. .,Medical School, The Notre Dame University, Henry Road, Fremantle (Perth), WA, 6959, Australia.
| | - Bart Leon De Keulenaer
- Intensive Care Unit, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch (Perth), WA, 6150, Australia.,School of Medicine and Pharmacology, The University of Western Australia, Sterling Highway, Crawley (Perth), WA, 6009, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth), WA, 6009, Australia.,Faculty of Science, The University of Western Australia, Sterling Highway, Crawley (Perth), WA, 6009, Australia.,West Australian Sleep Disorders Research Institute, QE II Medical Centre, Nedlands (Perth), WA, 6009, Australia
| | - Lisen Emma Hockings
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth), WA, 6009, Australia.,Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Commercial Road, Prahran (Melbourne), VIC, 3181, Australia
| | - Bill Noffsinger
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth), WA, 6009, Australia.,West Australian Sleep Disorders Research Institute, QE II Medical Centre, Nedlands (Perth), WA, 6009, Australia
| | - Peter Vernon van Heerden
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth), WA, 6009, Australia.,School of Medicine and Pharmacology, The University of Western Australia, Sterling Highway, Crawley (Perth), WA, 6009, Australia.,General Intensive Care Unit, Hadassah University Hospital, Kiryat Hadassah, Jerusalem, 91120, Israel
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Increased pressure within the abdominal compartment: intra-abdominal hypertension and the abdominal compartment syndrome. Curr Opin Crit Care 2016; 22:174-85. [PMID: 26844989 DOI: 10.1097/mcc.0000000000000289] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW This article reviews recent developments related to intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) and clinical practice guidelines published in 2013. RECENT FINDINGS IAH/ACS often develops because of the acute intestinal distress syndrome. Although the incidence of postinjury ACS is decreasing, IAH remains common and associated with significant morbidity and mortality among critically ill/injured patients. Many risk factors for IAH include those findings suggested to be indications for use of damage control surgery in trauma patients. Medical management strategies for IAH/ACS include sedation/analgesia, neuromuscular blocking and prokinetic agents, enteral decompression tubes, interventions that decrease fluid balance, and percutaneous catheter drainage. IAH/ACS may be prevented in patients undergoing laparotomy by leaving the abdomen open where appropriate. If ACS cannot be prevented with medical or surgical management strategies or treated with percutaneous catheter drainage, guidelines recommend urgent decompressive laparotomy. Use of negative pressure peritoneal therapy for temporary closure of the open abdomen may improve the systemic inflammatory response and patient-important outcomes. SUMMARY In the last 15 years, investigators have better clarified the pathogenesis, epidemiology, diagnosis, and appropriate prevention of IAH/ACS. Subsequent study should be aimed at understanding which treatments effectively lower intra-abdominal pressure and whether these treatments ultimately affect patient-important outcomes.
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Puiac C, Szederjesi J, Lazar A, Almasy E, Rad P, Puscasiu L. Influence of Ventilation Parameters on Intraabdominal Pressure. ACTA ACUST UNITED AC 2016; 2:80-84. [PMID: 29967842 DOI: 10.1515/jccm-2016-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/14/2016] [Indexed: 12/12/2022]
Abstract
Introduction Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named. Objectives To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index. Material and method This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point. Results We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045). Conclusions The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.
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Affiliation(s)
- Claudiu Puiac
- Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
| | - Janos Szederjesi
- Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
| | - Alexandra Lazar
- Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
| | - Emoke Almasy
- Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
| | - Paul Rad
- Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
| | - Lucian Puscasiu
- Gynecology and Obstetrics Department, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
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Heijnen BGADH, Spoelstra-de Man AME, Groeneveld ABJ. Low Transmission of Airway Pressures to the Abdomen in Mechanically Ventilated Patients With or Without Acute Respiratory Failure and Intra-Abdominal Hypertension. J Intensive Care Med 2016; 32:218-222. [PMID: 26732769 DOI: 10.1177/0885066615625180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Intra-abdominal pressure, measured at end expiration, may depend on ventilator settings and transmission of intrathoracic pressure. We determined the transmission of positive intrathoracic pressure during mechanical ventilation at inspiration and expiration into the abdominal compartment. METHODS AND RESULTS We included 9 patients after uncomplicated cardiac surgery and 9 with acute respiratory failure. Intravesical pressures were measured thrice (reproducibility of 1.8%) and averaged, at the end of each inspiratory and expiratory hold maneuvers of 5 seconds. Transmission, the change in intra-abdominal over intrathoracic pressures from end inspiration to end expiration, was about 8%. End-expiratory intra-abdominal pressure was lower than "total" intra-abdominal pressure over the entire respiratory cycle by 0.34 cm H2O. It was 0.73 cm H2O higher than "true" intra-abdominal pressure over the entire respiratory cycle, taking transmission into account. The percentage error was 3% for total and 10% for true pressure. Results did not differ among patients with or without acute respiratory failure and decreased respiratory compliance or between those with (≥12 mm Hg, n = 5) or without intra-abdominal hypertension. CONCLUSIONS Transmitted airway pressure only slightly affects intra-abdominal pressure in mechanically ventilated patients, irrespective of respiratory compliance and baseline intra-abdominal pressure values. End-expiratory measurements referenced against atmospheric pressure may suffice for clinical practice.
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Affiliation(s)
- Bram G A D H Heijnen
- 1 Department of Intensive Care, St Antonius Ziekenhuis, Nieuwegein, the Netherlands
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Impact of Chest Wall Modifications and Lung Injury on the Correspondence Between Airway and Transpulmonary Driving Pressures. Crit Care Med 2015; 43:e287-95. [PMID: 26186478 DOI: 10.1097/ccm.0000000000001036] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Recent interest has arisen in airway driving pressure (DP(AW)), the quotient of tidal volume (V(T)), and respiratory system compliance (C(RS)), which could serve as a direct and easily measured marker for ventilator-induced lung injury risk. We aimed to test the correspondence between DP(AW) and transpulmonary driving pressure (DP(TP))-the quotient of V(T) and lung compliance (C(L)), in response to intra-abdominal hypertension and changes in positive end-expiratory pressure during different models of lung pathology. DESIGN Well-controlled experimental setting that allowed reversible modification of chest wall compliance (C(CW)) in a variety of models of lung pathology. SETTING Large animal laboratory of a university-affiliated hospital. SUBJECTS Ten deeply anesthetized swine. INTERVENTIONS Application of intra-abdominal pressures of 0 and 20 cm H2O at positive end-expiratory pressure of 1 and 10 cm H2O, under volume-controlled mechanical ventilation in the settings of normal lungs (baseline), unilateral whole-lung atelectasis, and unilateral and bilateral lung injuries caused by saline lavage. MEASUREMENTS AND MAIN RESULTS Pulmonary mechanics including esophageal pressure and calculations of DP(AW), DP(TP), C(RS), C(L), and C(CW). When compared with normal intra-abdominal pressures, intra-abdominal hypertension increased DP(AW), during both "normal lung conditions" (p < 0.0001) and "unilateral atelectasis" (p = 0.0026). In contrast, DP(TP) remained virtually unaffected by changes in positive end-expiratory pressure or intra-abdominal pressures in both conditions. During unilateral lung injury, both DPA(W) and DP(TP) were increased by the presence of intra-abdominal hypertension (p < 0.0001 and p = 0.0222, respectively). During bilateral lung injury, intra-abdominal hypertension increased both DP(AW) (at positive end-expiratory pressure of 1 cm H2O, p < 0.0001; and at positive end-expiratory pressure of 10 cm H2O, p = 0.0091) and DP(TP) (at positive end-expiratory pressure of 1 cm H2O, p = 0.0510; and at positive end-expiratory pressure of 10 cm H2O, p = 0.0335). CONCLUSIONS Our data indicate that DP(AW) is influenced by reductions in chest wall compliance and by underlying lung properties. As with other measures of pulmonary mechanics that are based on unmodified P(AW), caution is advised in attempting to attribute hazard or safety to any specific absolute value of DP(AW).
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Ferrando C, Suárez-Sipmann F, Gutierrez A, Tusman G, Carbonell J, García M, Piqueras L, Compañ D, Flores S, Soro M, Llombart A, Belda FJ. Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:9. [PMID: 25583125 PMCID: PMC4352239 DOI: 10.1186/s13054-014-0726-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 12/18/2014] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The stress index (SI), a parameter derived from the shape of the pressure-time curve, can identify injurious mechanical ventilation. We tested the hypothesis that adjusting tidal volume (VT) to a non-injurious SI in an open lung condition avoids hypoventilation while preventing overdistension in an experimental model of combined lung injury and low chest-wall compliance (Ccw). METHODS Lung injury was induced by repeated lung lavages using warm saline solution, and Ccw was reduced by controlled intra-abdominal air-insufflation in 22 anesthetized, paralyzed and mechanically ventilated pigs. After injury animals were recruited and submitted to a positive end-expiratory pressure (PEEP) titration trial to find the PEEP level resulting in maximum compliance. During a subsequent four hours of mechanical ventilation, VT was adjusted to keep a plateau pressure (Pplat) of 30 cmH2O (Pplat-group, n = 11) or to a SI between 0.95 and 1.05 (SI-group, n = 11). Respiratory rate was adjusted to maintain a 'normal' PaCO2 (35 to 65 mmHg). SI, lung mechanics, arterial-blood gases haemodynamics pro-inflammatory cytokines and histopathology were analyzed. In addition Computed Tomography (CT) data were acquired at end expiration and end inspiration in six animals. RESULTS PaCO2 was significantly higher in the Pplat-group (82 versus 53 mmHg, P = 0.01), with a resulting lower pH (7.19 versus 7.34, P = 0.01). We observed significant differences in VT (7.3 versus 5.4 mlKg(-1), P = 0.002) and Pplat values (30 versus 35 cmH2O, P = 0.001) between the Pplat-group and SI-group respectively. SI (1.03 versus 0.99, P = 0.42) and end-inspiratory transpulmonary pressure (PTP) (17 versus 18 cmH2O, P = 0.42) were similar in the Pplat- and SI-groups respectively, without differences in overinflated lung areas at end- inspiration in both groups. Cytokines and histopathology showed no differences. CONCLUSIONS Setting tidal volume to a non-injurious stress index in an open lung condition improves alveolar ventilation and prevents overdistension without increasing lung injury. This is in comparison with limited Pplat protective ventilation in a model of lung injury with low chest-wall compliance.
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Affiliation(s)
- Carlos Ferrando
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Fernando Suárez-Sipmann
- Section of Anesthesiology and Critical Care, Uppsala University Hospital Uppsala, Uppsala, Sweden. .,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Andrea Gutierrez
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata, Argentina.
| | - Jose Carbonell
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Marisa García
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Laura Piqueras
- Clinical Research Foundation, Hospital Clínico Universitario of Valencia, Valencia, Spain.
| | - Desamparados Compañ
- Pathological Anatomy Department, Hospital Clínico Universitario of Valencia, Valencia, Spain.
| | - Susanie Flores
- Radiology Department, Hospital Clinico Universitario of Valencia, Valencia, Spain.
| | - Marina Soro
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
| | - Alicia Llombart
- Clinical Research Foundation, Hospital Clínico Universitario of Valencia, Valencia, Spain.
| | - Francisco Javier Belda
- Anesthesiology and Critical Care Department, Hospital Clínico Universitario of Valencia, Av. Blasco Ibañez, 17, Valencia, CP: 46010, Spain.
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Abstract
Intra-abdominal pressure (IAP) measurements are essential to the diagnosis and management of patients with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Peak inspiratory pressure (PIP), plateau pressure (Pplat), and mean airway pressure (Paw) are used by some surgeons as surrogate estimates of IAP during abdominal closure. Thirty mechanically ventilated surgical/trauma patients with risk factors for IAH/ACS underwent simultaneous triplicate measurements of PIP, Pplat, Paw, and IAP. PIP, Pplat, and Paw were compared with IAP using both coefficient of determination and Bland and Altman analysis. The coefficient of determination for each airway pressure in predicting change in IAP was: PIP 5 per cent ( P = 0.24), Pplat 17 per cent ( P = 0.02), and Paw 15 per cent ( P = 0.03). Bland and Altman analysis identified that marked variability exists between airway pressure and IAP measurements: PIP 19.3 ± 18.7 mmHg, Pplat 11.1 ± 13.7 mmHg, and Paw 2.0 ± 9.8 mmHg. Airway pressures do not accurately reflect IAP and cannot be substituted for IAP measurements in patients at risk for IAH/ACS.
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Affiliation(s)
- Avianne Bunnell
- University of Central Florida College of Medicine, Orlando, Florida; and the
| | - Michael L. Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
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Kang WS, Kim SH, Kim SY, Oh CS, Lee SA, Kim JS. The influence of positive end-expiratory pressure on stroke volume variation in patients undergoing cardiac surgery: An observational study. J Thorac Cardiovasc Surg 2014; 148:3139-45. [DOI: 10.1016/j.jtcvs.2014.07.103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/11/2014] [Accepted: 07/19/2014] [Indexed: 10/24/2022]
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The assessment of transpulmonary pressure in mechanically ventilated ARDS patients. Intensive Care Med 2014; 40:1670-8. [PMID: 25112501 DOI: 10.1007/s00134-014-3415-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/19/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The optimal method for estimating transpulmonary pressure (i.e. the fraction of the airway pressure transmitted to the lung) has not yet been established. METHODS In this study on 44 patients with acute respiratory distress syndrome (ARDS), we computed the end-inspiratory transpulmonary pressure as the change in airway and esophageal pressure from end-inspiration to atmospheric pressure (i.e. release derived) and as the product of the end-inspiratory airway pressure and the ratio of lung to respiratory system elastance (i.e. elastance derived). The end-expiratory transpulmonary pressure was estimated as the product of positive end-expiratory pressure (PEEP) minus the direct measurement of esophageal pressure and by the release method. RESULTS The mean elastance- and release-derived transpulmonary pressure were 14.4 ± 3.7 and 14.4 ± 3.8 cmH₂O at 5 cmH₂O of PEEP and 21.8 ± 5.1 and 21.8 ± 4.9 cmH₂O at 15 cmH₂O of PEEP, respectively (P = 0.32, P = 0.98, respectively), indicating that these parameters were significantly related (r(2) = 0.98, P < 0.001 at 5 cmH₂O of PEEP; r(2) = 0.93, P < 0.001 at 15 cmH₂O of PEEP). The percentage error was 5.6 and 12.0 %, respectively. The mean directly measured and release-derived transpulmonary pressure were -8.0 ± 3.8 and 3.9 ± 0.9 cmH₂O at 5 cmH₂O of PEEP and -1.2 ± 3.2 and 10.6 ± 2.2 cmH₂O at 15 cmH₂O of PEEP, respectively, indicating that these parameters were not related (r(2) = 0.07, P = 0.08 at 5 cmH₂O of PEEP; r (2) = 0.10, P = 0.53 at 15 cmH₂O of PEEP). CONCLUSIONS Based on our observations, elastance-derived transpulmonary pressure can be considered to be an adequate surrogate of the release-derived transpulmonary pressure, while the release-derived and directly measured end-expiratory transpulmonary pressure are not related.
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Santos CL, Moraes L, Santos RS, dos Santos Samary C, Silva JD, Morales MM, Capelozzi VL, de Abreu MG, Schanaider A, Silva PL, Garcia CSNB, Pelosi P, Rocco PRM. The biological effects of higher and lower positive end-expiratory pressure in pulmonary and extrapulmonary acute lung injury with intra-abdominal hypertension. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R121. [PMID: 24928415 PMCID: PMC4095606 DOI: 10.1186/cc13920] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/27/2014] [Indexed: 01/01/2023]
Abstract
Introduction Mechanical ventilation with high positive end-expiratory pressure (PEEP) has been used in patients with acute respiratory distress syndrome (ARDS) and intra-abdominal hypertension (IAH), but the role of PEEP in minimizing lung injury remains controversial. We hypothesized that in the presence of acute lung injury (ALI) with IAH: 1) higher PEEP levels improve pulmonary morphofunction and minimize lung injury; and 2) the biological effects of higher PEEP are more effective in extrapulmonary (exp) than pulmonary (p) ALI. Methods In 48 adult male Wistar rats, ALIp and ALIexp were induced by Escherichia coli lipopolysaccharide intratracheally and intraperitoneally, respectively. After 24 hours, animals were anesthetized and mechanically ventilated (tidal volume of 6 mL/kg). IAH (15 mmHg) was induced and rats randomly assigned to PEEP of 5 (PEEP5), 7 (PEEP7) or 10 (PEEP10) cmH2O for 1 hour. Results In both ALIp and ALIexp, higher PEEP levels improved oxygenation. PEEP10 increased alveolar hyperinflation and epithelial cell damage compared to PEEP5, independent of ALI etiology. In ALIp, PEEP7 and PEEP10 increased lung elastance compared to PEEP5 (4.3 ± 0.7 and 4.3 ± 0.9 versus 3.1 ± 0.3 cmH2O/mL, respectively, P <0.01), without changes in alveolar collapse, interleukin-6, caspase-3, type III procollagen, receptor for advanced glycation end-products, and vascular cell adhesion molecule-1 expressions. Moreover, PEEP10 increased diaphragmatic injury compared to PEEP5. In ALIexp, PEEP7 decreased lung elastance and alveolar collapse compared to PEEP5 (2.3 ± 0.5 versus 3.6 ± 0.7 cmH2O/mL, P <0.02, and 27.2 (24.7 to 36.8) versus 44.2 (39.7 to 56.9)%, P <0.05, respectively), while PEEP7 and PEEP10 increased interleukin-6 and type III procollagen expressions, as well as type II epithelial cell damage compared to PEEP5. Conclusions In the current models of ALI with IAH, in contrast to our primary hypothesis, higher PEEP is more effective in ALIp than ALIexp as demonstrated by the activation of biological markers. Therefore, higher PEEP should be used cautiously in the presence of IAH and ALI, mainly in ALIexp.
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Goligher EC, Fan E, Slutsky AS. Year in review 2012: Critical Care--Respirology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:249. [PMID: 24267541 PMCID: PMC4056602 DOI: 10.1186/cc13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Acute respiratory failure is a dominant feature of critical illness. In this review, we discuss 17 studies published last year in Critical Care. The discussion focuses on articles on several topics: respiratory monitoring, acute respiratory distress syndrome, noninvasive ventilation, airway management, secretion management and weaning.
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Value and limitations of transpulmonary pressure calculations during intra-abdominal hypertension. Crit Care Med 2013; 41:1870-7. [PMID: 23863222 DOI: 10.1097/ccm.0b013e31828a3bea] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To clarify the effect of progressively increasing intra-abdominal pressure on esophageal pressure, transpulmonary pressure, and functional residual capacity. DESIGN Controlled application of increased intra-abdominal pressure at two positive end-expiratory pressure levels (1 and 10 cm H2O) in an anesthetized porcine model of controlled ventilation. SETTING Large animal laboratory of a university-affiliated hospital. SUBJECTS Eleven deeply anesthetized swine (weight 46.2 ± 6.2 kg). INTERVENTIONS Air-regulated intra-abdominal hypertension (0-25 mm Hg). MEASUREMENTS Esophageal pressure, tidal compliance, bladder pressure, and end-expiratory lung aeration by gas dilution. MAIN RESULTS Functional residual capacity was significantly reduced by increasing intra-abdominal pressure at both positive end-expiratory pressure levels (p ≤ 0.0001) without corresponding changes of end-expiratory esophageal pressure. Above intra-abdominal pressure 5 mm Hg, plateau airway pressure increased linearly by ~ 50% of the applied intra-abdominal pressure value, associated with commensurate changes of esophageal pressure. With tidal volume held constant, negligible changes occurred in transpulmonary pressure due to intra-abdominal pressure. Driving pressures calculated from airway pressures alone (plateau airway pressure--positive end-expiratory pressure) did not equate to those computed from transpulmonary pressure (tidal changes in transpulmonary pressure). Increasing positive end-expiratory pressure shifted the predominantly negative end-expiratory transpulmonary pressure at positive end-expiratory pressure 1 cm H2O (mean -3.5 ± 0.4 cm H2O) into the positive range at positive end-expiratory pressure 10 cm H2O (mean 0.58 ± 1.2 cm H2O). CONCLUSIONS Despite its insensitivity to changes in functional residual capacity, measuring transpulmonary pressure may be helpful in explaining how different levels of positive end-expiratory pressure influence recruitment and collapse during tidal ventilation in the presence of increased intra-abdominal pressure and in calculating true transpulmonary driving pressure (tidal changes of transpulmonary pressure). Traditional interpretations of respiratory mechanics based on unmodified airway pressure were misleading regarding lung behavior in this setting.
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Pleural pressure and optimal positive end-expiratory pressure based on esophageal pressure versus chest wall elastance: incompatible results*. Crit Care Med 2013; 41:1951-7. [PMID: 23863227 DOI: 10.1097/ccm.0b013e31828a3de5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 1) To compare two published methods for estimating pleural pressure, one based on directly measured esophageal pressure and the other based on chest wall elastance. 2) To evaluate the agreement between two published positive end-expiratory pressure optimization strategies based on these methods, one targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H2O and the other targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H2O. DESIGN Retrospective study using clinical data. SETTING Medical and surgical ICUs. PATIENTS Sixty-four patients mechanically ventilated for acute respiratory failure with esophageal balloons placed for clinical management. METHODS Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure and setting positive end-expiratory pressure were retrospectively applied to each of the 64 patients. In patients who were ventilated at two positive end-expiratory pressure levels, chest wall and respiratory system elastances were calculated at each positive end-expiratory pressure level. MEASUREMENTS AND MAIN RESULTS The pleural pressure estimates using both methods were discordant and differed by as much as 10 cm H2O for a given patient. The two positive end-expiratory pressure optimization strategies recommended positive end-expiratory pressure changes in opposite directions in 33% of patients. The ideal positive end-expiratory pressure levels recommended by the two methods for each patient were discordant and uncorrelated (R = 0.05). Chest wall and respiratory system elastances grew with increases in positive end-expiratory pressure in patients with positive end-expiratory esophageal pressure-based transpulmonary pressures (p < 0.05). CONCLUSIONS Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure do not yield similar results. The strategies of targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H2O and targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H2O cannot be considered interchangeable. Finally, chest wall and respiratory system elastances may vary unpredictably with changes in positive end-expiratory pressure.
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Experimental intra-abdominal hypertension influences airway pressure limits for lung protective mechanical ventilation. J Trauma Acute Care Surg 2013; 74:1468-73. [PMID: 23694861 DOI: 10.1097/ta.0b013e31829243a7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) may complicate monitoring of pulmonary mechanics owing to their impact on the respiratory system. However, recommendations for mechanical ventilation of patients with IAH/ACS and the interpretation of thoracoabdominal interactions remain unclear. Our study aimed to characterize the influence of elevated intra-abdominal pressure (IAP) and positive end-expiratory pressure (PEEP) on airway plateau pressure (PPLAT) and bladder pressure (PBLAD). METHODS Nine deeply anesthetized swine were mechanically ventilated via tracheostomy: volume-controlled mode at tidal volume (VT) of 10 mL/kg, frequency of 15, inspiratory-expiratory ratio of 1:2, and PEEP of 1 and 10 cm H2O (PEEP1 and PEEP10, respectively). A tracheostomy tube was placed in the peritoneal cavity, and IAP levels of 5, 10, 15, 20, and 25 mm Hg were applied, using a continuous positive airway pressure system. At each IAP level, PBLAD and airway pressure measurements were performed during both PEEP1 and PEEP10. RESULTS PBLAD increased as experimental IAP rose (y = 0.83x + 0.5; R = 0.98; p < 0.001 at PEEP1). Minimal underestimation of IAP by PBLAD was observed (-2.5 ± 0.8 mm Hg at an IAP of 10-25 mm Hg). Applying PEEP10 did not significantly affect the correlation between experimental IAP and PBLAD. Approximately 50% of the PBLAD (in cm H2O) was reflected by changes in PPLAT, regardless of the PEEP level applied. Increasing IAP did not influence hemodynamics at any level of IAP generated. CONCLUSION With minimal underestimation, PBLAD measurements closely correlated with experimentally regulated IAP, independent of the PEEP level applied. For each PEEP level applied, a constant proportion (approximately 50%) of measured PBLAD (in cm H2O) was reflected in PPLAT. A higher safety threshold for PPLAT should be considered in the setting of IAH/ACS as the clinician considers changes in VT. A strategy of reducing VT to cap PPLAT at widely recommended values may not be warranted in the setting of increased IAP.
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Struck MF, Reske AW, Schmidt T, Hilbert P, Steen M, Wrigge H. Respiratory functions of burn patients undergoing decompressive laparotomy due to secondary abdominal compartment syndrome. Burns 2013; 40:120-6. [PMID: 23790395 DOI: 10.1016/j.burns.2013.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 04/23/2013] [Accepted: 05/21/2013] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The development of secondary abdominal compartment syndrome (ACS) is associated with multiple organ dysfunction. There is little information about the effects of decompressive laparotomy (DL) on respiratory function (RF) in burn patients developing ACS. PATIENTS AND METHODS We retrospectively obtained data characterising RF from the database of an adult burn intensive care unit (BICU). Peak inspiratory pressure (Pip), PaO2/FiO2-ratio (P/F), static compliance (Cstat) and airway resistance (Raw) were analysed over the course of 60 h at 8 time points relative to DL. RESULTS Thirty-five patients with ACS underwent DL with a mean percentage of total burned body surface area (TBSA) 39 ± 23% and mean intra-abdominal pressure 33 ± 7 mmHg. All patients presented with significantly deteriorating RF within 12h of DL (Pip 33 ± 4 to 39 ± 7 cm/H2O, p=0.003; P/F 232 ± 59 to 160 ± 55 mmHg, p<0.001, Cstat 34 ± 5 to 26 ± 6 mL/cmH2O, p<0.001; Raw 18 ± 3 to 24 ± 9 cm H2O/L/s, p=0.02). All these parameters improved significantly (p<0.001) after DL, regardless of the presence of inhalation injury or torso burns. Mortality was 71.4%. CONCLUSIONS Variables characterising RF demonstrated a rapid deterioration before and a significant and sustained improvement after DL in burn patients developing ACS. Despite these respiratory improvements, DL was associated with low survival rates. Secondary ACS remains a challenge in burn patients and thus warrants particular attention during intensive care treatment.
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Affiliation(s)
- Manuel F Struck
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Leipzig, Germany; Department of Plastic and Hand Surgery, Burn Trauma Centre, Bergmannstrost Hospital, Halle/Saale, Germany.
| | - Andreas W Reske
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Leipzig, Germany
| | - Thomas Schmidt
- Department of Medical Psychology, Bergmannstrost Hospital, Halle/Saale, Germany
| | - Peter Hilbert
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Bergmannstrost Hospital, Halle/Saale, Germany
| | - Michael Steen
- Department of Plastic and Hand Surgery, Burn Trauma Centre, Bergmannstrost Hospital, Halle/Saale, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Leipzig, Germany
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The importance of timing of decompression in severe acute pancreatitis combined with abdominal compartment syndrome. J Trauma Acute Care Surg 2013; 74:1060-6. [PMID: 23511145 DOI: 10.1097/ta.0b013e318283d927] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical decompression is widely considered as an important treatment in patients with severe acute pancreatitis (SAP) and abdominal compartment syndrome (ACS). Until now, the indication and optimal time of decompression remain unknown, and no experimental data exist, although extremely high mortality has been repeatedly reported in these patients. The aim of this study was to evaluate the effects of three different time points for decompression in a 24-hour lasting porcine model. METHODS Following baseline registrations, 32 animals were divided into four groups (8 animals each group) as follows: one SAP-alone group and three SAP + ACS groups, which received decompression at 6, 9, and 12 hours. We used a N2 pneumoperitoneum to increase the intra-abdominal pressure to 25 mm Hg and retrograde intra-ductal infusion of sodium taurocholate to induce SAP. Global hemodynamic profiles, urine output, systemic oxygenation, and serum biochemical parameters of the animals were studied. At the end of the experiment, histologic examination of the intestine and lung was performed. RESULTS The survival time of the 12-hour group was significantly shortened (p = 0.037 vs. 9 hours and p = 0.008 vs. 6 hours). In SAP + ACS animals, decompression at 6 hours restored systemic hemodynamics, oxygen-derived parameters, organ function, and inflammatory intensity to a level comparable with that of the SAP-alone group. In contrast, animals in the 9 hours and 12 hours developed more severe hemodynamic and organ dysfunction. The histopathologic analyses also revealed higher grade injury of the intestine and lung in animals receiving delayed decompression. CONCLUSION Well-timed decompression in a porcine model of SAP incorporating 25-mm Hg intra-abdominal hypertension/ACS was associated with significantly reduced mortality, improved systemic hemodynamics and organ function, as well as alleviated histologic injury and inflammatory intensity. According to our results and previous reports, both too early and too late decompression should be avoided owing to significant morbidity for the former and unfavorable outcomes for the latter.
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Rafiei MR, Aghadavoudi O, Shekarchi B, Sajjadi SS, Masoudifar M. Can selection of mechanical ventilation mode prevent increased intra-abdominal pressure in patients admitted to the intensive care unit? Int J Prev Med 2013; 4:552-6. [PMID: 23930166 PMCID: PMC3733186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 01/22/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Increased intra-abdominal pressure (IAP) results in dysfunction of vital organs. The aim of the present study was to evaluate the effect of mechanical ventilation mode on IAP. METHODS In a cohort study, a total of 60 patients aged 20-70 years who were admitted to the ICU and underwent mechanical ventilation were recruited. Mechanical ventilation included one of the three modes: Biphasic positive airway pressure (BIPAP) group, synchronize intermittent mandatory ventilation (SIMV) group, or continuous positive airway pressure (CPAP) group. For each patient, mechanical ventilation mode and its parameters, blood pressure, SpO2, and status of tube feeding and IAP were recorded. RESULTS Our findings indicate that the study groups were not significantly different in terms of anthropometric characteristics including age (64.5 ± 4, P = 0.1), gender (male/female 31/29, P = 0.63), and body mass index (24 ± 1.2, P = 0.11). Increase IAP was related to the type of respiratory mode with the more increased IAP observed in SIMV mode, followed by BIPAP and CPAP modes (P = 0.01). There were significant correlations between increased IAP and respiratory variables including respiratory rate, pressure support ventilation, and inspiratory pressure (P < 0.05). Tube feeding tolerance through NG-tube was lower in SIMV group, followed by BIPAP and CPAP groups (P < 0.05). CONCLUSIONS There is a significant relationship between respiratory modes and IAP; therefore, it is better to utilize those types of mechanical ventilation like CPAP and BIPAP mode in patients who are prone to Intra-abdominal hypertension.
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Affiliation(s)
- Mohammad Reza Rafiei
- Department of Anesthesiology, AJA University of Medical Sciences, Emam Reza Hospital, Tehran, Iran
| | - Omid Aghadavoudi
- Department of Anesthesiology and Critical Care, Isfahan University of Medical Sciences, Isfahan, Iran,Correspondence to: Prof. Omid Aghadavoudi, Department of Anesthesiology and Critical Care, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail:
| | - Babak Shekarchi
- Department of Radiology, AJA University of Medical Sciences, Emam Reza Hospital, Tehran, Iran
| | - Seyed Sajed Sajjadi
- Department of Anesthesiology, AJA University of Medical Sciences, Emam Reza Hospital, Tehran, Iran
| | - Mehrdad Masoudifar
- Department of Anesthesiology and Critical Care, Isfahan University of Medical Sciences, Isfahan, Iran
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Thammanomai A, Hamakawa H, Bartolák-Suki E, Suki B. Combined effects of ventilation mode and positive end-expiratory pressure on mechanics, gas exchange and the epithelium in mice with acute lung injury. PLoS One 2013; 8:e53934. [PMID: 23326543 PMCID: PMC3541132 DOI: 10.1371/journal.pone.0053934] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 12/07/2012] [Indexed: 11/23/2022] Open
Abstract
The accepted protocol to ventilate patients with acute lung injury is to use low tidal volume (V(T)) in combination with recruitment maneuvers or positive end-expiratory pressure (PEEP). However, an important aspect of mechanical ventilation has not been considered: the combined effects of PEEP and ventilation modes on the integrity of the epithelium. Additionally, it is implicitly assumed that the best PEEP-V(T) combination also protects the epithelium. We aimed to investigate the effects of ventilation mode and PEEP on respiratory mechanics, peak airway pressures and gas exchange as well as on lung surfactant and epithelial cell integrity in mice with acute lung injury. HCl-injured mice were ventilated at PEEPs of 3 and 6 cmH(2)O with conventional ventilation (CV), CV with intermittent large breaths (CV(LB)) to promote recruitment, and a new mode, variable ventilation, optimized for mice (VV(N)). Mechanics and gas exchange were measured during ventilation and surfactant protein (SP)-B, proSP-B and E-cadherin levels were determined from lavage and lung homogenate. PEEP had a significant effect on mechanics, gas exchange and the epithelium. The higher PEEP reduced lung collapse and improved mechanics and gas exchange but it also down regulated surfactant release and production and increased epithelial cell injury. While CV(LB) was better than CV, VV(N) outperformed CV(LB) in recruitment, reduced epithelial injury and, via a dynamic mechanotransduction, it also triggered increased release and production of surfactant. For long-term outcome, selection of optimal PEEP and ventilation mode may be based on balancing lung physiology with epithelial injury.
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Affiliation(s)
- Apiradee Thammanomai
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, United States of America
| | - Hiroshi Hamakawa
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, United States of America
| | - Erzsébet Bartolák-Suki
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, United States of America
| | - Béla Suki
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, United States of America
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Regli A, Mahendran R, Fysh ET, Roberts B, Noffsinger B, De Keulenaer BL, Singh B, van Heerden PV. Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension. Crit Care 2012; 16:R208. [PMID: 23098278 PMCID: PMC3682312 DOI: 10.1186/cc11840] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/05/2012] [Accepted: 10/18/2012] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Intra-abdominal hypertension (IAH) causes atelectasis, reduces lung volumes and increases respiratory system elastance. Positive end-expiratory pressure (PEEP) in the setting of IAH and healthy lungs improves lung volumes but not oxygenation. However, critically ill patients with IAH often suffer from acute lung injury (ALI). This study, therefore, examined the respiratory and cardiac effects of positive end-expiratory pressure in an animal model of IAH, with sick lungs. METHODS Nine pigs were anesthetized and ventilated (48 +/- 6 kg). Lung injury was induced with oleic acid. Three levels of intra-abdominal pressure (baseline, 18, and 22 mmHg) were randomly generated. At each level of intra-abdominal pressure, three levels of PEEP were randomly applied: baseline (5 cmH2O), moderate (0.5 × intra-abdominal pressure), and high (1.0 × intra-abdominal pressure). We measured end-expiratory lung volumes, arterial oxygen levels, respiratory mechanics, and cardiac output 10 minutes after each new IAP and PEEP setting. RESULTS At baseline PEEP, IAH (22 mmHg) decreased oxygen levels (-55%, P <0.001) and end-expiratory lung volumes (-45%, P = 0.007). At IAP of 22 mmHg, moderate and high PEEP increased oxygen levels (+60%, P = 0.04 and +162%, P <0.001) and end-expiratory lung volume (+44%, P = 0.02 and +279%, P <0.001) and high PEEP reduced cardiac output (-30%, P = 0.04). Shunt and dead-space fraction inversely correlated with oxygen levels and end-expiratory lung volumes. In the presence of IAH, lung, chest wall and respiratory system elastance increased. Subsequently, PEEP decreased respiratory system elastance by decreasing chest wall elastance. CONCLUSIONS In a porcine sick lung model of IAH, PEEP matched to intra-abdominal pressure led to increased lung volumes and oxygenation and decreased chest wall elastance shunt and dead-space fraction. High PEEP decreased cardiac output. The study shows that lung injury influences the effects of IAH and PEEP on oxygenation and respiratory mechanics. Our findings support the application of PEEP in the setting of acute lung injury and IAH.
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Affiliation(s)
- Adrian Regli
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle 6160, Australia
- School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, 6009 Crawley, Australia
- Medical School, The University of Notre Dame Australia, 19 Mouat Street, 6959 Fremantle, Australia
| | - Rohan Mahendran
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle 6160, Australia
| | - Edward T Fysh
- School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, 6009 Crawley, Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Brigit Roberts
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Bill Noffsinger
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Bart L De Keulenaer
- Intensive Care Unit, Fremantle Hospital, Alma Street, Fremantle 6160, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
| | - Peter V van Heerden
- School of Medicine and Pharmacology, The University of Western Australia, 35 Stirling Highway, 6009 Crawley, Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, 6009 Nedlands, Australia
- Medical Intensive Care Unit, Hadassah University Hospital, Ein Kerem, 91120 Jerusalem, Israel
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Matching positive end-expiratory pressure to intra-abdominal pressure prevents end-expiratory lung volume decline in a pig model of intra-abdominal hypertension. Crit Care Med 2012; 40:1879-86. [PMID: 22488004 DOI: 10.1097/ccm.0b013e31824e0e80] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Intra-abdominal hypertension is common in critically ill patients and is associated with increased morbidity and mortality. In a previous experimental study, positive end-expiratory pressures of up to 15 cm H2O did not prevent end-expiratory lung volume decline caused by intra-abdominal hypertension. Therefore, we examined the effect of matching positive end-expiratory pressure to the intra-abdominal pressure on cardio-respiratory parameters. DESIGN Experimental pig model of intra-abdominal hypertension. SETTING Large animal facility, University of Western Australia. SUBJECTS Nine anesthetized, nonparalyzed, and ventilated pigs (48 ± 7 kg). INTERVENTIONS Four levels of intra-abdominal pressure (baseline, 12, 18, and 22 mm Hg) were generated in a randomized order by inflating an intra-abdominal balloon. At each level of intra-abdominal pressure, three levels of positive end-expiratory pressure were randomly applied with varying degrees of matching the corresponding intra-abdominal pressure: baseline positive end-expiratory pressure (= 5 cm H2O), moderate positive end-expiratory pressure (= half intra-abdominal pressure in cm H2O + 5 cm H2O), and high positive end-expiratory pressure (= intra-abdominal pressure in cm H2O). MEASUREMENTS We measured end-expiratory lung volume, arterial oxygen levels, respiratory mechanics, and cardiac output 5 mins after each new intra-abdominal pressure and positive end-expiratory pressure setting. MAIN RESULTS Intra-abdominal hypertension decreased end-expiratory lung volume and PaO2 (-49% [p < .001] and -8% [p < .05], respectively, at 22 mm Hg intra-abdominal pressure compared with baseline intra-abdominal pressure) but did not change cardiac output (p = .5). At each level of intra-abdominal pressure, moderate positive end-expiratory pressure increased end-expiratory lung volume (+119% [p < .001] at 22 mm Hg intra-abdominal pressure compared with 5 cm H2O positive end-expiratory pressure) while minimally decreasing cardiac output (-8%, p < .05). High positive end-expiratory pressure further increased end-expiratory lung volume (+233% [p < .001] at 22 mm Hg intra-abdominal pressure compared with 5 cm H2O positive end-expiratory pressure) but led to a greater decrease in cardiac output (-26%, p < .05). Neither moderate nor high positive end-expiratory pressure improved PaO2 (p = .7). Intra-abdominal hypertension decreased end-expiratory transpulmonary pressure but did not alter end-inspiratory transpulmonary pressure. Intra-abdominal hypertension decreased total respiratory compliance through a decrease in chest wall compliance. Positive end-expiratory pressure decreased the respiratory compliance by reducing lung compliance. CONCLUSIONS In a pig model of intra-abdominal hypertension, positive end-expiratory pressure matched to intra-abdominal pressure led to a preservation of end-expiratory lung volume, but did not improve arterial oxygen tension and caused a reduction in cardiac output. Therefore, we do not recommend routine application of positive end-expiratory pressure matched to intra-abdominal pressure to prevent intra-abdominal pressure-induced end-expiratory lung volume decline in healthy lungs.
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Experimental intra-abdominal hypertension attenuates the benefit of positive end-expiratory pressure in ventilating effusion-compressed lungs*. Crit Care Med 2012; 40:2176-81. [DOI: 10.1097/ccm.0b013e318250aa40] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chao CS, Chang YP, Chin HK, Chin J. A Patient with Abdominal Compartment Syndrome and Perforated Transverse Colon Successfully Managed with ECMO. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2011. [DOI: 10.47102/annals-acadmedsg.v40n12p554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Chia Sheng Chao
- Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC
| | | | - Hsien Kuo Chin
- Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC
| | - Jen Chin
- Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, ROC
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Abstract
The lung parenchyma comprises a large number of thin-walled alveoli, forming an enormous surface area, which serves to maintain proper gas exchange. The alveoli are held open by the transpulmonary pressure, or prestress, which is balanced by tissues forces and alveolar surface film forces. Gas exchange efficiency is thus inextricably linked to three fundamental features of the lung: parenchymal architecture, prestress, and the mechanical properties of the parenchyma. The prestress is a key determinant of lung deformability that influences many phenomena including local ventilation, regional blood flow, tissue stiffness, smooth muscle contractility, and alveolar stability. The main pathway for stress transmission is through the extracellular matrix. Thus, the mechanical properties of the matrix play a key role both in lung function and biology. These mechanical properties in turn are determined by the constituents of the tissue, including elastin, collagen, and proteoglycans. In addition, the macroscopic mechanical properties are also influenced by the surface tension and, to some extent, the contractile state of the adherent cells. This chapter focuses on the biomechanical properties of the main constituents of the parenchyma in the presence of prestress and how these properties define normal function or change in disease. An integrated view of lung mechanics is presented and the utility of parenchymal mechanics at the bedside as well as its possible future role in lung physiology and medicine are discussed.
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Affiliation(s)
- Béla Suki
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA.
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Ruiz Ferrón F, Tejero Pedregosa A, Ruiz García M, Ferrezuelo Mata A, Pérez Valenzuela J, Quirós Barrera R, Rucabado Aguilar L. Presión intraabdominal y torácica en pacientes críticos con sospecha de hipertensión intraabdominal. Med Intensiva 2011; 35:274-9. [DOI: 10.1016/j.medin.2011.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 02/09/2011] [Accepted: 02/10/2011] [Indexed: 11/27/2022]
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Chest wall mechanics and abdominal pressure during general anaesthesia in normal and obese individuals and in acute lung injury. Curr Opin Crit Care 2011; 17:72-9. [PMID: 21150585 DOI: 10.1097/mcc.0b013e3283427213] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW This article discusses the methods available to evaluate chest wall mechanics and the relationship between intraabdominal pressure (IAP) and chest wall mechanics during general anaesthesia in normal and obese individuals, as well as in acute lung injury/acute respiratory distress syndrome. RECENT FINDINGS The interactions between the abdominal and thoracic compartments pose a specific challenge for intensive care physicians. IAP affects respiratory system, lung and chest wall elastance in an unpredictable way. Thus, transpulmonary pressure should be measured if IAP is more than 12 mmHg or if chest wall elastance is compromised for other reasons, even though the absolute values of pleural and transpulmonary pressures are not easily obtained at bedside. We suggest defining intraabdominal hypertension (IAH) as IAP at least 20 mmHg and abdominal compartment syndrome (ACS) as IAP at least 20 mmHg associated with failure of one or more organs, although further studies are required to confirm this hypothesis. Additionally, in the presence of IAH, controlled mechanical ventilation should be applied and positive end-expiratory pressure individually titrated. Prophylactic open abdomen should be considered in the presence of ACS. SUMMARY Increased IAP markedly affects respiratory function and complicates patient management. Frequent assessment of IAP is recommended.
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Rocco PRM, Pelosi P, de Abreu MG. Pros and cons of recruitment maneuvers in acute lung injury and acute respiratory distress syndrome. Expert Rev Respir Med 2010; 4:479-89. [PMID: 20658909 DOI: 10.1586/ers.10.43] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In patients with acute lung injury and acute respiratory distress syndrome, a protective mechanical ventilation strategy characterized by low tidal volumes has been associated with reduced mortality. However, such a strategy may result in alveolar collapse, leading to cyclic opening and closing of atelectatic alveoli and distal airways. Thus, recruitment maneuvers (RMs) have been used to open up collapsed lungs, while adequate positive end-expiratory pressure (PEEP) levels may counteract alveolar derecruitment during low tidal volume ventilation, improving respiratory function and minimizing ventilator-associated lung injury. Nevertheless, considerable uncertainty remains regarding the appropriateness of RMs. The most commonly used RM is conventional sustained inflation, associated with respiratory and cardiovascular side effects, which may be minimized by newly proposed strategies: prolonged or incremental PEEP elevation; pressure-controlled ventilation with fixed PEEP and increased driving pressure; pressure-controlled ventilation applied with escalating PEEP and constant driving pressure; and long and slow increase in pressure. The efficiency of RMs may be affected by different factors, including the nature and extent of lung injury, capability of increasing inspiratory transpulmonary pressures, patient positioning and cardiac preload. Current evidence suggests that RMs can be used before setting PEEP, after ventilator circuit disconnection or as a rescue maneuver to overcome severe hypoxemia; however, their routine use does not seem to be justified at present. The development of new lung recruitment strategies that have fewer hemodynamic and biological effects on the lungs, as well as randomized clinical trials analyzing the impact of RMs on morbidity and mortality of acute lung injury/acute respiratory distress syndrome patients, are warranted.
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Affiliation(s)
- Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute of Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão-21941-902, Rio de Janeiro, RJ, Brazil.
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Regli A, Hockings LE, Musk GC, Roberts B, Noffsinger B, Singh B, van Heerden PV. Commonly applied positive end-expiratory pressures do not prevent functional residual capacity decline in the setting of intra-abdominal hypertension: a pig model. Crit Care 2010; 14:R128. [PMID: 20598125 PMCID: PMC2945091 DOI: 10.1186/cc9095] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 04/28/2010] [Accepted: 07/02/2010] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Intra-abdominal hypertension is common in critically ill patients and is associated with increased morbidity and mortality. The optimal ventilation strategy remains unclear in these patients. We examined the effect of positive end-expiratory pressures (PEEP) on functional residual capacity (FRC) and oxygen delivery in a pig model of intra-abdominal hypertension. METHODS Thirteen adult pigs received standardised anaesthesia and ventilation. We randomised three levels of intra-abdominal pressure (3 mmHg (baseline), 18 mmHg, and 26 mmHg) and four commonly applied levels of PEEP (5, 8, 12 and 15 cmH2O). Intra-abdominal pressures were generated by inflating an intra-abdominal balloon. We measured intra-abdominal (bladder) pressure, functional residual capacity, cardiac output, haemoglobin and oxygen saturation, and calculated oxygen delivery. RESULTS Raised intra-abdominal pressure decreased FRC but did not change cardiac output. PEEP increased FRC at baseline intra-abdominal pressure. The decline in FRC with raised intra-abdominal pressure was partly reversed by PEEP at 18 mmHg intra-abdominal pressure and not at all at 26 mmHg intra-abdominal pressure. PEEP significantly decreased cardiac output and oxygen delivery at baseline and at 26 mmHg intra-abdominal pressure but not at 18 mmHg intra-abdominal pressure. CONCLUSIONS In a pig model of intra-abdominal hypertension, PEEP up to 15 cmH2O did not prevent the FRC decline caused by intra-abdominal hypertension and was associated with reduced oxygen delivery as a consequence of reduced cardiac output. This implies that PEEP levels inferior to the corresponding intra-abdominal pressures cannot be recommended to prevent FRC decline in the setting of intra-abdominal hypertension.
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Affiliation(s)
- Adrian Regli
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth) WA 6009, Australia
| | - Lisen E Hockings
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth) WA 6009, Australia
| | - Gabrielle C Musk
- Veterinary Anaesthesia, Murdoch University Veterinary Hospital, 90 South Street, Murdoch (Perth) WA 6150, Australia
| | - Brigit Roberts
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth) WA 6009, Australia
| | - Bill Noffsinger
- Department of Pulmonary Physiology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth) WA 6009, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth) WA 6009, Australia
| | - Peter V van Heerden
- Intensive Care Unit, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands (Perth) WA 6009, Australia
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