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Zeng C, Zhu M, Motta-Ribeiro G, Lagier D, Hinoshita T, Zang M, Grogg K, Winkler T, Vidal Melo MF. Dynamic lung aeration and strain with positive end-expiratory pressure individualized to maximal compliance versus ARDSNet low-stretch strategy: a study in a surfactant depletion model of lung injury. Crit Care 2023; 27:307. [PMID: 37537654 PMCID: PMC10401825 DOI: 10.1186/s13054-023-04591-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) individualized to a maximal respiratory system compliance directly implies minimal driving pressures with potential outcome benefits, yet, raises concerns on static and dynamic overinflation, strain and cyclic recruitment. Detailed accurate assessment and understanding of these has been hampered by methodological limitations. We aimed to investigate the effects of a maximal compliance-guided PEEP strategy on dynamic lung aeration, strain and tidal recruitment using current four-dimensional computed tomography (CT) techniques and analytical methods of tissue deformation in a surfactant depletion experimental model of acute respiratory distress syndrome (ARDS). METHODS ARDS was induced by saline lung lavage in anesthetized and mechanically ventilated healthy sheep (n = 6). Animals were ventilated in a random sequence with: (1) ARDSNet low-stretch protocol; (2) maximal compliance PEEP strategy. Lung aeration, strain and tidal recruitment were acquired with whole-lung respiratory-gated high-resolution CT and quantified using registration-based techniques. RESULTS Relative to the ARDSNet low-stretch protocol, the maximal compliance PEEP strategy resulted in: (1) improved dynamic whole-lung aeration at end-expiration (0.456 ± 0.064 vs. 0.377 ± 0.101, P = 0.019) and end-inspiration (0.514 ± 0.079 vs. 0.446 ± 0.083, P = 0.012) with reduced non-aerated and increased normally-aerated lung mass without associated hyperinflation; (2) decreased aeration heterogeneity at end-expiration (coefficient of variation: 0.498 ± 0.078 vs. 0.711 ± 0.207, P = 0.025) and end-inspiration (0.419 ± 0.135 vs. 0.580 ± 0.108, P = 0.014) with higher aeration in dorsal regions; (3) tidal aeration with larger inspiratory increases in normally-aerated and decreases in poorly-aerated areas, and negligible in hyperinflated lung (Aeration × Strategy: P = 0.026); (4) reduced tidal strains in lung regions with normal-aeration (Aeration × Strategy: P = 0.047) and improved regional distributions with lower tidal strains in middle and ventral lung (Region-of-interest [ROI] × Strategy: P < 0.001); and (5) less tidal recruitment in middle and dorsal lung (ROI × Strategy: P = 0.044) directly related to whole-lung tidal strain (r = 0.751, P = 0.007). CONCLUSIONS In well-recruitable ARDS models, a maximal compliance PEEP strategy improved end-expiratory/inspiratory whole-lung aeration and its homogeneity without overinflation. It further reduced dynamic strain in middle-ventral regions and tidal recruitment in middle-dorsal areas. These findings suggest the maximal compliance strategy minimizing whole-lung dynamically quantified mechanisms of ventilator-induced lung injury with less cyclic recruitment and no additional overinflation in large heterogeneously expanded and recruitable lungs.
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Affiliation(s)
- Congli Zeng
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | - Min Zhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriel Motta-Ribeiro
- Biomedical Engineering Program, Alberto Luiz Coimbra Institute for Graduate Studies and Research in Engineering, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - David Lagier
- Department of Cardiovascular Anesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France
| | | | - Mingyang Zang
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Kira Grogg
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Tilo Winkler
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Bem Junior LS, Ferreira Neto ODC, Dias AJA, Alencar Neto JFD, de Lima LFG, Lemos NB, Diniz AMS, Couto KM, Maia JHEG, Silva ACV, Azevedo Filho HRCD. Decompressive hemicraniectomy for acute ischemic stroke: A neurosurgical view in a pandemic COVID-19 time highlights of literature. INTERDISCIPLINARY NEUROSURGERY : ADVANCED TECHNIQUES AND CASE MANAGEMENT 2022; 28:101485. [PMID: 35018284 PMCID: PMC8739822 DOI: 10.1016/j.inat.2021.101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 01/08/2023]
Abstract
Background and purpose: The novel coronavirus, SARS-CoV-2, which was identified after the outbreak in Wuhan, China, in December 2019, has kept the whole world in tenterhooks due to its severe life-threatening nature of the infection. The World Health Organization (WHO) declared coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 a pandemic in 2020, an unprecedented challenge, having a high contagious life-threatening condition with unprecedented impacts for worldwide societies and health care systems. Neurologic symptoms related to SARS-CoV-2 have been described recently in the literature, and acute cerebrovascular disease is one of the most serious complications. The occurrence of large-vessel occlusion in young patients with COVID-19 infection has been exceedingly rare. In this article, we describe the profile of patients undergoing decompressive craniectomy for the treatment of intracranial hypertension by stroke associated with COVID-19 published so far. A narrative review of the central issue in focus was designed: decompressive craniectomy in a pandemic time.
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Key Words
- ARDS, acute respiratory distress syndrome
- COVID-19
- COVID-19, Coronavirus disease 2019
- CT, computed tomography
- CTA, Computed tomography angiography
- DHC, decompressive hemicraniectomy
- DWI, Diffusion-weighted imaging
- ECCO2R, Extracorporeal carbon dioxide removal
- ECMO, extracorporeal membrane oxygenation
- GCS, Glasgow coma scale
- Hemicraniectomy, Review
- ICU, intensive unit care
- MCA, middle cerebral artery
- MCE, malignant cerebral edema
- MRI, magnetic resonance imaging
- NIHSS, National Institutes of Health Stroke Scale
- SARS-CoV-2
- Stroke
- WHO, World Health Organization
- hACE2, angiotensin-converting enzyme 2
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Affiliation(s)
- Luiz Severo Bem Junior
- Department of Neurosurgery, Hospital da Restauração, Av. Gov. Agamenon Magalhães, s/n - Derby, Recife, PE 52171-011, Brazil
- Neuroscience Post-Graduate Program, Federal University of Pernambuco, Campus I - Lot. Cidade Universitaria, PB 58051-900, Brazil
- College of Medical Sciences, Unifacisa University Center, R. Manoel Cardoso Palhano, Itararé, 124-152, Campina Grande, PB 58408-326, Brazil
| | | | - Artêmio José Araruna Dias
- College of Medical Sciences, Unifacisa University Center, R. Manoel Cardoso Palhano, Itararé, 124-152, Campina Grande, PB 58408-326, Brazil
| | - Joaquim Fechine de Alencar Neto
- College of Medical Sciences, Unifacisa University Center, R. Manoel Cardoso Palhano, Itararé, 124-152, Campina Grande, PB 58408-326, Brazil
| | - Luís Felipe Gonçalves de Lima
- College of Medical Sciences, Unifacisa University Center, R. Manoel Cardoso Palhano, Itararé, 124-152, Campina Grande, PB 58408-326, Brazil
| | - Nilson Batista Lemos
- College of Medical Sciences, Unifacisa University Center, R. Manoel Cardoso Palhano, Itararé, 124-152, Campina Grande, PB 58408-326, Brazil
| | - Andrey Maia Silva Diniz
- Federal University of Paraíba, Campus I - Lot. Cidade Universitaria, João Pessoa, PB 58051-900, Brazil
| | - Kaio Moreira Couto
- College of Medical Sciences, Unifacisa University Center, R. Manoel Cardoso Palhano, Itararé, 124-152, Campina Grande, PB 58408-326, Brazil
| | | | - Ana Cristina Veiga Silva
- Neuroscience Post-Graduate Program, Federal University of Pernambuco, Campus I - Lot. Cidade Universitaria, PB 58051-900, Brazil
| | - Hildo Rocha Cirne de Azevedo Filho
- Department of Neurosurgery, Hospital da Restauração, Av. Gov. Agamenon Magalhães, s/n - Derby, Recife, PE 52171-011, Brazil
- Neuroscience Post-Graduate Program, Federal University of Pernambuco, Campus I - Lot. Cidade Universitaria, PB 58051-900, Brazil
- College of Medical Sciences, Unifacisa University Center, R. Manoel Cardoso Palhano, Itararé, 124-152, Campina Grande, PB 58408-326, Brazil
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Broberg E, Pierre L, Fakhro M, Algotsson L, Malmsjö M, Hyllén S, Lindstedt S. Different particle flow patterns from the airways after recruitment manoeuvres using volume-controlled or pressure-controlled ventilation. Intensive Care Med Exp 2019; 7:16. [PMID: 30868309 PMCID: PMC6419649 DOI: 10.1186/s40635-019-0231-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/03/2019] [Indexed: 02/06/2023] Open
Abstract
Objectives Noninvasive online monitoring of different particle flows from the airways may serve as an additional tool to assess mechanical ventilation. In the present study, we used a customised PExA, an optical particle counter for monitoring particle flow and size distribution in exhaled air, to analyse airway particle flow for three subsequent days. We compared volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) and performed recruitment manoeuvres (RM). Methods Six animals were randomised into two groups: half received VCV before PCV and the other half received PCV before VCV. Measurements were taken daily for 1 h in each mode during three subsequent days in six fully anaesthetised domestic pigs. A RM was performed twice daily for 60 s at positive end-expiratory pressure (PEEP) of 10, 4 breaths/min and inspiratory-expiratory ratio (I:E) of 2:1. Measurements were taken for 3 min before the RM, 1 min during the RM and for 3 min after the RM. The particle sizes measured were between 0.48 and 3.37 μm. Results A significant stepwise decrease was observed in total particle count from day 1 to day 3, and at the same time, an increase in fluid levels was seen. Comparing VCV to PCV, a significant increase in total particle count was observed on day 2, with the highest particle count occurring during VCV. A significant increase was observed comparing before and after RM on day 1 and 2 but not on day 3. One animal developed ARDS and showed a different particle pattern compared to the other animals. Conclusions This study shows the safety and useability of the PExA technique used in conjunction with mechanical ventilation. We detected differences between the ventilation modes VCV and PCV in total particle count without any significant changes in ventilator pressure levels, FiO2 levels or the animals’ vital parameters. The findings during RM indicate an opening of the small airways, but the effect is short lived. We have also showed that VCV and PCV may affect the lung physiology differently during recruitment manoeuvres. These findings might indicate that this technique may provide more refined information on the impact of mechanical ventilation.
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Affiliation(s)
- Ellen Broberg
- Department of Cardiothoracic Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Leif Pierre
- Department of Cardiothoracic Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Mohammed Fakhro
- Department of Cardiothoracic Surgery and Transplantation, Skane University Hospital, Lund University, Lund, Sweden
| | - Lars Algotsson
- Department of Cardiothoracic Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Malin Malmsjö
- Department of Ophthalmology, Skane University Hospital, Lund University, Lund, Sweden
| | - Snejana Hyllén
- Department of Cardiothoracic Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skane University Hospital, Lund University, Lund, Sweden. .,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.
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