1
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Sehgal A, Menahem S. The left ventricle in well newborns versus those with perinatal asphyxia, haemodynamically significant ductus arteriosus or fetal growth restriction. Transl Pediatr 2023; 12:1735-1743. [PMID: 37814715 PMCID: PMC10560354 DOI: 10.21037/tp-23-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/10/2023] [Indexed: 10/11/2023] Open
Abstract
Hemodynamic changes accompanying the initial breaths at the time of birth are especially important for a smooth transition of fetal to neonatal circulation. Understanding the normal transitional physiology and the clinical impact of adverse adaptation is important for delineating pathology so as to guide physiologically relevant therapies. Disorders such as severe perinatal asphyxia, hemodynamically significant patent ductus arteriosus (and its surgical ligation) and utero-placental insufficiency underlying fetal growth restriction, can adversely affect left ventricular (LV) function. The left ventricle is the predominant chamber involved in systemic perfusion during postnatal life. Cardiac output is closely linked to afterload; the latter is determined by arterial properties such as stiffness and compliance. This article outlines normal transition in term and preterm infants. It also highlights the adverse impact of three not uncommon neonatal disorders on LV function. Perinatal asphyxia leads to a reduced LV output, superior vena cava and coronary artery blood flow and an increase in the troponin level. Multiple haemodynamic changes are observed in the premature infant with a large patent ductus arteriosus. They need careful analysis to determine when ligation should proceed. Ligation itself generally results in a dramatic increase in afterload which may lead to a reduction in LV contractility and the need for ionotropic support. Fetal growth restricted infants have a higher systolic pressure, a somewhat hypertrophied heart arising from an increased arterial wall thickness/stiffness and systemic peripheral resistance. Point of care ultrasound (POCUS) helps differentiate normal transition and that resulting from neonatal disorders. It may be increasingly utilized in guiding management.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children’s Hospital, Clayton, VIC, Australia
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
| | - Samuel Menahem
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
- Murdoch Children’s Research Institute, University of Melbourne, Parkville, VIC, Australia
- Melbourne Children’s Cardiology, Caulfield North, VIC, Australia
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2
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Rodero C, Baptiste TMG, Barrows RK, Keramati H, Sillett CP, Strocchi M, Lamata P, Niederer SA. A systematic review of cardiac in-silico clinical trials. PROGRESS IN BIOMEDICAL ENGINEERING (BRISTOL, ENGLAND) 2023; 5:032004. [PMID: 37360227 PMCID: PMC10286106 DOI: 10.1088/2516-1091/acdc71] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023]
Abstract
Computational models of the heart are now being used to assess the effectiveness and feasibility of interventions through in-silico clinical trials (ISCTs). As the adoption and acceptance of ISCTs increases, best practices for reporting the methodology and analysing the results will emerge. Focusing in the area of cardiology, we aim to evaluate the types of ISCTs, their analysis methods and their reporting standards. To this end, we conducted a systematic review of cardiac ISCTs over the period of 1 January 2012-1 January 2022, following the preferred reporting items for systematic reviews and meta-analysis (PRISMA). We considered cardiac ISCTs of human patient cohorts, and excluded studies of single individuals and those in which models were used to guide a procedure without comparing against a control group. We identified 36 publications that described cardiac ISCTs, with most of the studies coming from the US and the UK. In 75% of the studies, a validation step was performed, although the specific type of validation varied between the studies. ANSYS FLUENT was the most commonly used software in 19% of ISCTs. The specific software used was not reported in 14% of the studies. Unlike clinical trials, we found a lack of consistent reporting of patient demographics, with 28% of the studies not reporting them. Uncertainty quantification was limited, with sensitivity analysis performed in only 19% of the studies. In 97% of the ISCTs, no link was provided to provide easy access to the data or models used in the study. There was no consistent naming of study types with a wide range of studies that could potentially be considered ISCTs. There is a clear need for community agreement on minimal reporting standards on patient demographics, accepted standards for ISCT cohort quality control, uncertainty quantification, and increased model and data sharing.
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Affiliation(s)
- Cristobal Rodero
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Electro-Mechanics Research Group (CEMRG), Department of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Cardiac Modelling and Imaging Biomarkers (CMIB), Department of Biomedical Engineering and Imaging Sciences Department, King’s College London, London, United Kingdom
| | - Tiffany M G Baptiste
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Electro-Mechanics Research Group (CEMRG), Department of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Rosie K Barrows
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Electro-Mechanics Research Group (CEMRG), Department of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Hamed Keramati
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Electro-Mechanics Research Group (CEMRG), Department of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Cardiac Modelling and Imaging Biomarkers (CMIB), Department of Biomedical Engineering and Imaging Sciences Department, King’s College London, London, United Kingdom
| | - Charles P Sillett
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Electro-Mechanics Research Group (CEMRG), Department of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Marina Strocchi
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Electro-Mechanics Research Group (CEMRG), Department of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Pablo Lamata
- Cardiac Modelling and Imaging Biomarkers (CMIB), Department of Biomedical Engineering and Imaging Sciences Department, King’s College London, London, United Kingdom
| | - Steven A Niederer
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Electro-Mechanics Research Group (CEMRG), Department of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Turing Research and Innovation Cluster in Digital Twins (TRIC: DT), The Alan Turing Institute, London, United Kingdom
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Guilló-Moreno V, Gutiérrez-Martínez A, Serrano-Zueras C, Santos-González M, Romero-Berrocal A, García-Fernández J. Shortened Automatic Lung Recruitment Maneuvers in an In Vivo Model of Neonatal ARDS. Respir Care 2023; 68:628-637. [PMID: 36396332 PMCID: PMC10171351 DOI: 10.4187/respcare.10438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study was to assess the safety and efficacy of 2 protocols for automatic lung recruitment maneuvers (LRMs) using stepwise increases in PEEP in a neonatal ARDS model. These protocols were designed with lower maximum opening pressures than traditional methods and differ each one in the duration of the opening phases (short vs prolonged). We described hemodynamic changes through invasive monitoring, and we analyzed if the behavior of the variables depends on the duration of the opening phase of the LRM. METHODS We designed a prospective, experimental study with 10 Landrace x Large White pigs < 48 h old. Under general anesthesia, tracheal intubation, invasive hemodynamic monitoring with a pediatric arterial thermodilution catheter was performed. An ARDS model was developed with bronchoalveolar lavages. Two types of LRMs were performed in each piglet, with a maximum peak inspiratory pressure (PIP) of 30 cm H2O and a PEEP 15 cm H2O applied during 8.5 s in the short LRM and 17 s in the prolonged LRM. A comparative analysis by virtue of the Wilcoxon signed-rank test and a regression analysis using generalized estimation equation were performed. RESULTS We found that both LRMs were effective regarding oxygenation and respiratory mechanics. Shortening the duration of the opening phase and lowering the maximum opening pressures to PIP 30 and PEEP 15 cm H2O were above the critical opening pressure to reverse alveolar collapse in our neonatal ARDS model. Although we observed hemodynamic variations during both types of LRMs, these were well tolerated. CONCLUSIONS Our LRM protocols exceeded critical opening pressures to reverse alveolar collapse in our neonatal ARDS model. This range of pressures might involve less hemodynamic disturbance. Duration of the maximum opening pressure step is a determining factor for hemodynamic alterations.
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Affiliation(s)
- Verónica Guilló-Moreno
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain.
| | - Alberto Gutiérrez-Martínez
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Clara Serrano-Zueras
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Martín Santos-González
- Medical and Surgical Research Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Antonio Romero-Berrocal
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Javier García-Fernández
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
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Benes J, Kasperek J, Smekalova O, Tegl V, Kletecka J, Zatloukal J. Individualizing Fluid Management in Patients with Acute Respiratory Distress Syndrome and with Reduced Lung Tissue Due to Surgery—A Narrative Review. J Pers Med 2023; 13:jpm13030486. [PMID: 36983668 PMCID: PMC10056120 DOI: 10.3390/jpm13030486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
Fluids are the cornerstone of therapy in all critically ill patients. During the last decades, we have made many steps to get fluid therapy personalized and based on individual needs. In patients with lung involvement—acute respiratory distress syndrome—finding the right amount of fluids after lung surgery may be extremely important because lung tissue is one of the most vulnerable to fluid accumulation. In the current narrative review, we focus on the actual perspectives of fluid therapy with the aim of showing the possibilities to tailor the treatment to a patient’s individual needs using fluid responsiveness parameters and other therapeutic modalities.
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Affiliation(s)
- Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Correspondence:
| | - Jiri Kasperek
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Fachkrankenhaus Coswig GmbH, Zentrum für Pneumologie, Allergologie, Beatmungsmedizin, Thoraxchirurgie, 01640 Coswig, Germany
| | - Olga Smekalova
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
| | - Vaclav Tegl
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
| | - Jakub Kletecka
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
| | - Jan Zatloukal
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
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5
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Gutiérrez Martínez A, Guilló Moreno V, Santos M, Mingote Lladó Á, González-Pizarro P, García-Fernández J. Safe Inspiratory Pressures Threshold in Lung Recruitment Maneuvers: An In Vivo Neonatal ARDS Model. Respir Care 2022; 67:1300-1309. [PMID: 35853701 PMCID: PMC9994314 DOI: 10.4187/respcare.09739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The aim of this study was to define the level of peak inspiratory pressure (PIP) and mean airway pressure ([Formula: see text]) at which a pneumothorax is produced in an in vivo ARDS neonate model. In addition, we analyzed the hemodynamic response and cerebral parameters during the progressive increase of intrathoracic pressure. METHODS We designed a prospective, experimental study with 11 Landrace × Large White pigs < 48 h from their birth. With the pigs under general anesthesia, tracheal intubation, invasive hemodynamic monitoring with a pediatric arterial thermodilution catheter, intracranial pressure, cerebral oximetry through near-infrared spectroscopy, and bilateral chest tube catheterization were performed. The ARDS model was developed with bronchoalveolar lavages. The rise in inspiratory pressure was performed achieved by increasing PEEP in stepwise increments at a constant driving pressure. PEEP was increased 5 cm H2O every 2 min until a pneumothorax was observed. A descriptive analysis, a Kaplan-Meier curve, and a regression analysis by using a generalized estimation equation were performed. RESULTS A pneumothorax was observed in a median (interquartile range [IQR]) [Formula: see text] of 54 (46-56) cm H2O and median (IQR) PIP of 65 (58-73) cm H2O; asystole at median (IQR) [Formula: see text] of 49 (36-54) cm H2O and median (IQR) PIP of 60 (48-65) cm H2O. Hemodynamic changes in the median artery pressure, cardiac output, and myocardial contractility were observed above the range of [Formula: see text] of 14 cm H2O (PIP 25 and PEEP 10 cm H2O). Disturbances in intracranial pressure and cerebral oximetry through near-infrared spectroscopy appeared when deep hypotension and asystole occurred. CONCLUSIONS A progressive increase of PEEP at a constant driving pressure did not increase severe adverse events at the range of pressures that we routinely use in neonates with ARDS. Asystole, pneumothorax, and cerebral compromise appeared at high intrathoracic ranges of pressure. Hemodynamics must be strictly monitored in all patients during the performance of lung recruitment maneuvers because hemodynamic deflections emerge early, at a range of pressures commonly used in ventilated neonates with ARDS.
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Affiliation(s)
- Alberto Gutiérrez Martínez
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain.
| | - Verónica Guilló Moreno
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Martín Santos
- Medical and Surgical Research Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana. Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Álvaro Mingote Lladó
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Patricio González-Pizarro
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario La Paz, Madrid, Spain
| | - Javier García-Fernández
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
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Tsolaki V, Zakynthinos GE. Simulation to minimise patient self-inflicted lung injury: are we almost there? Br J Anaesth 2022; 129:150-153. [PMID: 35729011 PMCID: PMC9551385 DOI: 10.1016/j.bja.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 11/25/2022] Open
Abstract
Computational modelling has been used to enlighten pathophysiological issues in patients with acute respiratory distress syndrome (ARDS) using a sophisticated, integrated cardiopulmonary model. COVID-19 ARDS is a pathophysiologically distinct entity characterised by dissociation between impairment in gas exchange and respiratory system mechanics, especially in the early stages of ARDS. Weaver and colleagues used computational modelling to elucidate factors contributing to generation of patient self-inflicted lung injury, and evaluated the effects of various spontaneous respiratory efforts with different oxygenation and ventilatory support modes. Their findings indicate that mechanical forces generated in the lung parenchyma are only counterbalanced when the respiratory support mode reduces the intensity of respiratory efforts.
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Affiliation(s)
- Vasiliki Tsolaki
- Department of Intensive Care Medicine, General University of Larissa, University of Thessaly, Faculty of Medicine, Larissa, Thessaly, Greece.
| | - George E Zakynthinos
- Department of Intensive Care Medicine, General University of Larissa, University of Thessaly, Faculty of Medicine, Larissa, Thessaly, Greece
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Morakul S, Prachanpanich N, Permsakmesub P, Pinsem P, Mongkolpun W, Trongtrakul K. Prediction of Fluid Responsiveness by the Effect of the Lung Recruitment Maneuver on the Perfusion Index in Mechanically Ventilated Patients During Surgery. Front Med (Lausanne) 2022; 9:881267. [PMID: 35783653 PMCID: PMC9247540 DOI: 10.3389/fmed.2022.881267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionExcessive or inadequate fluid administration during perioperative period affects outcomes. Adjustment of volume expansion (VE) by performing fluid responsiveness (FR) test plays an important role in optimizing fluid infusion. Since changes in stroke volume (SV) during lung recruitment maneuver (LRM) can predict FR, and peripheral perfusion index (PI) is related to SV; therefore, we hypothesized that the changes in PI during LRM (ΔPILRM) could predict FR during perioperative period.MethodsPatients who were scheduled for elective non-laparoscopic surgery under general anesthesia with a mechanical ventilator and who required VE (250 mL of crystalloid solution infusion over 10 min) were included. Before VE, LRM was performed by a continuous positive airway pressure of 30 cm H2O for 30 sec; hemodynamic variables with their changes (PI, obtained by pulse oximetry; and ΔPILRM, calculated by using [(PI before LRM—PI after LRM)/PI before LRM]*100) were obtained before and after LRM. After SV (measured by esophageal doppler) and PI had returned to the baseline values, VE was infused, and the values of these variables were recorded again, before and after VE. Fluid responders (Fluid-Res) were defined by an increase in SV ≥10% after VE. Receiver operating characteristic curves of the baseline values and ΔPILRM were constructed and reported as areas under the curve (AUC) with 95% confidence intervals, to predict FR.ResultsOf 32 mechanically ventilated adult patients included, 13 (41%) were in the Fluid-Res group. Before VE and LRM, there were no differences in the mean arterial pressure (MAP), heart rate, SV, and PI between patients in the Fluid-Res and fluid non-responders (Fluid-NonRes) groups. After LRM, SV, MAP, and, PI decreased in both groups, ΔPILRM was greater in the Fluid-Res group than in Fluid-NonRes group (55.2 ± 17.8% vs. 35.3 ± 17.3%, p < 0.001, respectively). After VE, only SV and cardiac index increased in the Fluid-Res group. ΔPILRM had the highest AUC [0.81 (0.66–0.97)] to predict FR with a cut-off value of 40% (sensitivity 92.3%, specificity 73.7%).ConclusionsΔPILRM can be applied to predict FR in mechanical ventilated patients during the perioperative period.
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Hannon DM, Mistry S, Das A, Saffaran S, Laffey JG, Brook BS, Hardman JG, Bates DG. Modeling Mechanical Ventilation In Silico-Potential and Pitfalls. Semin Respir Crit Care Med 2022; 43:335-345. [PMID: 35451046 DOI: 10.1055/s-0042-1744446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Computer simulation offers a fresh approach to traditional medical research that is particularly well suited to investigating issues related to mechanical ventilation. Patients receiving mechanical ventilation are routinely monitored in great detail, providing extensive high-quality data-streams for model design and configuration. Models based on such data can incorporate very complex system dynamics that can be validated against patient responses for use as investigational surrogates. Crucially, simulation offers the potential to "look inside" the patient, allowing unimpeded access to all variables of interest. In contrast to trials on both animal models and human patients, in silico models are completely configurable and reproducible; for example, different ventilator settings can be applied to an identical virtual patient, or the same settings applied to different patients, to understand their mode of action and quantitatively compare their effectiveness. Here, we review progress on the mathematical modeling and computer simulation of human anatomy, physiology, and pathophysiology in the context of mechanical ventilation, with an emphasis on the clinical applications of this approach in various disease states. We present new results highlighting the link between model complexity and predictive capability, using data on the responses of individual patients with acute respiratory distress syndrome to changes in multiple ventilator settings. The current limitations and potential of in silico modeling are discussed from a clinical perspective, and future challenges and research directions highlighted.
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Affiliation(s)
- David M Hannon
- Anesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Ireland
| | - Sonal Mistry
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Sina Saffaran
- Faculty of Engineering Science, University College London, London, United Kingdom
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Ireland
| | - Bindi S Brook
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Jonathan G Hardman
- Anesthesia and Critical Care, Injury Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, United Kingdom
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Hemodynamic consequences of respiratory interventions in preterm infants. J Perinatol 2022; 42:1153-1160. [PMID: 35690691 PMCID: PMC9436777 DOI: 10.1038/s41372-022-01422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 12/14/2022]
Abstract
Advances in perinatal management have led to improvements in survival rates for premature infants. It is known that the transitional period soon after birth, and the subsequent weeks, remain periods of rapid circulatory changes. Preterm infants, especially those born at the limits of viability, are susceptible to hemodynamic effects of routine respiratory care practices. In particular, the immature myocardium and cardiovascular system is developmentally vulnerable. Standard of care (but essential) respiratory interventions, administered as part of neonatal care, may negatively impact heart function and/or pulmonary or systemic hemodynamics. The available evidence regarding the hemodynamic impact of these respiratory practices is not well elucidated. Enhanced diagnostic precision and therapeutic judiciousness are warranted. In this narrative, we outline (1) the vulnerability of preterm infants to hemodynamic disturbances (2) the hemodynamic effects of common respiratory practices; including positive pressure ventilation and surfactant therapy, and (3) identify tools to assess cardiopulmonary interactions and guide management.
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10
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Mistry S, Das A, Hardman JG, Bates DG, Scott TE. Pre-hospital continuous positive airway pressure after blast lung injury and hypovolaemic shock: a modelling study. Br J Anaesth 2021; 128:e151-e157. [PMID: 34863511 DOI: 10.1016/j.bja.2021.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/14/2021] [Accepted: 10/14/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In non-traumatic respiratory failure, pre-hospital application of CPAP reduces the need for intubation. Primary blast lung injury (PBLI) accompanied by haemorrhagic shock is common after mass casualty incidents. We hypothesised that pre-hospital CPAP is also beneficial after PBLI accompanied by haemorrhagic shock. METHODS We performed a computer-based simulation of the cardiopulmonary response to PBLI followed by haemorrhage, calibrated from published controlled porcine experiments exploring blast injury and haemorrhagic shock. The effect of different CPAP levels was simulated in three in silico patients who had sustained mild, moderate, or severe PBLI (10%, 25%, 50% contusion of the total lung) plus haemorrhagic shock. The primary outcome was arterial partial pressure of oxygen (Pao2) at the end of each simulation. RESULTS In mild blast lung injury, 5 cm H2O ambient-air CPAP increased Pao2 from 10.6 to 12.6 kPa. Higher CPAP did not further improve Pao2. In moderate blast lung injury, 10 cm H2O CPAP produced a larger increase in Pao2 (from 8.5 to 11.1 kPa), but 15 cm H2O CPAP produced no further benefit. In severe blast lung injury, 5 cm H2O CPAP inceased Pao2 from 4.06 to 8.39 kPa. Further increasing CPAP to 10-15 cm H2O reduced Pao2 (7.99 and 7.90 kPa, respectively) as a result of haemodynamic impairment resulting from increased intrathoracic pressures. CONCLUSIONS Our modelling study suggests that ambient air 5 cm H2O CPAP may benefit casualties suffering from blast lung injury, even with severe haemorrhagic shock. However, higher CPAP levels beyond 10 cm H2O after severe lung injury reduced oxygen delivery as a result of haemodynamic impairment.
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Affiliation(s)
- Sonal Mistry
- School of Engineering, University of Warwick, Coventry, UK
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, UK
| | - Jonathan G Hardman
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, UK.
| | - Timothy E Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK.
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Serrano Zueras C, Guilló Moreno V, Santos González M, Gómez Nieto FJ, Hedenstierna G, García Fernández J. Safety and efficacy evaluation of the automatic stepwise recruitment maneuver in the neonatal population: An in vivo interventional study. Can anesthesiologists safely perform automatic lung recruitment maneuvers in neonates? Paediatr Anaesth 2021; 31:1003-1010. [PMID: 34152683 DOI: 10.1111/pan.14243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND A new software has recently been incorporated in almost all new anesthesia machines to enable automatic lung recruitment maneuvers. To date, no studies have assessed the safety and efficacy of these automatic software programs in the neonatal population. AIMS We aimed to evaluate the safety and efficacy of the lung recruitment maneuver performed using the automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System® in a healthy and live neonatal model. METHODS Eight male newborn piglets were included in the study. The lung recruitment maneuver was performed in pressure-controlled ventilation with a constant driving pressure (15 cmH2 O) in a stepwise increasing positive end-expiratory pressure (PEEP) model. The target peak inspiratory pressure (PIP) was 30 cmH2 O and PEEP was 15 cmH2 O. The maneuver lasted for 39 seconds. The hemodynamic variables were monitored using the PICCO® system. The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen and carbon dioxide in the arterial blood, end-tidal carbon dioxide pressure, PIP, plateau pressure, PEEP, static compliance (Cstat ), and dynamic compliance (Cdyn ). Safety was evaluated by assessing the accuracy of the software, need for not interrupting the maneuver, hemodynamic stability, and absence of adverse respiratory events with the lung recruitment maneuver. Efficacy was evaluated by improvement in Cstat and Cdyn after performing the lung recruitment maneuver. RESULTS All lung recruitment maneuvers were safely performed as scheduled without any interruptions. No pneumothorax or other side effects were observed. Hemodynamic stability was maintained during the lung recruitment maneuver. We observed an improvement of 33% in Cdyn and 24% in Cstat after the maneuver. CONCLUSIONS The automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System® is safe and efficacious in a healthy neonatal model. We did not observe any adverse respiratory or hemodynamic events during the implementation of the lung recruitment maneuver in the pressure-controlled ventilation mode using a stepwise increasing PEEP (30/15 cmH2 O) approach.
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Affiliation(s)
- Clara Serrano Zueras
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | - Verónica Guilló Moreno
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | - Martín Santos González
- Medical and surgical research unit Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | - Francisco Javier Gómez Nieto
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | | | - Javier García Fernández
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
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Weaver L, Das A, Saffaran S, Yehya N, Scott TE, Chikhani M, Laffey JG, Hardman JG, Camporota L, Bates DG. High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: a computational modelling study. Ann Intensive Care 2021; 11:109. [PMID: 34255207 PMCID: PMC8276227 DOI: 10.1186/s13613-021-00904-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is on-going controversy regarding the potential for increased respiratory effort to generate patient self-inflicted lung injury (P-SILI) in spontaneously breathing patients with COVID-19 acute hypoxaemic respiratory failure. However, direct clinical evidence linking increased inspiratory effort to lung injury is scarce. We adapted a computational simulator of cardiopulmonary pathophysiology to quantify the mechanical forces that could lead to P-SILI at different levels of respiratory effort. In accordance with recent data, the simulator parameters were manually adjusted to generate a population of 10 patients that recapitulate clinical features exhibited by certain COVID-19 patients, i.e., severe hypoxaemia combined with relatively well-preserved lung mechanics, being treated with supplemental oxygen. RESULTS Simulations were conducted at tidal volumes (VT) and respiratory rates (RR) of 7 ml/kg and 14 breaths/min (representing normal respiratory effort) and at VT/RR of 7/20, 7/30, 10/14, 10/20 and 10/30 ml/kg / breaths/min. While oxygenation improved with higher respiratory efforts, significant increases in multiple indicators of the potential for lung injury were observed at all higher VT/RR combinations tested. Pleural pressure swing increased from 12.0 ± 0.3 cmH2O at baseline to 33.8 ± 0.4 cmH2O at VT/RR of 7 ml/kg/30 breaths/min and to 46.2 ± 0.5 cmH2O at 10 ml/kg/30 breaths/min. Transpulmonary pressure swing increased from 4.7 ± 0.1 cmH2O at baseline to 17.9 ± 0.3 cmH2O at VT/RR of 7 ml/kg/30 breaths/min and to 24.2 ± 0.3 cmH2O at 10 ml/kg/30 breaths/min. Total lung strain increased from 0.29 ± 0.006 at baseline to 0.65 ± 0.016 at 10 ml/kg/30 breaths/min. Mechanical power increased from 1.6 ± 0.1 J/min at baseline to 12.9 ± 0.2 J/min at VT/RR of 7 ml/kg/30 breaths/min, and to 24.9 ± 0.3 J/min at 10 ml/kg/30 breaths/min. Driving pressure increased from 7.7 ± 0.2 cmH2O at baseline to 19.6 ± 0.2 cmH2O at VT/RR of 7 ml/kg/30 breaths/min, and to 26.9 ± 0.3 cmH2O at 10 ml/kg/30 breaths/min. CONCLUSIONS Our results suggest that the forces generated by increased inspiratory effort commonly seen in COVID-19 acute hypoxaemic respiratory failure are comparable with those that have been associated with ventilator-induced lung injury during mechanical ventilation. Respiratory efforts in these patients should be carefully monitored and controlled to minimise the risk of lung injury.
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Affiliation(s)
- Liam Weaver
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Sina Saffaran
- Faculty of Engineering Science, University College London, London, WC1E 6BT, UK
| | - Nadir Yehya
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy E Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, B15 2SQ, UK
| | - Marc Chikhani
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Galway, Ireland
| | - Jonathan G Hardman
- Anaesthesia & Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
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Li L, Zhao L, Wang T, Xu N, Wang P, An Y, Li Z, Jiao L, Yang B, Hua Y. Alveolar Recruitment Maneuver Reduces Cerebral Oxygen Saturation and Cerebral Blood Flow Velocity in Patients During Carotid Endarterectomy. Med Sci Monit 2021; 27:e930617. [PMID: 34148051 PMCID: PMC8223757 DOI: 10.12659/msm.930617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This study aimed to determine the effects of alveolar recruitment maneuver (RM) on cerebral oxygen saturation and cerebral blood velocity in patients undergoing carotid endarterectomy (CEA) before clamping of the carotid artery. MATERIAL AND METHODS In this crossover exploratory study, all patients were randomized to undergo an RM (30 cmH₂O of continuous airway pressure for 30 s) and a "sham" maneuver (SM; 5 cmH₂O for 30 s), followed by an alternative intervention after a 5-min equilibration period. Near-infrared spectroscopy (NIRS) was used to monitor regional cerebral oxygen saturation (rSO₂), and transcranial Doppler ultrasonography (TCD) to evaluate blood velocity of the middle cerebral artery (V-MCA). Changes in rSO₂, V-MCA, mean arterial pressure (MAP), and heart rate (HR) in response to the 2 interventions were compared. RESULTS A total of 59 patients underwent the study procedure. RM reduced rSO₂, V-MCA, MAP, and HR, but these variables slightly changed during SM. A significant drop in rSO₂ was observed immediately after RM compared with the baseline value (68.51±4.4% vs 64.12±5.15%; P<0.001). The decrease in rSO₂ was higher during the RM than during the SM (-6±4% vs 1±2%; P<0.001). Similarly, change in V-MCA was more significant in response to RM than SM (-26±19% vs 19±16%; P<0.001). The V-MCA value changed from 39 cm/s to 29 cm/s after RM. In addition, V-MCA of the ipsilateral to the surgical side decreased more obviously than the contralateral side (-26±19% vs -20±17%; P=0.001). CONCLUSIONS An RM at 30 cmH₂O of continuous airway pressure for 30 s decreased rSO₂ and V-MCA. In addition, MAP and HR were affected.
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Affiliation(s)
- Lixia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Lei Zhao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Na Xu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ping Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yi An
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Zhongjia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Liqun Jiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Bin Yang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yang Hua
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
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Maracaja L, Khanna AK, Royster R, Maracaja D, Lane M, Jordan JE. Selective Lobe Ventilation and a Novel Platform for Pulmonary Drug Delivery. J Cardiothorac Vasc Anesth 2021; 35:3416-3422. [PMID: 34103214 PMCID: PMC8095071 DOI: 10.1053/j.jvca.2021.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/18/2021] [Accepted: 04/24/2021] [Indexed: 11/17/2022]
Abstract
The current methods of mechanical ventilation and pulmonary drug delivery do not account for the heterogeneity of acute respiratory distress syndrome or its dependence on gravity. The severe lung disease caused by severe acute respiratory distress syndrome coronavirus 2, coronavirus disease 2019, is one of the many causes of acute respiratory distress syndrome. Severe acute respiratory distress syndrome coronavirus 2 has caused more than three million deaths worldwide and has challenged all therapeutic options for mechanical ventilation. Thus, new therapies are necessary to prevent deaths and long-term complications of severe lung diseases and prolonged mechanical ventilation. The authors of the present report have developed a novel device that allows selective lobe ventilation and selective lobe recruitment and provides a new platform for pulmonary drug delivery. A major advantage of separating lobes that are mechanically heterogeneous is to allow for customization of ventilator parameters to match the needs of segments with similar compliance, a better overall ventilation perfusion relationship, and prevention of ventilator-induced lung injury of more compliant lobes. This device accounts for lung heterogeneity and is a potential new therapy for acute lung injury by allowing selective lobe mechanical ventilation using two novel modes of mechanical ventilation (differential positive end-expiratory pressure and asynchronous ventilation), and two new modalities of alveolar recruitment (selective lobe recruitment and continuous positive airway pressure of lower lobes with continuous ventilation of upper lobes). Herein the authors report their initial experience with this novel device, including a brief overview of device development; the initial in vitro, ex vivo, and in vivo testing; layout of future research; potential benefits and new therapies; and expected challenges before its uniform implementation into clinical practice.
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Affiliation(s)
- Luiz Maracaja
- Department of Anesthesiology, Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, NC.
| | - Ashish K Khanna
- Department of Anesthesiology, Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, NC
| | - Roger Royster
- Department of Anesthesiology, Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, NC
| | - Danielle Maracaja
- Department of Pathology, Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, NC
| | - Magan Lane
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, NC
| | - James Eric Jordan
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Wake Forest University, Winston-Salem, NC
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In Silico Modeling of Coronavirus Disease 2019 Acute Respiratory Distress Syndrome: Pathophysiologic Insights and Potential Management Implications. Crit Care Explor 2020; 2:e0202. [PMID: 32984832 PMCID: PMC7505291 DOI: 10.1097/cce.0000000000000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Patients with coronavirus disease 2019 acute respiratory distress syndrome appear to present with at least two distinct phenotypes: severe hypoxemia with relatively well-preserved lung compliance and lung gas volumes (type 1) and a more conventional acute respiratory distress syndrome phenotype, displaying the typical characteristics of the “baby lung” (type 2). We aimed to test plausible hypotheses regarding the pathophysiologic mechanisms underlying coronavirus disease 2019 acute respiratory distress syndrome and to evaluate the resulting implications for ventilatory management. Design: We adapted a high-fidelity computational simulator, previously validated in several studies of acute respiratory distress syndrome, to: 1) develop quantitative insights into the key pathophysiologic differences between the coronavirus disease 2019 acute respiratory distress syndrome and the conventional acute respiratory distress syndrome and 2) assess the impact of different positive end-expiratory pressure, Fio2, and tidal volume settings. Setting: Interdisciplinary Collaboration in Systems Medicine Research Network. Subjects: The simulator was calibrated to represent coronavirus disease 2019 acute respiratory distress syndrome patients with both normal and elevated body mass indices undergoing invasive mechanical ventilation. Interventions: None. Measurements and Main Results: An acute respiratory distress syndrome model implementing disruption of hypoxic pulmonary vasoconstriction and vasodilation leading to hyperperfusion of collapsed lung regions failed to replicate clinical data on type 1 coronavirus disease 2019 acute respiratory distress syndrome patients. Adding mechanisms to reflect disruption of alveolar gas-exchange due to the effects of pneumonitis and heightened vascular resistance due to the emergence of microthrombi produced levels of ventilation perfusion mismatch and hypoxemia consistent with data from type 1 coronavirus disease 2019 acute respiratory distress syndrome patients, while preserving close-to-normal lung compliance and gas volumes. Atypical responses to positive end-expiratory pressure increments between 5 and 15 cm H2O were observed for this type 1 coronavirus disease 2019 acute respiratory distress syndrome model across a range of measures: increasing positive end-expiratory pressure resulted in reduced lung compliance and no improvement in oxygenation, whereas mechanical power, driving pressure, and plateau pressure all increased. Fio2 settings based on acute respiratory distress syndrome network protocols at different positive end-expiratory pressure levels were insufficient to achieve adequate oxygenation. Incrementing tidal volumes from 5 to 10 mL/kg produced similar increases in multiple indicators of ventilator-induced lung injury in the type 1 coronavirus disease 2019 acute respiratory distress syndrome model to those seen in a conventional acute respiratory distress syndrome model. Conclusions: Our model suggests that use of standard positive end-expiratory pressure/Fio2 tables, higher positive end-expiratory pressure strategies, and higher tidal volumes may all be potentially deleterious in type 1 coronavirus disease 2019 acute respiratory distress syndrome patients, and that a highly personalized approach to treatment is advisable.
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16
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Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial. Anesthesiology 2020; 132:667-677. [PMID: 32011334 DOI: 10.1097/aln.0000000000003146] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. METHODS Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. RESULTS Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. CONCLUSIONS Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.
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17
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Management of primary blast lung injury: a comparison of airway pressure release versus low tidal volume ventilation. Intensive Care Med Exp 2020; 8:26. [PMID: 32577915 PMCID: PMC7309205 DOI: 10.1186/s40635-020-00314-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/04/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Primary blast lung injury (PBLI) presents as a syndrome of respiratory distress and haemoptysis resulting from explosive shock wave exposure and is a frequent cause of mortality and morbidity in both military conflicts and terrorist attacks. The optimal mode of mechanical ventilation for managing PBLI is not currently known, and clinical trials in humans are impossible due to the sporadic and violent nature of the disease. METHODS A high-fidelity multi-organ computational simulator of PBLI pathophysiology was configured to replicate data from 14 PBLI casualties from the conflict in Afghanistan. Adaptive and responsive ventilatory protocols implementing low tidal volume (LTV) ventilation and airway pressure release ventilation (APRV) were applied to each simulated patient for 24 h, allowing direct quantitative comparison of their effects on gas exchange, ventilatory parameters, haemodynamics, extravascular lung water and indices of ventilator-induced lung injury. RESULTS The simulated patients responded well to both ventilation strategies. Post 24-h investigation period, the APRV arm had similar PF ratios (137 mmHg vs 157 mmHg), lower sub-injury threshold levels of mechanical power (11.9 J/min vs 20.7 J/min) and lower levels of extravascular lung water (501 ml vs 600 ml) compared to conventional LTV. Driving pressure was higher in the APRV group (11.9 cmH2O vs 8.6 cmH2O), but still significantly less than levels associated with increased mortality. CONCLUSIONS Appropriate use of APRV may offer casualties with PBLI important mortality-related benefits and should be considered for management of this challenging patient group.
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18
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Navarro-Ripoll R, Aliaga Medina JL, López-Baamonde M, López Hernández A, Perdomo Linares JM. Lung recruitment maneuvers: opening the door to a hidden enemy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2020; 67:99-102. [PMID: 31955890 DOI: 10.1016/j.redar.2019.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 06/10/2023]
Abstract
Recruitment manoeuvres (RM) are common practice in anaesthesiology; however, they can have adverse effects. We present an unforeseen complication in a patient undergoing surgical resection of a bronchial tumour who presented cardiac arrest due to pulseless electrical activity immediately after RMs. A transoesophageal echocardiogram performed after return of spontaneous circulation showed a patent foramen ovale (PFO), left ventricular dysfunction with segmental changes, and air in the left ventricle, leading to suspicion of paradoxical air embolism. The contractility changes normalised spontaneously, and postoperative evolution was uneventful. RMs cause changes in intracavitary pressures that can lead to opening of a PFO (present in up to 30% of the population) and reversal of the physiological left-right shunt. Transoesophageal echocardiography facilitated immediate diagnosis and follow-up.
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Affiliation(s)
- R Navarro-Ripoll
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España.
| | - J L Aliaga Medina
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - M López-Baamonde
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - A López Hernández
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
| | - J M Perdomo Linares
- Servicio de Anestesiología y Reanimación, Hospital Clínic de Barcelona, Barcelona, España
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Laviola M, Niklas C, Das A, Bates DG, Hardman JG. Effect of oxygen fraction on airway rescue: a computational modelling study. Br J Anaesth 2020; 125:e69-e74. [PMID: 32008701 DOI: 10.1016/j.bja.2020.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/14/2019] [Accepted: 01/04/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND During induction of general anaesthesia, patients frequently experience apnoea, which can lead to dangerous hypoxaemia. An obstructed upper airway can impede attempts to provide ventilation. Although unrelieved apnoea is rare, it continues to cause deaths. Clinical investigation of management strategies for such scenarios is effectively impossible because of ethical and practical considerations. METHODS A population-representative cohort of 100 virtual (in silico) subjects was configured using a high-fidelity computational model of the pulmonary and cardiovascular systems. Each subject breathed 100% oxygen for 3 min and then became apnoeic, with an obstructed upper airway, during induction of general anaesthesia. Apnoea continued throughout the protocol. When arterial oxygen saturation (Sao2) reached 20%, 40%, or 60%, airway obstruction was relieved. We examined the effect of varying supraglottic oxygen fraction (Fo2) on the degree of passive re-oxygenation occurring without tidal ventilation. RESULTS Relief of airway obstruction during apnoea produced a single, passive inhalation (caused by intrathoracic hypobaric pressure) in all cases. The degree of re-oxygenation after airway opening was markedly influenced by the supraglottic Fo2, with a supraglottic Fo2 of 100% providing significant and sustained re-oxygenation (post-rescue Pao2 42.3 [4.4] kPa, when the airway rescue occurred after desaturation to Sao2 60%). CONCLUSIONS Supraglottic oxygen supplementation before relieving upper airway obstruction improves the effectiveness of simulated airway rescue. Management strategies should be implemented to assure a substantially increased pharyngeal Fo2 during difficult airway management.
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Affiliation(s)
- Marianna Laviola
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Christian Niklas
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Anup Das
- School of Engineering, University of Warwick, Warwick, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Warwick, UK
| | - Jonathan G Hardman
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
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Collier TE, Kataria V, Modrykamien A. Inhaled epoprostenol utilization pattern after implementation of an administration policy. Proc (Bayl Univ Med Cent) 2019; 33:10-14. [PMID: 32063756 DOI: 10.1080/08998280.2019.1668668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/31/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022] Open
Abstract
Epoprostenol, a pulmonary vasodilator, is used to reduce pulmonary artery pressure. Its inhaled administration results in ventilation and perfusion matching with oxygenation improvement. Epoprostenol is used as treatment for various conditions, particularly acute respiratory distress syndrome (ARDS) and pulmonary arterial hypertension. In 2018, Baylor University Medical Center implemented a policy for inhaled epoprostenol utilization aimed at standardizing clinical practice. This study analyzed epoprostenol utilization patterns in patients with ARDS after implementation of this administration policy. Drug responders and nonresponders were compared for clinical outcomes and physiologic changes before and after use, and policy compliance was evaluated. Of 79 eligible patients, 30 fulfilled inclusion criteria: 14 (47%) had ARDS and 16 (53%) had non-ARDS. In all patients with ARDS, epoprostenol was a second rescue agent after neuromuscular blockade, prone positioning, corticosteroids, and extracorporeal membrane oxygenation. Epoprostenol was associated with statistically significant improvement of oxygenation before and after utilization in patients with ARDS (ratio of arterial oxygen partial pressure to fractional inspired oxygen 70 vs 140, respectively; P = 0.04). Overall, 10 (71%) ARDS patients were epoprostenol responders; 9 (56%) were deemed responders among subjects with non-ARDS. Comparison of outcomes between responders and nonresponders showed no statistically significant variations. Policy compliance was obtained in 24 (80%) patients.
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Affiliation(s)
- Tia E Collier
- Department of Pharmacy, Baylor University Medical CenterDallasTexas
| | - Vivek Kataria
- Department of Pharmacy, Baylor University Medical CenterDallasTexas
| | - Ariel Modrykamien
- Medical Intensive Care Unit, Department of Critical Care, Baylor University Medical CenterDallasTexas.,Pulmonary and Critical Care Specialists of DallasDallasTexas
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Das A, Camporota L, Hardman JG, Bates DG. What links ventilator driving pressure with survival in the acute respiratory distress syndrome? A computational study. Respir Res 2019; 20:29. [PMID: 30744629 PMCID: PMC6371576 DOI: 10.1186/s12931-019-0990-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/23/2019] [Indexed: 01/07/2023] Open
Abstract
Background Recent analyses of patient data in acute respiratory distress syndrome (ARDS) showed that a lower ventilator driving pressure was associated with reduced relative risk of mortality. These findings await full validation in prospective clinical trials. Methods To investigate the association between driving pressures and ventilator induced lung injury (VILI), we calibrated a high fidelity computational simulator of cardiopulmonary pathophysiology against a clinical dataset, capturing the responses to changes in mechanical ventilation of 25 adult ARDS patients. Each of these in silico patients was subjected to the same range of values of driving pressure and positive end expiratory pressure (PEEP) used in the previous analyses of clinical trial data. The resulting effects on several physiological variables and proposed indices of VILI were computed and compared with data relating ventilator settings with relative risk of death. Results Three VILI indices: dynamic strain, mechanical power and tidal recruitment, showed a strong correlation with the reported relative risk of death across all ranges of driving pressures and PEEP. Other variables, such as alveolar pressure, oxygen delivery and lung compliance, correlated poorly with the data on relative risk of death. Conclusions Our results suggest a credible mechanistic explanation for the proposed association between driving pressure and relative risk of death. While dynamic strain and tidal recruitment are difficult to measure routinely in patients, the easily computed VILI indicator known as mechanical power also showed a strong correlation with mortality risk, highlighting its potential usefulness in designing more protective ventilation strategies for this patient group. Electronic supplementary material The online version of this article (10.1186/s12931-019-0990-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anup Das
- School of Engineering, University of Warwick, Coventry, UK
| | - Luigi Camporota
- Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust and Division of Asthma Allergy and Lung Biology, King's College London, London, UK
| | - Jonathan G Hardman
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust and School of Medicine, University of Nottingham, Nottingham, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, UK.
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Haque M, Das A, Scott TE, Bates D, Hardman JG. Primary blast lung injury simulator: a new computerised model. J ROY ARMY MED CORPS 2018; 165:45-50. [PMID: 30077974 DOI: 10.1136/jramc-2018-000989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/03/2022]
Abstract
Mathematical modelling and computational simulation are becoming increasingly important tools in many fields of medicine where in vivo studies are expensive, difficult or impractical. This is particularly the case with primary blast lung injury, and in this paper, we give a brief overview of mathematical models before describing how we generated our blast lung injury simulator and describe some early results of its use.
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Affiliation(s)
- Mainul Haque
- Anaesthesia and Critical Care, School of Medicine, University of Nottingham, Nottingham
| | - A Das
- School of Engineering, University of Warwick, Warwick, UK
| | - T E Scott
- Academic Department of Military Anaesthesia and Critical Care, Ministry of Defence, Birmingham, UK
| | - D Bates
- School of Engineering, University of Warwick, Warwick, UK
| | - J G Hardman
- Anaesthesia and Critical Care, School of Medicine, University of Nottingham, Nottingham
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Saffaran S, Wang W, Das A, Schmitt W, Becker‐Pelster E, Hardman JG, Weimann G, Bates DG. Inhaled sGC Modulator Can Lower PH in Patients With COPD Without Deteriorating Oxygenation. CPT Pharmacometrics Syst Pharmacol 2018; 7:491-498. [PMID: 29962065 PMCID: PMC6118299 DOI: 10.1002/psp4.12308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/25/2018] [Indexed: 01/12/2023] Open
Abstract
This study uses a highly fidelity computational simulator of pulmonary physiology to evaluate the impact of a soluble guanylate cyclase (sGC) modulator on gas exchange in patients with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension (PH) as a complication. Three virtual patients with COPD were configured in the simulator based on clinical data. In agreement with previous clinical studies, modeling systemic application of an sGC modulator results in reduced partial pressure of oxygen (PaO2 ) and increased partial pressure of carbon dioxide (PaCO2 ) in arterial blood, if a drug-induced reduction of pulmonary vascular resistance (PVR) equal to that observed experimentally is assumed. In contrast, for administration via dry powder inhalation (DPI), our simulations suggest that the treatment results in no deterioration in oxygenation. For patients under exercise, DPI administration lowers PH, whereas oxygenation is improved with respect to baseline values.
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Affiliation(s)
- Sina Saffaran
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
| | - Wenfei Wang
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
| | - Anup Das
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
| | | | | | | | | | - Declan G. Bates
- School of EngineeringUniversity of WarwickCoventryWest MidlandsUK
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Laviola M, Das A, Chikhani M, Bates DG, Hardman JG. Investigating the effect of cardiac oscillations and deadspace gas mixing during apnea using computer simulation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:337-340. [PMID: 29059879 DOI: 10.1109/embc.2017.8036831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Gaseous mixing in the anatomical deadspace with stimulation of respiratory ventilation through cardiogenic oscillations is an important physiological mechanism at the onset of apnea, which has been credited with various beneficial effects, e.g. reduction of hypercapnia during the use of low flow ventilation techniques. In this paper, a novel method is proposed to investigate the effect of these mechanisms in silico. An existing computational model of cardio-pulmonary physiology is extended to include the apneic state, gas mixing within the anatomical deadspace, insufflation into the trachea and cardiogenic oscillations. The new model is validated against data published in an experimental animal (dog) study that reported an increase in arterial partial pressure of carbon dioxide (PaCO2) during apnea. Computational simulations confirm that the model outputs accurately reproduce the available experimental data. This new model can be used to investigate the physiological mechanisms underlying clearance of carbon dioxide during apnea, and hence to develop more effective ventilation strategies for apneic patients.
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