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Itagaki T, Akimoto Y, Takashima T, Oto J. Ultrasonographic Assessment of the Diaphragm. Diagnostics (Basel) 2024; 14:1481. [PMID: 39061618 PMCID: PMC11276413 DOI: 10.3390/diagnostics14141481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Mechanical ventilation injures not only the lungs but also the diaphragm, resulting in dysfunction associated with poor outcomes. Diaphragm ultrasonography is a noninvasive, cost-effective, and reproducible diagnostic method used to monitor the condition and function of the diaphragm. With advances in ultrasound technology and the expansion of its clinical applications, diaphragm ultrasonography has become increasingly important as a tool to visualize and quantify diaphragmatic morphology and function across multiple medical specialties, including pulmonology, critical care, and rehabilitation medicine. This comprehensive review aims to provide an in-depth analysis of the role and limitations of ultrasonography in assessing the diaphragm, especially among critically ill patients. Furthermore, we discuss a recently published expert consensus and provide a perspective for the future.
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Affiliation(s)
- Taiga Itagaki
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
| | - Yusuke Akimoto
- Emergency Department, Tokushima Prefectural Miyoshi Hospital, 815-2 Ikedacho Shima, Miyoshi 778-0005, Japan;
| | - Takuya Takashima
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate Hospital of Biomedical Sciences, 3-18-15 Kuramoto, Tokushima 770-8503, Japan; (T.T.); (J.O.)
| | - Jun Oto
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate Hospital of Biomedical Sciences, 3-18-15 Kuramoto, Tokushima 770-8503, Japan; (T.T.); (J.O.)
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Junhasavasdikul D, Kasemchaiyanun A, Tassaneyasin T, Petnak T, Bezerra FS, Mellado-Artigas R, Chen L, Sutherasan Y, Theerawit P, Brochard L. Expiratory flow limitation during mechanical ventilation: real-time detection and physiological subtypes. Crit Care 2024; 28:171. [PMID: 38773629 PMCID: PMC11106966 DOI: 10.1186/s13054-024-04953-9] [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: 03/04/2024] [Accepted: 05/13/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Tidal expiratory flow limitation (EFLT) complicates the delivery of mechanical ventilation but is only diagnosed by performing specific manoeuvres. Instantaneous analysis of expiratory resistance (Rex) can be an alternative way to detect EFLT without changing ventilatory settings. This study aimed to determine the agreement of EFLT detection by Rex analysis and the PEEP reduction manoeuvre using contingency table and agreement coefficient. The patterns of Rex were explored. METHODS Medical patients ≥ 15-year-old receiving mechanical ventilation underwent a PEEP reduction manoeuvre from 5 cmH2O to zero for EFLT detection. Waveforms were recorded and analyzed off-line. The instantaneous Rex was calculated and was plotted against the volume axis, overlapped by the flow-volume loop for inspection. Lung mechanics, characteristics of the patients, and clinical outcomes were collected. The result of the Rex method was validated using a separate independent dataset. RESULTS 339 patients initially enrolled and underwent a PEEP reduction. The prevalence of EFLT was 16.5%. EFLT patients had higher adjusted hospital mortality than non-EFLT cases. The Rex method showed 20% prevalence of EFLT and the result was 90.3% in agreement with PEEP reduction manoeuvre. In the validation dataset, the Rex method had resulted in 91.4% agreement. Three patterns of Rex were identified: no EFLT, early EFLT, associated with airway disease, and late EFLT, associated with non-airway diseases, including obesity. In early EFLT, external PEEP was less likely to eliminate EFLT. CONCLUSIONS The Rex method shows an excellent agreement with the PEEP reduction manoeuvre and allows real-time detection of EFLT. Two subtypes of EFLT are identified by Rex analysis. TRIAL REGISTRATION Clinical trial registered with www.thaiclinicaltrials.org (TCTR20190318003). The registration date was on 18 March 2019, and the first subject enrollment was performed on 26 March 2019.
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Affiliation(s)
- Detajin Junhasavasdikul
- Division of Pulmonary and Pulmonary Critical Care, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Rd. Rajthevi, Bangkok, Thailand.
| | - Akarawut Kasemchaiyanun
- Division of Pulmonary and Pulmonary Critical Care, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Rd. Rajthevi, Bangkok, Thailand
- Division of Critical Care, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tanakorn Tassaneyasin
- Division of Pulmonary and Pulmonary Critical Care, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Rd. Rajthevi, Bangkok, Thailand
| | - Tananchai Petnak
- Division of Pulmonary and Pulmonary Critical Care, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Rd. Rajthevi, Bangkok, Thailand
| | - Frank Silva Bezerra
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Laboratory of Experimental Pathophysiology, Department of Biological Sciences and Center of Research in Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Ricard Mellado-Artigas
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Surgical Intensive Care Unit, Department of Anesthesia, Hospital Clinic, Barcelona, Spain
| | - Lu Chen
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Yuda Sutherasan
- Division of Pulmonary and Pulmonary Critical Care, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama 6 Rd. Rajthevi, Bangkok, Thailand
| | - Pongdhep Theerawit
- Division of Critical Care, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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Fogagnolo A, Spadaro S, Karbing DS, Scaramuzzo G, Mari M, Guirrini S, Ragazzi R, Al-Husinat L, Greco P, Rees SE, Volta CA. Effect of expiratory flow limitation on ventilation/perfusion mismatch and perioperative lung function during pneumoperitoneum and Trendelenburg position. Minerva Anestesiol 2023; 89:733-743. [PMID: 36748283 DOI: 10.23736/s0375-9393.22.17006-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic surgery and Trendelenburg position may affect the respiratory function and alter the gas exchange. Further the reduction of the lung volumes may contribute to the development of expiratory flow limitation (EFL). The latter is associated with an increased risk of postoperative pulmonary complications. Our aim was to investigate the incidence of EFL and to evaluate its effect on pulmonary function and intraoperative V/Q mismatch. METHODS This is a prospective study on patients undergoing elective laparoscopic gynecological surgery. We evaluated respiratory mechanics, V/Q mismatch and presence of EFL after anesthesia induction, during pneumoperitoneum and Trendelenburg position and at the end of surgery. Intraoperative gas exchange and hemodynamic were also recorded. Clinical data were collected until seven days after surgery to evaluate the onset of pulmonary postoperative complications (PPCs). RESULTS Among the 66 patients enrolled, 25/66 (38%) exhibited EFL during surgery, of whom 10/66 (15%) after anesthesia induction, and the remaining 15 patients after pneumoperitoneum and Trendelenburg position. Median PEEP able to reverse flow limitation was 7 [7-10] cmH2O after anesthesia induction and 9 [8-15] cmH2O after pneumoperitoneum and Trendelenburg position. Patients with EFL had significantly higher shunt (17 [2-25] vs. 9 [1-19]; P=0.05), low V̇/Q̇ (27 [20-70] vs. 15 [10-22]; P=0.05) and high V̇/Q̇ (10 [7-14] vs. 6 [4-7]; P=0.024). At the end of surgery, only high V/Q was significantly higher in EFL patients. Further, they exhibited higher incidence of postoperative pulmonary complication (48% (12/25) vs. 15% (6/41), P=0.005), hypoxemia and hypercapnia (80% [20/25] vs. 32% [13/41]; P<0.001). CONCLUSIONS Expiratory flow limitation is a common phenomenon during gynecological laparoscopic surgery associated with worsen gas exchange, increased V/Q mismatch and altered lung mechanics. Our study showed that patients experiencing EFL during surgery showed a higher risk for PPCs.
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Affiliation(s)
| | - Savino Spadaro
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy -
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Dan S Karbing
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Gaetano Scaramuzzo
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Matilde Mari
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Silvia Guirrini
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Riccardo Ragazzi
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Lou'i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Pantaleo Greco
- Section of Obstetrics and Gynecology, Department of Surgical Sciences, AOU Ferrara, Ferrara, Italy
| | - Stephen E Rees
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Carlo A Volta
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
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Sklar MC, Grieco DL. Personalized positive end-expiratory pressure during general anesthesia: go with the flow. Minerva Anestesiol 2023; 89:727-729. [PMID: 36752610 DOI: 10.23736/s0375-9393.23.17193-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network/Sinai Health System, Toronto, ON, Canada
| | - Domenico L Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy
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Grieco DL, Russo A, Anzellotti GM, Romanò B, Bongiovanni F, Dell'Anna AM, Mauti L, Cascarano L, Gallotta V, Rosà T, Varone F, Menga LS, Polidori L, D'Indinosante M, Cappuccio S, Galletta C, Tortorella L, Costantini B, Gueli Alletti S, Sollazzi L, Scambia G, Antonelli M. Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial. J Clin Anesth 2023; 85:111037. [PMID: 36495775 DOI: 10.1016/j.jclinane.2022.111037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS Parallel-group, randomized trial. SETTING Operating room of a university hospital, Italy. PATIENTS Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Mauti
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Cascarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorenzo Polidori
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco D'Indinosante
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Serena Cappuccio
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Galletta
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Airway dysfunction and IgA immunity in COVID-unrelated and COVID-related ARDS. Rev Mal Respir 2023. [DOI: 10.1016/j.rmr.2022.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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SCARAMUZZO G, OTTAVIANI I, VOLTA CA, SPADARO S. Mechanical ventilation and COPD: from pathophysiology to ventilatory management. Minerva Med 2022; 113:460-470. [DOI: 10.23736/s0026-4806.22.07974-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Vemuri SV, Rolfsen ML, Sykes AV, Takiar PG, Leonard AJ, Malhotra A, Spragg RG, Macedo E, Hepokoski ML. Association Between Acute Kidney Injury During Invasive Mechanical Ventilation and ICU Outcomes and Respiratory System Mechanics. Crit Care Explor 2022; 4:e0720. [PMID: 35782295 PMCID: PMC9246080 DOI: 10.1097/cce.0000000000000720] [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] [Indexed: 11/25/2022] Open
Abstract
Compare ICU outcomes and respiratory system mechanics in patients with and without acute kidney injury during invasive mechanical ventilation.
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9
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Itagaki T. Diaphragm-protective mechanical ventilation in acute respiratory failure. THE JOURNAL OF MEDICAL INVESTIGATION 2022; 69:165-172. [DOI: 10.2152/jmi.69.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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10
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Spadaro S, Dalla Corte F, Scaramuzzo G, Grasso S, Cinnella G, Rosta V, Chiavieri V, Alvisi V, Di Mussi R, Volta CA, Bellini T, Trentini A. Circulating Skeletal Troponin During Weaning From Mechanical Ventilation and Their Association to Diaphragmatic Function: A Pilot Study. Front Med (Lausanne) 2021; 8:770408. [PMID: 35004739 PMCID: PMC8727747 DOI: 10.3389/fmed.2021.770408] [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: 09/03/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Patients with acute respiratory failure (ARF) may need mechanical ventilation (MV), which can lead to diaphragmatic dysfunction and muscle wasting, thus making difficult the weaning from the ventilator. Currently, there are no biomarkers specific for respiratory muscle and their function can only be assessed trough ultrasound or other invasive methods. Previously, the fast and slow isoform of the skeletal troponin I (fsTnI and ssTnI, respectively) have shown to be specific markers of muscle damage in healthy volunteers. We aimed therefore at describing the trend of skeletal troponin in mixed population of ICU patients undergoing weaning from mechanical ventilation and compared the value of fsTnI and ssTnI with diaphragmatic ultrasound derived parameters. Methods: In this prospective observational study we enrolled consecutive patients recovering from acute hypoxemic respiratory failure (AHRF) within 24 h from the start of weaning. Every day an arterial blood sample was collected to measure fsTnI, ssTnI, and global markers of muscle damage, such as ALT, AST, and CPK. Moreover, thickening fraction (TF) and diaphragmatic displacement (DE) were assessed by diaphragmatic ultrasound. The trend of fsTnI and ssTnI was evaluated during the first 3 days of weaning. Results: We enrolled 62 consecutive patients in the study, with a mean age of 67 ± 13 years and 43 of them (69%) were male. We did not find significant variations in the ssTnI trend (p = 0.623), but fsTnI significantly decreased over time by 30% from Day 1 to Day 2 and by 20% from Day 2 to Day 3 (p < 0.05). There was a significant interaction effect between baseline ssTnI and DE [F(2) = 4.396, p = 0.015], with high basal levels of ssTnI being associated to a higher decrease in DE. On the contrary, the high basal levels of fsTnI at day 1 were characterized by significant higher DE at each time point. Conclusions: Skeletal muscle proteins have a distinctive pattern of variation during weaning from mechanical ventilation. At day 1, a high basal value of ssTnI were associated to a higher decrease over time of diaphragmatic function while high values of fsTnI were associated to a higher displacement at each time point.
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Affiliation(s)
- Savino Spadaro
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
- *Correspondence: Savino Spadaro
| | - Francesca Dalla Corte
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Gaetano Scaramuzzo
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Gilda Cinnella
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Valentina Rosta
- Section of Medical Biochemistry, Molecular Biology and Genetics, Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Valentina Chiavieri
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Valentina Alvisi
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Rosa Di Mussi
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Carlo Alberto Volta
- Department of Translational Medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Tiziana Bellini
- Section of Medical Biochemistry, Molecular Biology and Genetics, Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Alessandro Trentini
- Section of Medical Biochemistry, Molecular Biology and Genetics, Department of Biomedical and Specialist Surgical Sciences, University of Ferrara, Ferrara, Italy
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Grieco DL, Jaber S. Pre-Emptive Noninvasive Ventilation to Facilitate Weaning from Mechanical Ventilation in Obese Patients at High Risk of Re-Intubation. Am J Respir Crit Care Med 2021; 205:382-383. [PMID: 34910895 DOI: 10.1164/rccm.202111-2649ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Domenico Luca Grieco
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 18654, Anesthesiology and Intensive Care Medicine, Roma, Italy.,Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, 60234, Anesthesia, Emergency and Intensive care medicine, Roma, Italy;
| | - Samir Jaber
- University hospital. CHU de MONTPELLIER HOPITAL SAINT ELOI, Intensive Care Unit and transplantation-Departement of Anesthesiology DAR B, Montpellier Cedex 5, France
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Roesthuis LH, van der Hoeven JG, Guérin C, Doorduin J, Heunks LMA. Three bedside techniques to quantify dynamic pulmonary hyperinflation in mechanically ventilated patients with chronic obstructive pulmonary disease. Ann Intensive Care 2021; 11:167. [PMID: 34862945 PMCID: PMC8643378 DOI: 10.1186/s13613-021-00948-9] [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: 07/30/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dynamic pulmonary hyperinflation may develop in patients with chronic obstructive pulmonary disease (COPD) due to dynamic airway collapse and/or increased airway resistance, increasing the risk of volutrauma and hemodynamic compromise. The reference standard to quantify dynamic pulmonary hyperinflation is the measurement of the volume at end-inspiration (Vei). As this is cumbersome, the aim of this study was to evaluate if methods that are easier to perform at the bedside can accurately reflect Vei. METHODS Vei was assessed in COPD patients under controlled protective mechanical ventilation (7 ± mL/kg) on zero end-expiratory pressure, using three techniques in a fixed order: (1) reference standard (Veireference): passive exhalation to atmosphere from end-inspiration in a calibrated glass burette; (2) ventilator maneuver (Veimaneuver): measuring the expired volume during a passive exhalation of 45s using the ventilator flow sensor; (3) formula (Veiformula): (Vt × Pplateau)/(Pplateau - PEEPi), with Vt tidal volume, Pplateau is plateau pressure after an end-inspiratory occlusion, and PEEPi is intrinsic positive end-expiratory pressure after an end-expiratory occlusion. A convenience sample of 17 patients was recruited. RESULTS Veireference was 1030 ± 380 mL and had no significant correlation with Pplateau (r2 = 0.06; P = 0.3710) or PEEPi (r2 = 0.11; P = 0.2156), and was inversely related with Pdrive (calculated as Pplateau -PEEPi) (r2 = 0.49; P = 0.0024). A low bias but rather wide limits of agreement and fairly good correlations were found when comparing Veimaneuver and Veiformula to Veireference. Vei remained stable during the study period (low bias 15 mL with high agreement (95% limits of agreement from - 100 to 130 mL) and high correlation (r2 = 0.98; P < 0.0001) between both measurements of Veireference). CONCLUSIONS In patients with COPD, airway pressures are not a valid representation of Vei. The three techniques to quantify Vei show low bias, but wide limits of agreement.
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Affiliation(s)
- L H Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - J G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - C Guérin
- Service de Medicine Intensive Réanimation, Hôpital Edouard Herriot, Lyon, France
| | - J Doorduin
- Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
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13
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Can Abdominal Muscle Ultrasonography During Spontaneous Breathing and Cough Predict Reintubation in Mechanically Ventilated Patients? Chest 2021; 160:1163-1164. [PMID: 34625161 DOI: 10.1016/j.chest.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022] Open
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14
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Pellegrini M, Larina A, Mourtos E, Frithiof R, Lipcsey M, Hultström M, Segelsjö M, Hansen T, Perchiazzi G. A quantitative analysis of extension and distribution of lung injury in COVID-19: a prospective study based on chest computed tomography. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:276. [PMID: 34348797 PMCID: PMC8334337 DOI: 10.1186/s13054-021-03685-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 07/09/2021] [Indexed: 01/08/2023]
Abstract
Background Typical features differentiate COVID-19-associated lung injury from acute respiratory distress syndrome. The clinical role of chest computed tomography (CT) in describing the progression of COVID-19-associated lung injury remains to be clarified. We investigated in COVID-19 patients the regional distribution of lung injury and the influence of clinical and laboratory features on its progression. Methods This was a prospective study. For each CT, twenty images, evenly spaced along the cranio-caudal axis, were selected. For regional analysis, each CT image was divided into three concentric subpleural regions of interest and four quadrants. Hyper-, normally, hypo- and non-inflated lung compartments were defined. Nonparametric tests were used for hypothesis testing (α = 0.05). Spearman correlation test was used to detect correlations between lung compartments and clinical features. Results Twenty-three out of 111 recruited patients were eligible for further analysis. Five hundred-sixty CT images were analyzed. Lung injury, composed by hypo- and non-inflated areas, was significantly more represented in subpleural than in core lung regions. A secondary, centripetal spread of lung injury was associated with exposure to mechanical ventilation (p < 0.04), longer spontaneous breathing (more than 14 days, p < 0.05) and non-protective tidal volume (p < 0.04). Positive fluid balance (p < 0.01), high plasma D-dimers (p < 0.01) and ferritin (p < 0.04) were associated with increased lung injury. Conclusions In a cohort of COVID-19 patients with severe respiratory failure, a predominant subpleural distribution of lung injury is observed. Prolonged spontaneous breathing and high tidal volumes, both causes of patient self-induced lung injury, are associated to an extensive involvement of more central regions. Positive fluid balance, inflammation and thrombosis are associated with lung injury. Trial registration Study registered a priori the 20th of March, 2020. Clinical Trials ID NCT04316884. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03685-4.
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Affiliation(s)
- Mariangela Pellegrini
- Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden.,Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Aleksandra Larina
- Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden
| | - Evangelos Mourtos
- Radiology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Robert Frithiof
- Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden
| | - Miklos Lipcsey
- Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden.,Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Michael Hultström
- Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden.,Integrative Physiology, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Monica Segelsjö
- Radiology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Tomas Hansen
- Radiology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gaetano Perchiazzi
- Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden. .,Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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15
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Ball L, Volta CA, Saglietti F, Spadaro S, Di Lullo A, De Simone G, Guarnieri M, Della Corte F, Serpa Neto A, Gama de Abreu M, Schultz MJ, Zangrillo A, Pelosi P, Bignami E. Associations Between Expiratory Flow Limitation and Postoperative Pulmonary Complications in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:815-824. [PMID: 34404594 DOI: 10.1053/j.jvca.2021.07.035] [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: 04/02/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine whether driving pressure and expiratory flow limitation are associated with the development of postoperative pulmonary complications (PPCs) in cardiac surgery patients. DESIGN Prospective cohort study. SETTING University Hospital San Raffaele, Milan, Italy. PARTICIPANTS Patients undergoing elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the occurrence of a predefined composite of PPCs. The authors determined the association among PPCs and intraoperative ventilation parameters, mechanical power and energy load, and occurrence of expiratory flow limitation (EFL) assessed with the positive end-expiratory pressure test. Two hundred patients were enrolled, of whom 78 (39%) developed one or more PPCs. Patients with PPCs, compared with those without PPCs, had similar driving pressure (mean difference [MD] -0.1 [95% confidence interval (CI), -1.0 to 0.7] cmH2O, p = 0.561), mechanical power (MD 0.5 [95% CI, -0.3 to 1.1] J/m, p = 0.364), and total energy load (MD 95 [95% CI, -78 to 263] J, p = 0.293), but they had a higher incidence of EFL (51% v 38%, p = 0.005). Only EFL was associated independently with the development of PPCs (odds ratio 2.46 [95% CI, 1.28-4.80], p = 0.007). CONCLUSIONS PPCs occurred frequently in this patient population undergoing cardiac surgery. PPCs were associated independently with the presence of EFL but not with driving pressure, total energy load, or mechanical power.
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Affiliation(s)
- Lorenzo Ball
- Anesthesia and Intensive Care Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Carlo Alberto Volta
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Francesco Saglietti
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Antonio Di Lullo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio De Simone
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marcello Guarnieri
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Francesca Della Corte
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
| | | | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
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16
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Fogagnolo A, Montanaro F, Al-Husinat L, Turrini C, Rauseo M, Mirabella L, Ragazzi R, Ottaviani I, Cinnella G, Volta CA, Spadaro S. Management of Intraoperative Mechanical Ventilation to Prevent Postoperative Complications after General Anesthesia: A Narrative Review. J Clin Med 2021; 10:jcm10122656. [PMID: 34208699 PMCID: PMC8234365 DOI: 10.3390/jcm10122656] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 01/02/2023] Open
Abstract
Mechanical ventilation (MV) is still necessary in many surgical procedures; nonetheless, intraoperative MV is not free from harmful effects. Protective ventilation strategies, which include the combination of low tidal volume and adequate positive end expiratory pressure (PEEP) levels, are usually adopted to minimize the ventilation-induced lung injury and to avoid post-operative pulmonary complications (PPCs). Even so, volutrauma and atelectrauma may co-exist at different levels of tidal volume and PEEP, and therefore, the physiological response to the MV settings should be monitored in each patient. A personalized perioperative approach is gaining relevance in the field of intraoperative MV; in particular, many efforts have been made to individualize PEEP, giving more emphasis on physiological and functional status to the whole body. In this review, we summarized the latest findings about the optimization of PEEP and intraoperative MV in different surgical settings. Starting from a physiological point of view, we described how to approach the individualized MV and monitor the effects of MV on lung function.
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Affiliation(s)
- Alberto Fogagnolo
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
- Correspondence:
| | - Federica Montanaro
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Cecilia Turrini
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Michela Rauseo
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Lucia Mirabella
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Riccardo Ragazzi
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Irene Ottaviani
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Carlo Alberto Volta
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Savino Spadaro
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
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17
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Pinède A, Cour M, Degivry F, Louis B, Argaud L, Guérin C. Bench Assessment of Expiratory Valve Resistance of Current ICU Ventilators in Dynamic Conditions. Respir Care 2021; 66:610-618. [PMID: 33144385 PMCID: PMC9993995 DOI: 10.4187/respcare.08098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We hypothesized that the lack of benefit of setting a low versus a high PEEP in patients with ARDS may be due in part to differences in the dynamic behavior of the expiratory valve in ventilators. We tested this hypothesis by conducting a bench comparison of the dynamic behavior of expiratory valves on ICU ventilators currently in use. METHODS We attached 7 ICU ventilators (C5, C6, Carescape, PB980, ServoU, V500, and V680) to the ASL 5000 lung model (passive condition with compliance 20 mL/cm H2O and resistance 5 cm H2O/L/s) and set in volume controlled mode (tidal volume 0.8 L, breathing frequency 10 breaths/min). Flow and pressure were measured just before the exhalation valve. At PEEP of 5, 10, and 15 cm H2O, the median instantaneous expiratory resistance, the time to valve opening, and the pressure time products above or below the values of PEEP (expressed in cm H2O × s) were determined. RESULTS Median instantaneous expiratory resistance values differed between the ventilators and PEEP settings with a significant interaction: at PEEP 5 cm H2O, the median (interquartile range) expiratory resistance values were 3.9 (3.5-4.7), 3.0 (3.0-3.1), 20.9 (15.8-24.9), 27.4 (26.5-43.2), 13.8 (13.6-13.9), 4.4 (4.0-4.6), and 34.3 (33.7-33.8) cm H2O/L/s, for the C5, C6, Carescape, PB980, ServoU, V500, and V680, respectively. For all the PEEP settings, the corresponding times to valve opening were 0.080 (0.077-0.082), 0.082 (0.080-0.085), 0.110 (0.105-0.110), 0.100 (0.085-1.05), 0.072 (0.062-0.072), 0.145 (0.115-0.150), and 0.075 (0.070-0.080) s, respectively, and pressure-time products were 2.8 (2.1-7.4), 6.8 (6.7-7.3), 2.4 (2.1-2.4), 3.5 (2.7-3.6), 1.8 (1.8-2.1), 2.8 (2.7-2.9), and 5.7 (5.4-5.9) cm H2O × s, respectively. CONCLUSIONS The resistance of active expiratory valves differed significantly between the 7 ICU ventilators tested.
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Affiliation(s)
- Alexandre Pinède
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
| | - Martin Cour
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecin Lyon-Est, Université de Lyon, Lyon, France
| | - Florian Degivry
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales, INSERM 955/CNRS ERL 7000, Créteil, France
| | - Laurent Argaud
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France
- Faculté de Médecin Lyon-Est, Université de Lyon, Lyon, France
| | - Claude Guérin
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Lyon, France.
- Faculté de Médecin Lyon-Est, Université de Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955/CNRS ERL 7000, Créteil, France
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18
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Marinakis G, Paraschos M, Patrani M, Tsoutsouras T, Vassiliou M. Non-interventional monitoring of expiratory flow limitation during experimental mechanical ventilation. ERJ Open Res 2021; 7:00264-2020. [PMID: 33532479 PMCID: PMC7836650 DOI: 10.1183/23120541.00264-2020] [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: 05/12/2020] [Accepted: 09/25/2020] [Indexed: 11/17/2022] Open
Abstract
Background Expiratory flow limitation (EFL) is common among patients in the intensive care unit under mechanical ventilation (MV) and may have significant clinical consequences. In the present study, we examine the possibility of non-interventional detection of EFL during experimental MV. Methods Eight artificially ventilated New Zealand rabbits were included in the experiments. EFL was induced during MV by application of negative expiratory pressure (−5, −8 and −10 hPa) and detected by the negative expiratory pressure technique. Airway pressure (Paw) and gas flow (V′) were digitally recorded and processed off-line for the evaluation of respiratory mechanics. The method is based on the computation and monitoring of instantaneous respiratory resistance Rrs(t). The resistive pressure (Paw,res(t)) is calculated by subtracting from Paw its elastic component and the end-expiratory pressure, as assessed by linear regression. Then, Rrs(t) is computed as the instant ratio Paw,res(t)/V′(t). Results Two completely different patterns of expiratory Rrs(t) separate the cases with EFL from those without EFL. Small and random fluctuations are noticed when EFL is absent, whereas the onset of EFL is accompanied by an abrupt and continuous rise in Rrs(t), towards the end of expiration. Thus, EFL is not only detected but may also be quantified from the volume still to be expired at the time EFL occurs. Conclusion The proposed technique is a simple, accurate and non-interventional tool for EFL monitoring during MV. Respiratory system resistance in expiratory flow limitation during mechanical ventilationhttps://bit.ly/34hU6Bv
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Affiliation(s)
- Giorgos Marinakis
- Dept of Critical Care Medicine, General Hospital of Athens, "Korgialenio - Benakio" Hellenic Red Cross, Athens, Greece
| | - Michael Paraschos
- Dept of Critical Care Medicine, General Hospital of Athens, "Korgialenio - Benakio" Hellenic Red Cross, Athens, Greece
| | - Maria Patrani
- Dept of Critical Care Medicine, General Hospital of Athens, "Korgialenio - Benakio" Hellenic Red Cross, Athens, Greece
| | - Theodoros Tsoutsouras
- Dept of Critical Care Medicine, General Hospital of Athens, "Korgialenio - Benakio" Hellenic Red Cross, Athens, Greece
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19
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Spadaro S, Capuzzo M, Volta CA. Fatigue of ICU Survivors, No Longer to Be Neglected. Chest 2020; 158:848-849. [DOI: 10.1016/j.chest.2020.05.521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/02/2020] [Indexed: 01/09/2023] Open
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20
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Grieco DL, Bongiovanni F, Chen L, Menga LS, Cutuli SL, Pintaudi G, Carelli S, Michi T, Torrini F, Lombardi G, Anzellotti GM, De Pascale G, Urbani A, Bocci MG, Tanzarella ES, Bello G, Dell’Anna AM, Maggiore SM, Brochard L, Antonelli M. Respiratory physiology of COVID-19-induced respiratory failure compared to ARDS of other etiologies. Crit Care 2020; 24:529. [PMID: 32859264 PMCID: PMC7453378 DOI: 10.1186/s13054-020-03253-2] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Whether respiratory physiology of COVID-19-induced respiratory failure is different from acute respiratory distress syndrome (ARDS) of other etiologies is unclear. We conducted a single-center study to describe respiratory mechanics and response to positive end-expiratory pressure (PEEP) in COVID-19 ARDS and to compare COVID-19 patients to matched-control subjects with ARDS from other causes. METHODS Thirty consecutive COVID-19 patients admitted to an intensive care unit in Rome, Italy, and fulfilling moderate-to-severe ARDS criteria were enrolled within 24 h from endotracheal intubation. Gas exchange, respiratory mechanics, and ventilatory ratio were measured at PEEP of 15 and 5 cmH2O. A single-breath derecruitment maneuver was performed to assess recruitability. After 1:1 matching based on PaO2/FiO2, FiO2, PEEP, and tidal volume, COVID-19 patients were compared to subjects affected by ARDS of other etiologies who underwent the same procedures in a previous study. RESULTS Thirty COVID-19 patients were successfully matched with 30 ARDS from other etiologies. At low PEEP, median [25th-75th percentiles] PaO2/FiO2 in the two groups was 119 mmHg [101-142] and 116 mmHg [87-154]. Average compliance (41 ml/cmH2O [32-52] vs. 36 ml/cmH2O [27-42], p = 0.045) and ventilatory ratio (2.1 [1.7-2.3] vs. 1.6 [1.4-2.1], p = 0.032) were slightly higher in COVID-19 patients. Inter-individual variability (ratio of standard deviation to mean) of compliance was 36% in COVID-19 patients and 31% in other ARDS. In COVID-19 patients, PaO2/FiO2 was linearly correlated with respiratory system compliance (r = 0.52 p = 0.003). High PEEP improved PaO2/FiO2 in both cohorts, but more remarkably in COVID-19 patients (p = 0.005). Recruitability was not different between cohorts (p = 0.39) and was highly inter-individually variable (72% in COVID-19 patients and 64% in ARDS from other causes). In COVID-19 patients, recruitability was independent from oxygenation and respiratory mechanics changes due to PEEP. CONCLUSIONS Early after establishment of mechanical ventilation, COVID-19 patients follow ARDS physiology, with compliance reduction related to the degree of hypoxemia, and inter-individually variable respiratory mechanics and recruitability. Physiological differences between ARDS from COVID-19 and other causes appear small.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lu Chen
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Luca S. Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simone Carelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Flava Torrini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianmarco Lombardi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Urbani
- Department of Basic Biotechnological Science, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Laboratory and Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Grazia Bocci
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eloisa S. Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio M. Dell’Anna
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Salvatore M. Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Laurent Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
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21
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Pellegrini M, Gudmundsson M, Bencze R, Segelsjö M, Freden F, Rylander C, Hedenstierna G, Larsson AS, Perchiazzi G. Expiratory Resistances Prevent Expiratory Diaphragm Contraction, Flow Limitation, and Lung Collapse. Am J Respir Crit Care Med 2020; 201:1218-1229. [PMID: 32150440 DOI: 10.1164/rccm.201909-1690oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Tidal expiratory flow limitation (tidal-EFL) is not completely avoidable by applying positive end-expiratory pressure and may cause respiratory and hemodynamic complications in ventilated patients with lungs prone to collapse. During spontaneous breathing, expiratory diaphragmatic contraction counteracts tidal-EFL. We hypothesized that during both spontaneous breathing and controlled mechanical ventilation, external expiratory resistances reduce tidal-EFL.Objectives: To assess whether external expiratory resistances 1) affect expiratory diaphragmatic contraction during spontaneous breathing, 2) reduce expiratory flow and make lung compartments more homogeneous with more similar expiratory time constants, and 3) reduce tidal atelectasis, preventing hyperinflation.Methods: Three positive end-expiratory pressure levels and four external expiratory resistances were tested in 10 pigs after lung lavage. We analyzed expiratory diaphragmatic electric activity and respiratory mechanics. On the basis of computed tomography scans, four lung compartments-not inflated (atelectasis), poorly inflated, normally inflated, and hyperinflated-were defined.Measurements and Main Results: Consequently to additional external expiratory resistances, and mainly in lungs prone to collapse (at low positive end-expiratory pressure), 1) the expiratory transdiaphragmatic pressure decreased during spontaneous breathing by >10%, 2) expiratory flow was reduced and the expiratory time constants became more homogeneous, and 3) the amount of atelectasis at end-expiration decreased from 24% to 16% during spontaneous breathing and from 32% to 18% during controlled mechanical ventilation, without increasing hyperinflation.Conclusions: The expiratory modulation induced by external expiratory resistances preserves the positive effects of the expiratory brake while minimizing expiratory diaphragmatic contraction. External expiratory resistances optimize lung mechanics and limit tidal-EFL and tidal atelectasis, without increasing hyperinflation.
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Affiliation(s)
- Mariangela Pellegrini
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Magni Gudmundsson
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Reka Bencze
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Monica Segelsjö
- Department of Radiology, Uppsala University Hospital, Uppsala, Sweden; and
| | - Filip Freden
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Hedenstierna
- Department of Medical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - Anders S Larsson
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
| | - Gaetano Perchiazzi
- Department of Surgical Sciences and.,Central Intensive Care Unit, Department of Anesthesia, Operation, and Intensive Care and
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22
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Spadaro S, Volta CA. A Physiological Point of View on Expiratory (Re)action during Mechanical Ventilation. Am J Respir Crit Care Med 2020; 201:1170-1172. [PMID: 32233982 PMCID: PMC7233354 DOI: 10.1164/rccm.202003-0645ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Savino Spadaro
- Department Morphology, Surgery and Experimental MedicineUniversity of FerraraFerrara, Italy
| | - Carlo Alberto Volta
- Department Morphology, Surgery and Experimental MedicineUniversity of FerraraFerrara, Italy
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23
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Guérin C, Terzi N, Galerneau LM, Mezidi M, Yonis H, Baboi L, Kreitmann L, Turbil E, Cour M, Argaud L, Louis B. Lung and chest wall mechanics in patients with acute respiratory distress syndrome, expiratory flow limitation, and airway closure. J Appl Physiol (1985) 2020; 128:1594-1603. [PMID: 32352339 DOI: 10.1152/japplphysiol.00059.2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Tidal expiratory flow limitation (EFL), which may herald airway closure (AC), is a mechanism of loss of aeration in ARDS. In this prospective, short-term, two-center study, we measured static and dynamic chest wall (Est,cw and Edyn,cw) and lung (Est,L and Edyn,L) elastance with esophageal pressure, EFL, and AC at 5 cmH2O positive end-expiratory pressure (PEEP) in intubated, sedated, and paralyzed ARDS patients. For EFL determination, we used the atmospheric method and a new device allowing comparison of tidal flow during expiration to PEEP and to atmosphere. AC was validated when airway opening pressure (AOP) assessed from volume-pressure curve was found greater than PEEP by at least 1 cmH2O. EFL was defined whenever flow did not increase between exhalation to PEEP and to atmosphere over all or part of expiration. Elastance values were expressed as percentage of normal predicted values (%N). Among the 25 patients included, eight had EFL (32%) and 13 AOP (52%). Between patients with and without EFL Edyn,cw [median (1st to 3rd quartiles)] was 70 (16-127) and 102 (70-142) %N (P = 0.32) and Edyn,L338 (332-763) and 224 (160-275) %N (P < 0.001). The corresponding values for Est,cw and Est,L were 70 (56-88) and 85 (64-103) %N (P = 0.35) and 248 (206-348) and 170 (144-195) (P = 0.02), respectively. Dynamic EL had an area receiver operating characteristic curve of 0.88 [95% confidence intervals 0.83-0.92] for EFL and 0.74[0.68-0.79] for AOP. Higher Edyn,L was accurate to predict EFL in ARDS patients; AC can occur independently of EFL, and both should be assessed concurrently in ARDS patients.NEW & NOTEWORTHY Expiratory flow limitation (EFL) and airway closure (AC) were observed in 32% and 52%, respectively, of 25 patients with ARDS investigated during mechanical ventilation in supine position with a positive end-expiratory pressure of 5 cmH2O. The performance of dynamic lung elastance to detect expiratory flow limitation was good and better than that to detect airway closure. The vast majority of patients with EFL also had AC; however, AC can occur in the absence of EFL.
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Affiliation(s)
- Claude Guérin
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France.,Institut Mondor de Recherches Biomédicales INSERM 955 CNRS ERL 7000, Créteil, France
| | - Nicolas Terzi
- Medecine Intensive-Réanimation, CHU Grenoble-Alpes, Grenoble, France.,Université de Grenoble-Alpes, Grenoble, France
| | - Louis-Marie Galerneau
- Medecine Intensive-Réanimation, CHU Grenoble-Alpes, Grenoble, France.,Université de Grenoble-Alpes, Grenoble, France
| | - Mehdi Mezidi
- Université de Lyon, Lyon, France.,Médecine Intensive-Réanimation, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Hodane Yonis
- Médecine Intensive-Réanimation, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Loredana Baboi
- Médecine Intensive-Réanimation, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Louis Kreitmann
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Emanuele Turbil
- Department of Anesthesia and Critical Care, University of Sassari, Sassari, Italy
| | - Martin Cour
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Laurent Argaud
- Medecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM 955 CNRS ERL 7000, Créteil, France
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24
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Fogagnolo A, Spadaro S. Can regional lung mechanics evaluation represent the next step towards precision medicine in respiratory care? Minerva Anestesiol 2020; 86:124-125. [DOI: 10.23736/s0375-9393.19.14314-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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25
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Wang H, He H. Expiratory flow limitation developed in ICU patients: relationship of fluid overload, respiratory mechanics, and outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:24. [PMID: 31980028 PMCID: PMC6979074 DOI: 10.1186/s13054-019-2723-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/27/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Heyan Wang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang City, Guizhou Province, China
| | - Hangyong He
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
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