1
|
Gao R, Zhou JX, Yang YL, Xu SS, Zhou YM, Zhang L, Miao MY. Use of pressure muscle index to predict the contribution of patient's inspiratory effort during pressure support ventilation: a prospective physiological study. Front Med (Lausanne) 2024; 11:1390878. [PMID: 38737762 PMCID: PMC11082330 DOI: 10.3389/fmed.2024.1390878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Background The successful implementation of assisted ventilation depends on matching the patient's effort with the ventilator support. Pressure muscle index (PMI), an airway pressure based measurement, has been used as noninvasive monitoring to assess the patient's inspiratory effort. The authors aimed to evaluate the feasibility of pressure support adjustment according to the PMI target and the diagnostic performance of PMI to predict the contribution of the patient's effort during ventilator support. Methods In this prospective physiological study, 22 adult patients undergoing pressure support ventilation were enrolled. After an end-inspiratory airway occlusion, airway pressure reached a plateau, and the magnitude of change in plateau from peak airway pressure was defined as PMI. Pressure support was adjusted to obtain the PMI which was closest to -1, 0, +1, +2, and + 3 cm H2O. Each pressure support level was maintained for 20 min. Esophageal pressure was monitored. Pressure-time products of respiratory muscle and ventilator insufflation were measured, and the fraction of pressure generated by the patient was calculated to represent the contribution of the patient's inspiratory effort. Results A total of 105 datasets were collected at different PMI-targeted pressure support levels. The differences in PMI between the target and the obtained value were all within ±1 cm H2O. As targeted PMI increased, pressure support settings decreased significantly from a median (interquartile range) of 11 (10-12) to 5 (4-6) cm H2O (p < 0.001), which resulted in a significant increase in pressure-time products of respiratory muscle [from 2.9 (2.1-5.0) to 6.8 (5.3-8.1) cm H2O•s] and the fraction of pressure generated by the patient [from 25% (19-31%) to 72% (62-87%)] (p < 0.001). The area under receiver operating characteristic curves for PMI to predict 30 and 70% contribution of patient's effort were 0.93 and 0.95, respectively. High sensitivity (all 1.00), specificity (0.86 and 0.78), and negative predictive value (all 1.00), but low positive predictive value (0.61 and 0.43) were obtained to predict either high or low contribution of patient's effort. Conclusion Our results preliminarily suggested the feasibility of pressure support adjustment according to the PMI target from the ventilator screen. PMI could reliably predict the high and low contribution of a patient's effort during assisted ventilation.Clinical trial registration: ClinicalTrials.gov, identifier NCT05970393.
Collapse
Affiliation(s)
- Ran Gao
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Clinical and Research Center on Acute Lung Injury, Emergency, and Critical Care Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Clinical and Research Center on Acute Lung Injury, Emergency, and Critical Care Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shan-Shan Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming-Yue Miao
- Clinical and Research Center on Acute Lung Injury, Emergency, and Critical Care Center, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
2
|
Stamatopoulou V, Akoumianaki E, Vaporidi K, Stamatopoulos E, Kondili E, Georgopoulos D. Driving pressure of respiratory system and lung stress in mechanically ventilated patients with active breathing. Crit Care 2024; 28:19. [PMID: 38217038 PMCID: PMC10785492 DOI: 10.1186/s13054-024-04797-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND During control mechanical ventilation (CMV), the driving pressure of the respiratory system (ΔPrs) serves as a surrogate of transpulmonary driving pressure (ΔPlung). Expiratory muscle activity that decreases end-expiratory lung volume may impair the validity of ΔPrs to reflect ΔPlung. This prospective observational study in patients with acute respiratory distress syndrome (ARDS) ventilated with proportional assist ventilation (PAV+), aimed to investigate: (1) the prevalence of elevated ΔPlung, (2) the ΔPrs-ΔPlung relationship, and (3) whether dynamic transpulmonary pressure (Plungsw) and effort indices (transdiaphragmatic and respiratory muscle pressure swings) remain within safe limits. METHODS Thirty-one patients instrumented with esophageal and gastric catheters (n = 22) were switched from CMV to PAV+ and respiratory variables were recorded, over a maximum of 24 h. To decrease the contribution of random breaths with irregular characteristics, a 7-breath moving average technique was applied. In each patient, measurements were also analyzed per deciles of increasing lung elastance (Elung). Patients were divided into Group A, if end-inspiratory transpulmonary pressure (PLEI) increased as Elung increased, and Group B, which showed a decrease or no change in PLEI with Elung increase. RESULTS In 44,836 occluded breaths, ΔPlung ≥ 12 cmH2O was infrequently observed [0.0% (0.0-16.9%) of measurements]. End-expiratory lung volume decrease, due to active expiration, was associated with underestimation of ΔPlung by ΔPrs, as suggested by a negative linear relationship between transpulmonary pressure at end-expiration (PLEE) and ΔPlung/ΔPrs. Group A included 17 and Group B 14 patients. As Elung increased, ΔPlung increased mainly due to PLEI increase in Group A, and PLEE decrease in Group B. Although ΔPrs had an area receiver operating characteristic curve (AUC) of 0.87 (95% confidence intervals 0.82-0.92, P < 0.001) for ΔPlung ≥ 12 cmH2O, this was due exclusively to Group A [0.91 (0.86-0.95), P < 0.001]. In Group B, ΔPrs showed no predictive capacity for detecting ΔPlung ≥ 12 cmH2O [0.65 (0.52-0.78), P > 0.05]. Most of the time Plungsw and effort indices remained within safe range. CONCLUSION In patients with ARDS ventilated with PAV+, injurious tidal lung stress and effort were infrequent. In the presence of expiratory muscle activity, ΔPrs underestimated ΔPlung. This phenomenon limits the usefulness of ΔPrs as a surrogate of tidal lung stress, regardless of the mode of support.
Collapse
Affiliation(s)
- Vaia Stamatopoulou
- Intensive Care Medicine Department, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Evangelia Akoumianaki
- Intensive Care Medicine Department, University Hospital of Heraklion, Heraklion, Crete, Greece
- Medical School, University of Crete, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- Intensive Care Medicine Department, University Hospital of Heraklion, Heraklion, Crete, Greece
- Medical School, University of Crete, Heraklion, Crete, Greece
| | - Efstathios Stamatopoulos
- Decision Support Systems, Laboratory, School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Eumorfia Kondili
- Intensive Care Medicine Department, University Hospital of Heraklion, Heraklion, Crete, Greece
- Medical School, University of Crete, Heraklion, Crete, Greece
| | - Dimitrios Georgopoulos
- Intensive Care Medicine Department, University Hospital of Heraklion, Heraklion, Crete, Greece.
- Medical School, University of Crete, Heraklion, Crete, Greece.
| |
Collapse
|
3
|
Yang YL, Liu Y, Gao R, Song DJ, Zhou YM, Miao MY, Chen W, Wang SP, Wang YF, Zhang L, Zhou JX. Use of airway pressure-based indices to detect high and low inspiratory effort during pressure support ventilation: a diagnostic accuracy study. Ann Intensive Care 2023; 13:111. [PMID: 37955842 PMCID: PMC10643759 DOI: 10.1186/s13613-023-01209-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/27/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Assessment of the patient's respiratory effort is essential during assisted ventilation. We aimed to evaluate the accuracy of airway pressure (Paw)-based indices to detect potential injurious inspiratory effort during pressure support (PS) ventilation. METHODS In this prospective diagnostic accuracy study conducted in four ICUs in two academic hospitals, 28 adult acute respiratory failure patients undergoing PS ventilation were enrolled. A downward PS titration was conducted from 20 cmH2O to 2 cmH2O at a 2 cmH2O interval. By performing an end-expiratory airway occlusion maneuver, the negative Paw generated during the first 100 ms (P0.1) and the maximal negative swing of Paw (∆Pocc) were measured. After an end-inspiratory airway occlusion, Paw reached a plateau, and the magnitude of change in plateau from peak Paw was measured as pressure muscle index (PMI). Esophageal pressure was monitored and inspiratory muscle pressure (Pmus) and Pmus-time product per minute (PTPmus/min) were used as the reference standard for the patient's effort. High and low effort was defined as Pmus > 10 and < 5 cmH2O, or PTPmus/min > 200 and < 50 cmH2O s min-1, respectively. RESULTS A total of 246 levels of PS were tested. The low inspiratory effort was diagnosed in 145 (59.0%) and 136 (55.3%) PS levels using respective Pmus and PTPmus/min criterion. The receiver operating characteristic area of the three Paw-based indices by the respective two criteria ranged from 0.87 to 0.95, and balanced sensitivity (0.83-0.96), specificity (0.74-0.88), and positive (0.80-0.91) and negative predictive values (0.78-0.94) were obtained. The high effort was diagnosed in 34 (13.8%) and 17 (6.9%) support levels using Pmus and PTPmus/min criterion, respectively. High receiver operating characteristic areas of the three Paw-based indices by the two criteria were found (0.93-0.95). A high sensitivity (0.80-1.00) and negative predictive value (0.97-1.00) were found with a low positive predictive value (0.23-0.64). CONCLUSIONS By performing simple airway occlusion maneuvers, the Paw-based indices could be reliably used to detect low inspiratory efforts. Non-invasive and easily accessible characteristics support their potential bedside use for avoiding over-assistance. More evaluation of their performance is required in cohorts with high effort.
Collapse
Affiliation(s)
- Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Clinical and Research Center on Acute Lung Injury, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Yang Liu
- Clinical and Research Center on Acute Lung Injury, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Surgical Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Ran Gao
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - De-Jing Song
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, Beijing, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming-Yue Miao
- Clinical and Research Center on Acute Lung Injury, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Wei Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu-Peng Wang
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, Beijing, China
| | - Yue-Fu Wang
- Clinical and Research Center on Acute Lung Injury, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
- Surgical Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Clinical and Research Center on Acute Lung Injury, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Clinical and Research Center on Acute Lung Injury, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
| |
Collapse
|
4
|
Pérez J, Dorado JH, Accoce M, Plotnikow GA. Airway and Transpulmonary Driving Pressure by End-Inspiratory Holds During Pressure Support Ventilation. Respir Care 2023; 68:1483-1492. [PMID: 37463722 PMCID: PMC10589108 DOI: 10.4187/respcare.10802] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND The precision of quasi-static airway driving pressure (ΔP) assessed in pressure support ventilation (PSV) as a surrogate of tidal lung stress is debatable because persistent muscular activity frequently alters the readability of end-inspiratory holds. In this study, we used strict criteria to discard excessive muscular activity during holds and assessed the accuracy of ΔP in predicting global lung stress in PSV. Additionally, we explored whether the physiological effects of high PEEP differed according to the response of respiratory system compliance (CRS). METHODS Adults with ARDS undergoing PSV were enrolled. An esophageal catheter was inserted to calculate lung stress through transpulmonary driving pressure (ΔPL). ΔP and ΔPL were assessed in PSV at PEEP 5, 10, and 15 cm H2O by end-inspiratory holds. CRS was calculated as tidal volume (VT)/ΔP. We analyzed the effects of high PEEP on pressure-time product per minute (PTPmin), airway pressure at 100 ms (P0.1), and VT over PTP per breath (VT/PTPbr) in subjects with increased versus decreased CRS at high PEEP. RESULTS Eighteen subjects and 162 end-inspiratory holds were analyzed; 51/162 (31.5%) of the holds had ΔPL ≥ 12 cm H2O. Significant association between ΔP and ΔPL was found at all PEEP levels (P < .001). ΔP had excellent precision to predict ΔPL, with 15 cm H2O being identified as the best threshold for detecting ΔPL ≥ 12 cm H2O (area under the receiver operating characteristics 0.99 [95% CI 0.98-1.00]). CRS changes from low to high PEEP corresponded well with lung compliance changes (R2 0.91, P < .001) When CRS increased, a significant improvement of PTPmin and VT/PTPbr was found, without changes in P0.1. No benefits were observed when CRS decreased. CONCLUSIONS In subjects with ARDS undergoing PSV, high ΔP assessed by readable end-inspiratory holds accurately detected potentially dangerous thresholds of ΔPL. Using ΔP to assess changes in CRS induced by PEEP during assisted ventilation may inform whether higher PEEP could be beneficial.
Collapse
Affiliation(s)
- Joaquin Pérez
- Sanatorio Anchorena San Martín, Buenos Aires, Argentina; and Hospital Carlos G Durand, Ciudad Autónoma de Buenos Aires, Argentina.
| | | | - Matías Accoce
- Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Hospital de Quemados "Arturo H Illia," Ciudad Autónoma de Buenos Aires, Argentina; and Universidad Abierta Interamericana, Facultad de Medicina y Ciencias de la Salud, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gustavo A Plotnikow
- Universidad Abierta Interamericana, Facultad de Medicina y Ciencias de la Salud, Ciudad Autónoma de Buenos Aires, Argentina; and Hospital Británico, Ciudad Autónoma de Buenos Aires, Argentina
| |
Collapse
|
5
|
Mireles-Cabodevila E, Fischer M, Wiles S, Chatburn RL. Esophageal Pressure Measurement: A Primer. Respir Care 2023; 68:1281-1294. [PMID: 37433629 PMCID: PMC10468172 DOI: 10.4187/respcare.11157] [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: 07/13/2023]
Abstract
Over the last decade, the literature exploring clinical applications for esophageal manometry in critically ill patients has increased. New mechanical ventilators and bedside monitors allow measurement of esophageal pressures easily at the bedside. The bedside clinician can now evaluate the magnitude and timing of esophageal pressure swings to evaluate respiratory muscle activity and transpulmonary pressures. The respiratory therapist has all the tools to perform these measurements to optimize mechanical ventilation delivery. However, as with any measurement, technique, fidelity, and accuracy are paramount. This primer highlights key knowledge necessary to perform measurements and highlights areas of both uncertainty and ongoing development.
Collapse
Affiliation(s)
| | | | - Samuel Wiles
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | | |
Collapse
|
6
|
Soundoulounaki S, Sylligardos E, Akoumianaki E, Sigalas M, Kondili E, Georgopoulos D, Trahanias P, Vaporidi K. Neural Network-Enabled Identification of Weak Inspiratory Efforts during Pressure Support Ventilation Using Ventilator Waveforms. J Pers Med 2023; 13:jpm13020347. [PMID: 36836581 PMCID: PMC9966968 DOI: 10.3390/jpm13020347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023] Open
Abstract
During pressure support ventilation (PSV), excessive assist results in weak inspiratory efforts and promotes diaphragm atrophy and delayed weaning. The aim of this study was to develop a classifier using a neural network to identify weak inspiratory efforts during PSV, based on the ventilator waveforms. Recordings of flow, airway, esophageal and gastric pressures from critically ill patients were used to create an annotated dataset, using data from 37 patients at 2-5 different levels of support, computing the inspiratory time and effort for every breath. The complete dataset was randomly split, and data from 22 patients (45,650 breaths) were used to develop the model. Using a One-Dimensional Convolutional Neural Network, a predictive model was developed to characterize the inspiratory effort of each breath as weak or not, using a threshold of 50 cmH2O*s/min. The following results were produced by implementing the model on data from 15 different patients (31,343 breaths). The model predicted weak inspiratory efforts with a sensitivity of 88%, specificity of 72%, positive predictive value of 40%, and negative predictive value of 96%. These results provide a 'proof-of-concept' for the ability of such a neural-network based predictive model to facilitate the implementation of personalized assisted ventilation.
Collapse
Affiliation(s)
- Stella Soundoulounaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Emmanouil Sylligardos
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Markos Sigalas
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Panos Trahanias
- Institute of Computer Science, Foundation for Research and Technology—Hellas (FORTH), 70013 Heraklion, Greece
- Department of Computer Science, University of Crete, 70013 Heraklion, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Correspondence:
| |
Collapse
|
7
|
Pavez N, Damiani LF. Inspiratory and expiratory pause during pressure support ventilation: Maneuvers that we should incorporate into clinical practice. Med Intensiva 2022; 46:213-216. [PMID: 35210174 DOI: 10.1016/j.medine.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/15/2021] [Accepted: 11/05/2021] [Indexed: 06/14/2023]
Affiliation(s)
- N Pavez
- Sección Medicina Intensiva, Departamento de Medicina Interna, Universidad de Concepción, Concepción, Chile
| | - L F Damiani
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| |
Collapse
|
8
|
Karageorgos V, Proklou A, Vaporidi K. Lung and diaphragm protective ventilation: a synthesis of recent data. Expert Rev Respir Med 2022; 16:375-390. [PMID: 35354361 DOI: 10.1080/17476348.2022.2060824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION : To adhere to the Hippocratic Oath, to "first, do no harm", we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of the mechanisms of ventilator-induced lung injury (VILI) and ventilator-induced diaphragm dysfunction (VIDD) has increased in recent years. Research focuses now on methods to monitor lung stress and inhomogeneity and targets we should aim for when setting the ventilator. In parallel, efforts to promote early assisted ventilation to prevent VIDD have revealed new challenges, such as titrating inspiratory effort and synchronizing the mechanical with the patients' spontaneous breaths, while at the same time adhering to lung-protective targets. AREAS COVERED This is a narrative review of the key mechanisms contributing to VILI and VIDD and the methods currently available to evaluate and mitigate the risk of lung and diaphragm injury. EXPERT OPINION Implementing lung and diaphragm protective ventilation requires individualizing the ventilator settings, and this can only be accomplished by exploiting in everyday clinical practice the tools available to monitor lung stress and inhomogeneity, inspiratory effort, and patient-ventilator interaction.
Collapse
Affiliation(s)
- Vlasios Karageorgos
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Athanasia Proklou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Katerina Vaporidi
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| |
Collapse
|
9
|
Bianchi I, Grassi A, Pham T, Telias I, Teggia Droghi M, Vieira F, Jonkman A, Brochard L, Bellani G. Reliability of plateau pressure during patient-triggered assisted ventilation. Analysis of a multicentre database. J Crit Care 2021; 68:96-103. [PMID: 34952477 DOI: 10.1016/j.jcrc.2021.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/20/2021] [Accepted: 12/02/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE An inspiratory hold during patient-triggered assisted ventilation potentially allows to measure driving pressure and inspiratory effort. However, muscular activity can make this measurement unreliable. We aim to define the criteria for inspiratory holds reliability during patient-triggered breaths. MATERIAL AND METHODS Flow, airway and esophageal pressure recordings during patient-triggered breaths from a multicentre observational study (BEARDS, NCT03447288) were evaluated by six independent raters, to determine plateau pressure readability. Features of "readable" and "unreadable" holds were compared. Muscle pressure estimate from the hold was validated against other measures of inspiratory effort. RESULTS Ninety-two percent of the recordings were consistently judged as readable or unreadable by at least four raters. Plateau measurement showed a high consistency among raters. A short time from airway peak to plateau pressure and a stable and longer plateau characterized readable holds. Unreadable plateaus were associated with higher indexes of inspiratory effort. Muscular pressure computed from the hold showed a strong correlation with independent indexes of inspiratory effort. CONCLUSION The definition of objective parameters of plateau reliability during assisted-breath provides the clinician with a tool to target a safer assisted-ventilation and to detect the presence of high inspiratory effort.
Collapse
Affiliation(s)
- Isabella Bianchi
- Department of Anesthesia and Intensive Care Medicine, Papa Giovanni XXXIII Hospital, Bergamo, Italy; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Clinical-Surgical, diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Alice Grassi
- Department of Anesthesia and Pain Medicine, University of Toronto, Ontario, Canada; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
| | - Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.
| | - Maddalena Teggia Droghi
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.
| | - Fernando Vieira
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Annemijn Jonkman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands.
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.
| |
Collapse
|
10
|
Pavez N, Damiani L. Pausa inspiratoria y espiratoria durante la ventilación con presión de soporte: Maniobras que debemos incorporar en la práctica clínica. Med Intensiva 2021. [DOI: 10.1016/j.medin.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
11
|
COVID-19 ARDS: Points to Be Considered in Mechanical Ventilation and Weaning. J Pers Med 2021; 11:jpm11111109. [PMID: 34834461 PMCID: PMC8618434 DOI: 10.3390/jpm11111109] [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: 08/30/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/21/2022] Open
Abstract
The COVID-19 disease can cause hypoxemic respiratory failure due to ARDS, requiring invasive mechanical ventilation. Although early studies reported that COVID-19-associated ARDS has distinctive features from ARDS of other causes, recent observational studies have demonstrated that ARDS related to COVID-19 shares common clinical characteristics and respiratory system mechanics with ARDS of other origins. Therefore, mechanical ventilation in these patients should be based on strategies aiming to mitigate ventilator-induced lung injury. Assisted mechanical ventilation should be applied early in the course of mechanical ventilation by considering evaluation and minimizing factors associated with patient-inflicted lung injury. Extracorporeal membrane oxygenation should be considered in selected patients with refractory hypoxia not responding to conventional ventilation strategies. This review highlights the current and evolving practice in managing mechanically ventilated patients with ARDS related to COVID-19.
Collapse
|
12
|
[Patient self-inflicted lung injury (P-SILI) : From pathophysiology to clinical evaluation with differentiated management]. Med Klin Intensivmed Notfmed 2021; 116:614-623. [PMID: 33961061 PMCID: PMC8103432 DOI: 10.1007/s00063-021-00823-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 02/08/2023]
Abstract
Die Etablierung der unterstützten Spontanatmung gilt allgemein als eine vorteilhafte und wenig gefährdende Phase der Beatmungstherapie. Allerdings geben neuere Erkenntnisse Hinweise auf eine potenzielle Schädigung durch exzessive Spontanatembemühungen vor allem bei akuter Lungenschädigung. Das Syndrom wird unter dem Begriff „patient self-inflicted lung injury“ zusammengefasst. Ärzte, Pflegepersonen und Atmungstherapeuten sollten für diese Thematik sensibilisiert werden. Parameter, die mittels Ösophagusdruckmessung oder einfacher Manöver am Respirator bestimmt werden können, sind bei der Entscheidung zur Durchführung und zur Überwachung von Spontanatmung auch in den akuten Phasen der Lungenschädigung hilfreich. Weiterhin gibt es im Umgang mit hohem Atemantrieb oder erhöhter Atemanstrengung therapeutische Möglichkeiten, diesen zu begegnen.
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Assess the most recent studies using driving pressure (DP) as a monitoring technique under mechanical ventilation and describe the technical challenges associated with its measurement. RECENT FINDINGS DP is consistently associated with survival in acute respiratory failure and acute respiratory distress syndrome (ARDS) and can detect patients at higher risk of ventilator-induced lung injury. Its measurement can be challenged by leaks and ventilator dyssynchrony, but is also feasible under pressure support ventilation. Interestingly, an aggregated summary of published results suggests that its level is on average slightly lower in patients with coronavirus disease-19 induced ARDS than in classical ARDS. SUMMARY The DP is easy to obtain and should be incorporated as a minimal monitoring technique under mechanical ventilation.
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent literature on mechanical ventilation strategies in patients with septic shock. RECENT FINDINGS Indirect clinical trial evidence has refined the use of neuromuscular blocking agents, positive end-expiratory pressure (PEEP) and recruitment manoeuvres in septic shock patients with acute respiratory distress syndrome. Weaning strategies and devices have also been recently evaluated. The role of lung protective ventilation in patients with healthy lungs, while recognized, still needs to be further refined. The possible detrimental effects of spontaneous breathing in patients who develop acute respiratory distress syndrome is increasingly recognized, but clinical trial evidence is still lacking to confirm this hypothesis. A new concept of lung and diaphragm protective is emerging in the critical care literature, but its application will need a complex intervention implementation approach to allow adequate scrutiny of this concept and uptake by clinicians. SUMMARY Many advances in the management of the mechanically ventilated patient with sepsis and septic shock have occurred in recent years, but clinical trial evidence is still necessary to translate new hypotheses to the bedside and find the right balance between benefits and risks of these new strategies.
Collapse
|
15
|
Goligher EC, Jonkman AH, Dianti J, Vaporidi K, Beitler JR, Patel BK, Yoshida T, Jaber S, Dres M, Mauri T, Bellani G, Demoule A, Brochard L, Heunks L. Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort. Intensive Care Med 2020; 46:2314-2326. [PMID: 33140181 PMCID: PMC7605467 DOI: 10.1007/s00134-020-06288-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022]
Abstract
Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.
Collapse
Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Annemijn H Jonkman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Samir Jaber
- Critical Care and Anesthesia Department (DAR B), Hôpital Saint-Éloi, CHU de Montpellier, PhyMedExp, Université de Montpellier, Montpellier, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Tommaso Mauri
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Leo Heunks
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| |
Collapse
|
16
|
Vaporidi K, Soundoulounaki S, Papadakis E, Akoumianaki E, Kondili E, Georgopoulos D. Esophageal and transdiaphragmatic pressure swings as indices of inspiratory effort. Respir Physiol Neurobiol 2020; 284:103561. [PMID: 33035709 DOI: 10.1016/j.resp.2020.103561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/03/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022]
Abstract
AIM To describe the correlation between the inspiratory esophageal and transdiaphragmatic pressure swings (ΔPes and ΔPdi), easily measured indices of inspiratory effort, with the gold-standard, the transdiaphragmatic pressure time product (PTPPdi/min), and assess the accuracy of swing pressures in predicting very high or low effort. METHOD Retrospective analysis of data from patients enrolled in four previous studies. ROC curves of ΔPes and ΔPdi values for specific PTPPdi/min thresholds (50, 150, 200 cmH2O × sec/min) were constructed, and the diagnostic accuracy of different thresholds of swing values were computed. RESULTS A threshold of inspiratory ΔP<7cmH2O can be used to identify most patients with low effort, as lower ΔP thresholds have low sensitivity. Thresholds of inspiratory ΔP>14-18cmH2O can be used to identify patients with very high inspiratory effort (PTPPdi/min> 200 cmH2O × sec/min). CONCLUSIONS The results of this study can help clinicians better select and interpret thresholds of ΔP to evaluate inspiratory effort.
Collapse
Affiliation(s)
- Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Greece.
| | - Stella Soundoulounaki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Greece
| | - Eleftherios Papadakis
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Greece
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Greece
| |
Collapse
|