1
|
Marini JJ. Detecting end-tidal hyperinflation. Intensive Care Med 2024; 50:752-754. [PMID: 38563895 DOI: 10.1007/s00134-024-07379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/27/2024] [Indexed: 04/04/2024]
|
2
|
Moncomble E, Tuffet S, Boujelben M, Gendreau S, Labedade P, Haudebourg AF, Dessap AM, Carteaux G. Paradoxical Response to Standardized Chest Loading May Unveil Occult Overdistension During Protective Ventilation. Am J Respir Crit Care Med 2024; 209:221-223. [PMID: 37956248 DOI: 10.1164/rccm.202309-1579le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/10/2023] [Indexed: 11/15/2023] Open
Affiliation(s)
- Elsa Moncomble
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - Mohamed Boujelben
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - Ségolène Gendreau
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Pascale Labedade
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| |
Collapse
|
3
|
Rezoagli E, Bastia L, Brochard L, Bellani G. Physical manoeuvres in patients with ARDS and low compliance: bedside approaches to detect lung hyperinflation and optimise mechanical ventilation. Eur Respir J 2023; 61:61/5/2202169. [PMID: 37208034 DOI: 10.1183/13993003.02169-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/30/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Co-first authors
| | - Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Co-first authors
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Co-senior authors
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Co-senior authors
| |
Collapse
|
4
|
Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022; 26:201. [PMID: 35791021 PMCID: PMC9255488 DOI: 10.1186/s13054-022-04073-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS.
Methods
Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O.
Results
Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients.
Conclusion
Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of ‘paradox’ should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
Collapse
|
5
|
Selickman J, Marini JJ. Chest wall loading in the ICU: pushes, weights, and positions. Ann Intensive Care 2022; 12:103. [PMID: 36346532 PMCID: PMC9640797 DOI: 10.1186/s13613-022-01076-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Clinicians monitor mechanical ventilatory support using airway pressures—primarily the plateau and driving pressure, which are considered by many to determine the safety of the applied tidal volume. These airway pressures are influenced not only by the ventilator prescription, but also by the mechanical properties of the respiratory system, which consists of the series-coupled lung and chest wall. Actively limiting chest wall expansion through external compression of the rib cage or abdomen is seldom performed in the ICU. Recent literature describing the respiratory mechanics of patients with late-stage, unresolving, ARDS, however, has raised awareness of the potential diagnostic (and perhaps therapeutic) value of this unfamiliar and somewhat counterintuitive practice. In these patients, interventions that reduce resting lung volume, such as loading the chest wall through application of external weights or manual pressure, or placing the torso in a more horizontal position, have unexpectedly improved tidal compliance of the lung and integrated respiratory system by reducing previously undetected end-tidal hyperinflation. In this interpretive review, we first describe underappreciated lung and chest wall interactions that are clinically relevant to both normal individuals and to the acutely ill who receive ventilatory support. We then apply these physiologic principles, in addition to published clinical observation, to illustrate the utility of chest wall modification for the purposes of detecting end-tidal hyperinflation in everyday practice.
Collapse
Affiliation(s)
- John Selickman
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| | - John J. Marini
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| |
Collapse
|
6
|
Abstract
OBJECTIVES Head-elevated body positioning, a default clinical practice, predictably increases end-expiratory transpulmonary pressure and aerated lung volume. In acute respiratory distress syndrome (ARDS), however, the net effect of such vertical inclination on tidal mechanics depends upon whether lung recruitment or overdistension predominates. We hypothesized that in moderate to severe ARDS, bed inclination toward vertical unloads the chest wall but adversely affects overall respiratory system compliance (C rs ). DESIGN Prospective physiologic study. SETTING Two medical ICUs in the United States. PATIENTS Seventeen patients with ARDS, predominantly moderate to severe. INTERVENTION Patients were ventilated passively by volume control. We measured airway pressures at baseline (noninclined) and following bed inclination toward vertical by an additional 15°. At baseline and following inclination, we manually loaded the chest wall to determine if C rs increased or paradoxically declined, suggestive of end-tidal overdistension. MEASUREMENTS AND MAIN RESULTS Inclination resulted in a higher plateau pressure (supineΔ: 2.8 ± 3.3 cm H 2 O [ p = 0.01]; proneΔ: 3.3 ± 2.5 cm H 2 O [ p = 0.004]), higher driving pressure (supineΔ: 2.9 ± 3.3 cm H 2 O [ p = 0.01]; proneΔ: 3.3 ± 2.8 cm H 2 O [ p = 0.007]), and lower C rs (supine Δ: 3.4 ± 3.7 mL/cm H 2 O [ p = 0.01]; proneΔ: 3.1 ± 3.2 mL/cm H 2 O [ p = 0.02]). Following inclination, manual loading of the chest wall restored C rs and driving pressure to baseline (preinclination) values. CONCLUSIONS In advanced ARDS, bed inclination toward vertical adversely affects C rs and therefore affects the numerical values for plateau and driving tidal pressures commonly targeted in lung protective strategies. These changes are fully reversed with manual loading of the chest wall, suggestive of end-tidal overdistension in the upright position. Body inclination should be considered a modifiable determinant of transpulmonary pressure and lung protection, directionally similar to tidal volume and positive end-expiratory pressure.
Collapse
|
7
|
Bedside Detection of End-Tidal Hyperinflation in Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2022; 19:1791-1795. [PMID: 35849421 DOI: 10.1513/annalsats.202205-460ps] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
8
|
Prone Positioning Decreases Inhomogeneity and Improves Dorsal Compliance in Invasively Ventilated Spontaneously Breathing COVID-19 Patients—A Study Using Electrical Impedance Tomography. Diagnostics (Basel) 2022; 12:diagnostics12102281. [PMID: 36291970 PMCID: PMC9600133 DOI: 10.3390/diagnostics12102281] [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: 08/30/2022] [Revised: 09/16/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: We studied prone positioning effects on lung aeration in spontaneously breathing invasively ventilated patients with coronavirus disease 2019 (COVID-19). Methods: changes in lung aeration were studied prospectively by electrical impedance tomography (EIT) from before to after placing the patient prone, and back to supine. Mixed effect models with a random intercept and only fixed effects were used to evaluate changes in lung aeration. Results: fifteen spontaneously breathing invasively ventilated patients were enrolled, and remained prone for a median of 19 [17 to 21] hours. At 16 h the global inhomogeneity index was lower. At 2 h, there were neither changes in dorsal nor in ventral compliance; after 16 h, only dorsal compliance (βFe +18.9 [95% Confidence interval (CI): 9.1 to 28.8]) and dorsal end-expiratory lung impedance (EELI) were increased (βFe, +252 [95% CI: 13 to 496]); at 2 and 16 h, dorsal silent spaces was unchanged (βFe, –4.6 [95% CI: –12.3 to +3.2]). The observed changes induced by prone positioning disappeared after turning patients back to supine. Conclusions: in this cohort of spontaneously breathing invasively ventilated COVID-19 patients, prone positioning decreased inhomogeneity, increased lung volumes, and improved dorsal compliance.
Collapse
|
9
|
Umbrello M, Lassola S, Sanna A, Pace R, Magnoni S, Miori S. Chest wall loading during supine and prone position in patients with COVID-19 ARDS: effects on respiratory mechanics and gas exchange. Crit Care 2022; 26:277. [PMID: 36100903 PMCID: PMC9470071 DOI: 10.1186/s13054-022-04141-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background Recent reports of patients with severe, late-stage COVID-19 ARDS with reduced respiratory system compliance described paradoxical decreases in plateau pressure and increases in respiratory system compliance in response to anterior chest wall loading. We aimed to assess the effect of chest wall loading during supine and prone position in ill patients with COVID-19-related ARDS and to investigate the effect of a low or normal baseline respiratory system compliance on the findings. Methods This is a single-center, prospective, cohort study in the intensive care unit of a COVID-19 referral center. Consecutive mechanically ventilated, critically ill patients with COVID-19-related ARDS were enrolled and classified as higher (≥ 40 ml/cmH2O) or lower respiratory system compliance (< 40 ml/cmH2O). The study included four steps, each lasting 6 h: Step 1, supine position, Step 2, 10-kg continuous chest wall compression (supine + weight), Step 3, prone position, Step 4, 10-kg continuous chest wall compression (prone + weight). The mechanical properties of the respiratory system, gas exchange and alveolar dead space were measured at the end of each step. Results Totally, 40 patients were enrolled. In the whole cohort, neither oxygenation nor respiratory system compliance changed between supine and supine + weight; both increased during prone positioning and were unaffected by chest wall loading in the prone position. Alveolar dead space was unchanged during all the steps. In 16 patients with reduced compliance, PaO2/FiO2 significantly increased from supine to supine + weight and further with prone and prone + weight (107 ± 15.4 vs. 120 ± 18.5 vs. 146 ± 27.0 vs. 159 ± 30.4, respectively; p < 0.001); alveolar dead space decreased from both supine and prone position after chest wall loading, and respiratory system compliance significantly increased from supine to supine + weight and from prone to prone + weight (23.9 ± 3.5 vs. 30.9 ± 5.7 and 31.1 ± 5.7 vs. 37.8 ± 8.7 ml/cmH2O, p < 0.001). The improvement was higher the lower the baseline compliance. Conclusions Unlike prone positioning, chest wall loading had no effects on respiratory system compliance, gas exchange or alveolar dead space in an unselected cohort of critically ill patients with C-ARDS. Only patients with a low respiratory system compliance experienced an improvement, with a higher response the lower the baseline compliance. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04141-7.
Collapse
|
10
|
Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022. [PMID: 35791021 DOI: 10.1186/s13054-022-04073-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in 'baby lungs' of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS. METHODS Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O. RESULTS Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients. CONCLUSION Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of 'paradox' should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
Collapse
Affiliation(s)
- John Selickman
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA.
| | - Pierre Tawfik
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
| | - David J Dries
- Department of Surgery, Regions Hospital, St Paul, MN, USA
- Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Jonathan Shelver
- Department of Pulmonary and Critical Care Medicine, Methodist Hospital, St. Louis Park, MN, USA
| | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
- Department of Critical Care Medicine, Regions Hospital, St. Paul, MN, USA
| |
Collapse
|
11
|
Rezoagli E, Laffey JG, Bellani G. Monitoring Lung Injury Severity and Ventilation Intensity during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:346-368. [PMID: 35896391 DOI: 10.1055/s-0042-1748917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure burden by high hospital mortality. No specific pharmacologic treatment is currently available and its ventilatory management is a key strategy to allow reparative and regenerative lung tissue processes. Unfortunately, a poor management of mechanical ventilation can induce ventilation induced lung injury (VILI) caused by physical and biological forces which are at play. Different parameters have been described over the years to assess lung injury severity and facilitate optimization of mechanical ventilation. Indices of lung injury severity include variables related to gas exchange abnormalities, ventilatory setting and respiratory mechanics, ventilation intensity, and the presence of lung hyperinflation versus derecruitment. Recently, specific indexes have been proposed to quantify the stress and the strain released over time using more comprehensive algorithms of calculation such as the mechanical power, and the interaction between driving pressure (DP) and respiratory rate (RR) in the novel DP multiplied by four plus RR [(4 × DP) + RR] index. These new parameters introduce the concept of ventilation intensity as contributing factor of VILI. Ventilation intensity should be taken into account to optimize protective mechanical ventilation strategies, with the aim to reduce intensity to the lowest level required to maintain gas exchange to reduce the potential for VILI. This is further gaining relevance in the current era of phenotyping and enrichment strategies in ARDS.
Collapse
Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| |
Collapse
|
12
|
Bastia L, Rezoagli E, Guarnieri M, Engelberts D, Forlini C, Marrazzo F, Spina S, Bassi G, Giudici R, Post M, Bellani G, Fumagalli R, Brochard LJ, Langer T. External chest-wall compression in prolonged COVID-19 ARDS with low-compliance: a physiological study. Ann Intensive Care 2022; 12:35. [PMID: 35412161 PMCID: PMC9003155 DOI: 10.1186/s13613-022-01008-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/23/2022] [Indexed: 12/13/2022] Open
Abstract
Background External chest-wall compression (ECC) is sometimes used in ARDS patients despite lack of evidence. It is currently unknown whether this practice has any clinical benefit in patients with COVID-19 ARDS (C-ARDS) characterized by a respiratory system compliance (Crs) < 35 mL/cmH2O. Objectives To test if an ECC with a 5 L-bag in low-compliance C-ARDS can lead to a reduction in driving pressure (DP) and improve gas exchange, and to understand the underlying mechanisms. Methods Eleven patients with low-compliance C-ARDS were enrolled and underwent 4 steps: baseline, ECC for 60 min, ECC discontinuation and PEEP reduction. Respiratory mechanics, gas exchange, hemodynamics and electrical impedance tomography were recorded. Four pigs with acute ARDS were studied with ECC to understand the effect of ECC on pleural pressure gradient using pleural pressure transducers in both non-dependent and dependent lung regions. Results Five minutes of ECC reduced DP from baseline 14.2 ± 1.3 to 12.3 ± 1.3 cmH2O (P < 0.001), explained by an improved lung compliance. Changes in DP by ECC were strongly correlated with changes in DP obtained with PEEP reduction (R2 = 0.82, P < 0.001). The initial benefit of ECC decreased over time (DP = 13.3 ± 1.5 cmH2O at 60 min, P = 0.03 vs. baseline). Gas exchange and hemodynamics were unaffected by ECC. In four pigs with lung injury, ECC led to a decrease in the pleural pressure gradient at end-inspiration [2.2 (1.1–3) vs. 3.0 (2.2–4.1) cmH2O, P = 0.035]. Conclusions In C-ARDS patients with Crs < 35 mL/cmH2O, ECC acutely reduces DP. ECC does not improve oxygenation but it can be used as a simple tool to detect hyperinflation as it improves Crs and reduces Ppl gradient. ECC benefits seem to partially fade over time. ECC produces similar changes compared to PEEP reduction. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01008-6.
Collapse
Affiliation(s)
- Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Emergency and Intensive Care, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Marcello Guarnieri
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Doreen Engelberts
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Clarissa Forlini
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Marrazzo
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Spina
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Bassi
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Riccardo Giudici
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martin Post
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Emergency and Intensive Care, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.
| | - Thomas Langer
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| |
Collapse
|
13
|
Xiao B, Zhang Y, Ci Z, Shi D, He H. Awake prone positioning on diaphragmatic function: Really bad or maybe good? Crit Care 2021; 25:449. [PMID: 34965892 PMCID: PMC8716084 DOI: 10.1186/s13054-021-03866-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/07/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Basang Xiao
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region, China
| | - Yuntao Zhang
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region, China
| | - Zhuoga Ci
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region, China
| | - Dandan Shi
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region, China
| | - Hangyong He
- Department of Pulmonary Medicine, Lhasa People's Hospital, Lhasa, Tibet Autonomous Region, China. .,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, Beijing, 100020, China.
| |
Collapse
|
14
|
Ambrose A, Detelich J, Weinmann M, Hammond FL. Evaluation of a Pneumatic Vest to Treat Symptoms of ARDS Caused by COVID-19. J Med Device 2021. [DOI: 10.1115/1.4053387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Critical care patients who experience symptoms of acute respiratory distress syndrome are commonly placed on mechanical ventilators to increase the oxygen provided to their pulmonary systems and monitor their condition. With the pulmonary inflammation typically accompanying ARDS, patients can experience lower ventilation-perfusion ratios resulting in lower blood oxygenation. In these cases, patients are typically rotated into a prone position to facilitate improved blood flow to portions of the lung that were not previously participating in the gas exchange process. However, proning a patient increases the risk of complications, requires up to seven hospital staff members to carry out, and does not guarantee an improvement in the patient's condition. The low-cost vest presented here was designed to reproduce the effects of proning while also requiring less hospital staff than the proning process. Additionally, the V/Q Vest helps hospital staff predict whether patients would respond well to a proning treatment. A pilot study was conducted on nine patients with ARDS from Coronavirus disease 2019 (COVID-19). The average increase in oxygenation with the V/Q Vest treatment for all patients was 19.7 ± 38.1%. Six of the nine patients responded positively to the V/Q Vest treatment, exhibiting increased oxygenation. The V/Q Vest also helped hospital staff predict that three of the five patients that were proned would experience an increase in oxygenation. An increase in oxygenation resulting from V/Q Vest treatment exceeded that of the proning treatment in two of these five proned patients.
Collapse
Affiliation(s)
- Alexander Ambrose
- Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 313 Ferst Drive NW, Atlanta, GA 30332
| | - Joshua Detelich
- Emory School of Medicine, Emory University Hospital, 1821 Clifton Rd, Atlanta, GA 30329
| | - Maxwell Weinmann
- Emory School of Medicine, Emory University Hospital, 1821 Clifton Rd, Atlanta, GA 30329
| | - Frank L. Hammond
- Woodruff School of Mechanical Engineering and Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Drive NW, Atlanta, GA 30332
| |
Collapse
|
15
|
Lassola S, Miori S, Sanna A, Pace R, Magnoni S, Vetrugno L, Umbrello M. Effect of chest wall loading during supine and prone position in a critically ill covid-19 patient: a new strategy for ARDS? Crit Care 2021; 25:442. [PMID: 34930393 PMCID: PMC8686100 DOI: 10.1186/s13054-021-03865-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/13/2021] [Indexed: 01/16/2023] Open
Affiliation(s)
- Sergio Lassola
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Sara Miori
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy.
| | - Andrea Sanna
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Rocco Pace
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Sandra Magnoni
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS, Annunziata Hospital, Chieti, Italy.,Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
| | - Michele Umbrello
- SC Anestesia E Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milan, Italy
| |
Collapse
|
16
|
Cupaciu A, Cohen V, Dudoignon E, Dépret F. Continuous Lower Abdominal Compression as a Therapeutic Intervention in COVID-19 ARDS. Clin Med Insights Circ Respir Pulm Med 2021; 15:11795484211053476. [PMID: 34899002 PMCID: PMC8655439 DOI: 10.1177/11795484211053476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 11/17/2022] Open
Abstract
We report the case of a patient with severe COVID-19 ARDS, suggesting a possible
therapeutic intervention by applying a continuous lower abdominal compression. In order to
assess ventilation distribution, a lung CT scan was performed with and without lower
abdominal compression.
Collapse
Affiliation(s)
- Alexandru Cupaciu
- AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France.,FHU PROMICE, Paris, France.,DMU PARABOL, Paris, France
| | - Vladimir Cohen
- AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | - Emmanuel Dudoignon
- AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France.,FHU PROMICE, Paris, France.,DMU PARABOL, Paris, France.,University of Paris, Paris, France.,INSERM UMR-S942, Institut National de la Santé et de la Recherche Médicale (INSERM), Lariboisière Hospital, Paris, France
| | - François Dépret
- AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France.,FHU PROMICE, Paris, France.,DMU PARABOL, Paris, France.,University of Paris, Paris, France.,INSERM UMR-S942, Institut National de la Santé et de la Recherche Médicale (INSERM), Lariboisière Hospital, Paris, France.,INI-CRCT Network, Nancy, France
| |
Collapse
|
17
|
Dorsal Push and Abdominal Binding Improve Respiratory Compliance and Driving Pressure in Proned Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0593. [PMID: 34841252 PMCID: PMC8613362 DOI: 10.1097/cce.0000000000000593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We describe seven proned patients with coronavirus disease 2019-related acute respiratory distress syndrome in whom a paradoxical decrease in driving pressure reversibly occurred during passive, volume-controlled ventilation when compressing the lower back by a sustained "dorsal push." We offer a potential explanation for these unexpected observations and suggest the possible importance of eliciting this response for lung-protective ventilation of similar patients. DESIGN/SETTING Case series at a single teaching hospital affiliated with the University of Minnesota. Measurements were recorded from continuously monitored airway pressure and flow data. PATIENTS Nonconsecutive and nonrandomized sample of coronavirus disease 2019 acute respiratory distress syndrome patients who were already prone and paralyzed for optimized lung protective clinical management while inhaling pure oxygen. INTERVENTIONS Sustained, firm manual pressure applied over the lower back in all patients, followed by abdominal binding in a subset of these. MEASUREMENTS AND MAIN RESULTS Respiratory system driving pressure declined and respiratory system compliance improved in seven patients with the dorsal push maneuver. In a subset of four of these, abdominal binding sustained those improvements over >3 hours. CONCLUSIONS Sustained compressive force applied to the dorsum of the passive and prone patient with severe respiratory failure due to coronavirus disease pneumonia may elicit a paradoxical response characterized by improved compliance and for a given tidal volume, lower plateau, and driving pressures. Such findings, which suggest end-tidal overinflation within the aerated part of the diseased lung despite the already compressed anterior chest wall of prone positioning, complement and extend those observations recently described for the supine position in coronavirus disease 2019 acute respiratory distress syndrome.
Collapse
|
18
|
Marini JJ, Gattinoni L. Improving lung compliance by external compression of the chest wall. Crit Care 2021; 25:264. [PMID: 34321060 PMCID: PMC8318320 DOI: 10.1186/s13054-021-03700-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
As exemplified by prone positioning, regional variations of lung and chest wall properties provide possibilities for modifying transpulmonary pressures and suggest that clinical interventions related to the judicious application of external pressure may yield benefit. Recent observations made in late-phase patients with severe ARDS caused by COVID-19 (C-ARDS) have revealed unexpected mechanical responses to local chest wall compressions over the sternum and abdomen in the supine position that challenge the clinician's assumptions and conventional bedside approaches to lung protection. These findings appear to open avenues for mechanism-defining research investigation with possible therapeutic implications for all forms and stages of ARDS.
Collapse
Affiliation(s)
- John J Marini
- Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, 640 Jackson St., Minneapolis/St. Paul, Minnesota, 55101, USA.
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany
| |
Collapse
|