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Spina S, Mantz L, Xin Y, Moscho DC, Ribeiro De Santis Santiago R, Grassi L, Nova A, Gerard SE, Bittner EA, Fintelmann FJ, Berra L, Cereda M. The pleural gradient does not reflect the superimposed pressure in patients with class III obesity. Crit Care 2024; 28:306. [PMID: 39285477 PMCID: PMC11406718 DOI: 10.1186/s13054-024-05097-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Accepted: 09/12/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND The superimposed pressure is the primary determinant of the pleural pressure gradient. Obesity is associated with elevated end-expiratory esophageal pressure, regardless of lung disease severity, and the superimposed pressure might not be the only determinant of the pleural pressure gradient. The study aims to measure partitioned respiratory mechanics and superimposed pressure in a cohort of patients admitted to the ICU with and without class III obesity (BMI ≥ 40 kg/m2), and to quantify the amount of thoracic adipose tissue and muscle through advanced imaging techniques. METHODS This is a single-center observational study including ICU-admitted patients with acute respiratory failure who underwent a chest computed tomography scan within three days before/after esophageal manometry. The superimposed pressure was calculated from lung density and height of the largest axial lung slice. Automated deep-learning pipelines segmented lung parenchyma and quantified thoracic adipose tissue and skeletal muscle. RESULTS N = 18 participants (50% female, age 60 [30-66] years), with 9 having BMI < 30 and 9 ≥ 40 kg/m2. Groups showed no significant differences in age, sex, clinical severity scores, or mortality. Patients with BMI ≥ 40 exhibited higher esophageal pressure (15.8 ± 2.6 vs. 8.3 ± 4.9 cmH2O, p = 0.001), higher pleural pressure gradient (11.1 ± 4.5 vs. 6.3 ± 4.9 cmH2O, p = 0.04), while superimposed pressure did not differ (6.8 ± 1.1 vs. 6.5 ± 1.5 cmH2O, p = 0.59). Subcutaneous and intrathoracic adipose tissue were significantly higher in subjects with BMI ≥ 40 and correlated positively with esophageal pressure and pleural pressure gradient (p < 0.05). Muscle areas did not differ between groups. CONCLUSIONS In patients with class III obesity, the superimposed pressure does not approximate the pleural pressure gradient, which is higher than in patients with lower BMI. The quantity and distribution of subcutaneous and intrathoracic adiposity also contribute to increased pleural pressure gradients in individuals with BMI ≥ 40. This study introduces a novel physiological concept that provides a solid rationale for tailoring mechanical ventilation in patients with high BMI, where specific guidelines recommendations are lacking.
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Affiliation(s)
- Stefano Spina
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA.
- Harvard Medical School, Boston, USA.
| | - Lea Mantz
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Yi Xin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - David C Moscho
- Department of Radiology, Massachusetts General Hospital, Boston, USA
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Clinic Duesseldorf, Heinrich-Heine University Duesseldorf, Düsseldorf, Germany
| | - Roberta Ribeiro De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Luigi Grassi
- Anestesia Rianimazione Donna-Bambino, Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Nova
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Sarah E Gerard
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Florian J Fintelmann
- Harvard Medical School, Boston, USA
- Department of Radiology, Massachusetts General Hospital, Boston, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
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Piquilloud L, Beloncle FM. The role of pleural pressure and airway closure during mechanical ventilation. Author's reply. Intensive Care Med 2024; 50:1200-1201. [PMID: 38864910 DOI: 10.1007/s00134-024-07503-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Route du Bugnon 48, 1011, Lausanne, Switzerland.
| | - François M Beloncle
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, Angers, France
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Cammarota G, Vaschetto R, Vetrugno L, Maggiore SM. Monitoring lung recruitment. Curr Opin Crit Care 2024; 30:268-274. [PMID: 38690956 DOI: 10.1097/mcc.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
PURPOSE OF REVIEW This review explores lung recruitment monitoring, covering techniques, challenges, and future perspectives. RECENT FINDINGS Various methodologies, including respiratory system mechanics evaluation, arterial bold gases (ABGs) analysis, lung imaging, and esophageal pressure (Pes) measurement are employed to assess lung recruitment. In support to ABGs analysis, the assessment of respiratory mechanics with hysteresis and recruitment-to-inflation ratio has the potential to evaluate lung recruitment and enhance mechanical ventilation setting. Lung imaging tools, such as computed tomography scanning, lung ultrasound, and electrical impedance tomography (EIT) confirm their utility in following lung recruitment with the advantage of radiation-free and repeatable application at the bedside for sonography and EIT. Pes enables the assessment of dorsal lung tendency to collapse through end-expiratory transpulmonary pressure. Despite their value, these methodologies may require an elevated expertise in their application and data interpretation. However, the information obtained by these methods may be conveyed to build machine learning and artificial intelligence algorithms aimed at improving the clinical decision-making process. SUMMARY Monitoring lung recruitment is a crucial component of managing patients with severe lung conditions, within the framework of a personalized ventilatory strategy. Although challenges persist, emerging technologies offer promise for a personalized approach to care in the future.
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Affiliation(s)
- Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, Novara
| | - Rosanna Vaschetto
- Department of Translational Medicine, Università del Piemonte Orientale, Novara
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences
| | - Salvatore M Maggiore
- Department of Anesthesiology and Intensive Care, Ospedale SS Annunziata & Department of Innovative Technologies in Medicine and Odonto-stomatology, Università Gabriele D'Annunzio di Chieti-Pescara, Chieti, Italy
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4
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Piquilloud L, Beitler JR, Beloncle FM. Monitoring esophageal pressure. Intensive Care Med 2024; 50:953-956. [PMID: 38602514 DOI: 10.1007/s00134-024-07401-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/22/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Lise Piquilloud
- Adult Intensive Care Unit, University Hospital of Lausanne and Lausanne University, Route du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Columbia University, New York, NY, USA
| | - François M Beloncle
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, Angers, France
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5
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Rezoagli E, Bastia L. Obesity Enhances the Gravity Effect on the Respiratory System: The Importance of Monitoring Lung Mechanics. Chest 2024; 165:475-477. [PMID: 38461004 DOI: 10.1016/j.chest.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 03/11/2024] Open
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.
| | - Luca Bastia
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
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Rodriguez Guerineau L, Vieira F, Rodrigues A, Reise K, Todd M, Guerguerian AM, Brochard L. Airway opening pressure maneuver to detect airway closure in mechanically ventilated pediatric patients. Front Pediatr 2024; 12:1310494. [PMID: 38379913 PMCID: PMC10877025 DOI: 10.3389/fped.2024.1310494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/12/2024] [Indexed: 02/22/2024] Open
Abstract
Background Airway closure, which refers to the complete collapse of the airway, has been described under mechanical ventilation during anesthesia and more recently in adult patients with acute respiratory distress syndrome (ARDS). A ventilator maneuver can be used to identify airway closure and measure the pressure required for the airway to reopen, known as the airway opening pressure (AOP). Without that maneuver, AOP is unknown to clinicians. Objective This study aims to demonstrate the technical adaptation of the adult maneuver for children and illustrate its application in two cases of pediatric ARDS (p-ARDS). Methods A bench study was performed to adapt the maneuver for 3-50 kg patients. Four maneuvers were performed for each simulated patient, with 1, 2, 3, and 4 s of insufflation time to deliver a tidal volume (Vt) of 6 ml/kg by a continuous flow. Results Airway closure was simulated, and AOP was visible at 15 cmH2O with a clear inflection point, except for the 3 kg simulated patient. Regarding insufflation time, a 4 s maneuver exhibited a better performance in 30 and 50 kg simulated patients since shorter insufflation times had excessive flowrates (>10 L/min). Below 20 kg, the difference in resistive pressure between a 3 s and a 4 sec maneuver was negligible; therefore, prolonging the maneuver beyond 3 s was not useful. Airway closure was identified in two p-ARDS patients, with the pediatric maneuver being employed in the 28 kg patient. Conclusions We propose a pediatric AOP maneuver delivering 6 ml/kg of Vt at a continuous low-flow inflation for 3 s for patients weighing up to 20 kg and for 4 s for patients weighing beyond 20 kg.
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Affiliation(s)
- Luciana Rodriguez Guerineau
- Department of Critical Care Medicine, Hospital for Sick Children, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Fernando Vieira
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Antenor Rodrigues
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Katherine Reise
- Department of Respiratory Therapy and Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Mark Todd
- Department of Respiratory Therapy and Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, Hospital for Sick Children, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Laurent Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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McNamara L, Baedorf Kassis E. Optimal positive-end expiratory pressure weaning in acute respiratory distress syndrome patients. Curr Opin Crit Care 2024; 30:85-88. [PMID: 38085868 DOI: 10.1097/mcc.0000000000001122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW Positive-end expiratory pressure (PEEP) is a tool in managing acute respiratory distress syndrome (ARDS). In this review, we discuss the various approaches to weaning PEEP after the acute phase of ARDS. RECENT FINDINGS There is a paucity of research specifically looking at the differences between PEEP weaning protocols. Data in some populations though, particularly those with elevated BMI, suggest that a physiologic approach to PEEP weaning may be helpful. Use of various tools to optimize PEEP prior to and during spontaneous breathing trials (SBTs) may allow for improved alveolar recruitment and respiratory outcomes. SUMMARY Although further prospective studies are warranted, we should consider using a physiologic approach to PEEP weaning in ARDS rather than a one size fits all model, which is currently the standard used in many clinical trials and throughout many ICUs.
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Affiliation(s)
| | - Elias Baedorf Kassis
- Division of Pulmonary and Critical Care
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Somhorst P, Mousa A, Jonkman AH. Setting positive end-expiratory pressure: the use of esophageal pressure measurements. Curr Opin Crit Care 2024; 30:28-34. [PMID: 38062927 PMCID: PMC10763716 DOI: 10.1097/mcc.0000000000001120] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW To summarize the key concepts, physiological rationale and clinical evidence for titrating positive end-expiratory pressure (PEEP) using transpulmonary pressure ( PL ) derived from esophageal manometry, and describe considerations to facilitate bedside implementation. RECENT FINDINGS The goal of an esophageal pressure-based PEEP setting is to have sufficient PL at end-expiration to keep (part of) the lung open at the end of expiration. Although randomized studies (EPVent-1 and EPVent-2) have not yet proven a clinical benefit of this approach, a recent posthoc analysis of EPVent-2 revealed a potential benefit in patients with lower APACHE II score and when PEEP setting resulted in end-expiratory PL values close to 0 ± 2 cmH 2 O instead of higher or more negative values. Technological advances have made esophageal pressure monitoring easier to implement at the bedside, but challenges regarding obtaining reliable measurements should be acknowledged. SUMMARY Esophageal pressure monitoring has the potential to individualize the PEEP settings. Future studies are needed to evaluate the clinical benefit of such approach.
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Affiliation(s)
- Peter Somhorst
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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