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He G, Han Y, Zhang L, He C, Cai H, Zheng X. Respiratory effort in mechanical ventilation weaning Prediction: An observational, case-control study. Intensive Crit Care Nurs 2024; 86:103831. [PMID: 39265413 DOI: 10.1016/j.iccn.2024.103831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 08/10/2024] [Accepted: 09/04/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND The diaphragm is crucial for ventilator weaning, but its specific impact on weaning indicators needs further clarification. This study investigated the variability in weaning outcomes across different diaphragm function populations and the value of respiratory drive and inspiratory effort in weaning. METHODS This observational case-control study enrolled patients on mechanical ventilation for more than 48 h and completed a 30-minute spontaneous breathing trial (SBT) with pressure-support ventilation for the first time. After the SBT, airway pressure at 100 ms during occlusion (P0.1), inspiratory effort, and diaphragmatic ultrasound were evaluated to predict weaning outcomes. Weaning failure was defined as re-intubation within 48 h of weaning, the need for therapeutic non-invasive ventilation, or death. RESULTS 68 patients with a mean age of 63.21 ± 15.15 years were included. In patients with diaphragm thickness (DT) ≥ 2 mm, P0.1 (P=0.002), pressure-muscle index (PMI) (P=0.012), and occluded expiratory airway pressure swing (ΔPocc) (P=0.030) were significantly higher in those who failed weaning. Conversely, for patients with DT<2 mm, PMI (P=0.003) and ΔPocc (P=0.002) were lower in the weaning failure group. Additionally, within the DT≥2 mm group, P0.1 demonstrated a higher area under the curve (AUC) for weaning prediction (0.889 vs. 0.739) compared to those with DT<2 mm. CONCLUSIONS PMI and ΔPocc are predictive of weaning outcomes in patients with diaphragm thickness ≥ 2 mm, where the assessment value of P0.1 is notably higher. Diaphragm function significantly influences the accuracy of weaning predictions based on respiratory drive and inspiratory effort. IMPLICATIONS FOR CLINICAL PRACTICE Our findings indicate that the effectiveness of respiratory drive and inspiratory effort in predicting successful weaning from mechanical ventilation may vary across different patient populations. Diaphragm function plays a crucial role in weaning assessments, particularly when using P0.1, the pressure-muscle index (PMI), and occluded expiratory airway pressure swing (ΔPocc).
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Affiliation(s)
- Guojun He
- Department of Respiratory Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China; Key Laboratory of Clinical Evaluation Technology for Medical Device of Zhejiang Province, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China
| | - Yijiao Han
- Department of Respiratory Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China
| | - Liang Zhang
- Department of Respiratory Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China
| | - Chunfeng He
- Department of Respiratory Care, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China
| | - Hongliu Cai
- Key Laboratory of Clinical Evaluation Technology for Medical Device of Zhejiang Province, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China; Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China.
| | - Xia Zheng
- Key Laboratory of Clinical Evaluation Technology for Medical Device of Zhejiang Province, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China; Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, PR China.
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Le Marec J, Hajage D, Decavèle M, Schmidt M, Laurent I, Ricard JD, Jaber S, Azoulay E, Fartoukh M, Hraiech S, Mercat A, Similowski T, Demoule A. High Airway Occlusion Pressure Is Associated with Dyspnea and Increased Mortality in Critically Ill Mechanically Ventilated Patients. Am J Respir Crit Care Med 2024; 210:201-210. [PMID: 38319128 DOI: 10.1164/rccm.202308-1358oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/05/2024] [Indexed: 02/07/2024] Open
Abstract
Rationale: Airway occlusion pressure at 100 ms (P0.1) reflects central respiratory drive. Objectives: We aimed to assess factors associated with P0.1 and whether an abnormally low or high P0.1 value is associated with higher mortality and longer duration of mechanical ventilation (MV). Methods: We performed a secondary analysis of a prospective cohort study conducted in 10 ICUs in France to evaluate dyspnea in communicative MV patients. In patients intubated for more than 24 hours, P0.1 was measured with dyspnea as soon as patients could communicate and the next day. Measurements and Main Results: Among 260 patients assessed after a median time of ventilation of 4 days, P0.1 was 1.9 (1-3.5) cm H2O at enrollment, 24% had P0.1 values >3.5 cm H2O, 37% had P0.1 values between 1.5 and 3.5 cm H2O, and 39% had P0.1 values <1.5 cm H2O. In multivariable linear regression, independent factors associated with P0.1 were the presence of dyspnea (P = 0.037), respiratory rate (P < 0.001), and PaO2 (P = 0.008). Ninety-day mortality was 33% in patients with P0.1 > 3.5 cm H2O versus 19% in those with P0.1 between 1.5 and 3.5 cm H2O and 17% in those with P0.1 < 1.5 cm H2O (P = 0.046). After adjustment for the main risk factors, P0.1 was associated with 90-day mortality (hazard ratio per 1 cm H2O, 1.19 [95% confidence interval, 1.04-1.37]; P = 0.011). P0.1 was also independently associated with a longer duration of MV (hazard ratio per 1 cm H2O, 1.10 [95% confidence interval, 1.02-1.19]; P = 0.016). Conclusions: In patients receiving invasive MV, abnormally high P0.1 values may suggest dyspnea and are associated with higher mortality and prolonged duration of MV.
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Affiliation(s)
- Julien Le Marec
- Assistance Publique-Hôpitaux de Paris, 26930, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Paris, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, Paris, France
| | - Maxens Decavèle
- Assistance Publique-Hôpitaux de Paris, 26930, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Sorbonne Université, GRC 30, Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aiguë, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aiguë, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université, INSERM, Research Unit on Cardiovascular Diseases, Metabolism and Nutrition, ICAN, Paris, France
| | - Isaura Laurent
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, Paris, France
| | - Jean-Damien Ricard
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
- Université Paris Cité, UMR1137 IAME, INSERM, Paris, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Elie Azoulay
- Service de Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, and Université de Paris, Paris, France
| | - Muriel Fartoukh
- Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Service de Médecine Intensive Réanimation, Hôpital Tenon, Paris, France
- Sorbonne Université, UFR Médecine, Paris, France
- Groupe de Recherche Clinique CARMAS, Université Paris Est Créteil, Créteil, France
| | - Sami Hraiech
- Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, Marseille, France
- Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Marseille, France
| | - Alain Mercat
- Service de Réanimation Médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France; and
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Alexandre Demoule
- Assistance Publique-Hôpitaux de Paris, 26930, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Sorbonne Université, GRC 30, Reanimation et Soins Intensifs du Patient en Insuffisance Respiratoire Aiguë, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
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Ball L, Talmor D, Pelosi P. Transpulmonary pressure monitoring in critically ill patients: pros and cons. Crit Care 2024; 28:177. [PMID: 38796447 PMCID: PMC11127359 DOI: 10.1186/s13054-024-04950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024] Open
Abstract
The use of transpulmonary pressure monitoring based on measurement of esophageal pressure has contributed importantly to the personalization of mechanical ventilation based on respiratory pathophysiology in critically ill patients. However, esophageal pressure monitoring is still underused in the clinical practice. This technique allows partitioning of the respiratory mechanics between the lungs and the chest wall, provides information on lung recruitment and risk of barotrauma, and helps titrating mechanical ventilation settings in patients with respiratory failure. In assisted ventilation modes and during non-invasive respiratory support, esophageal pressure monitoring provides important information on the inspiratory effort and work of breathing. Nonetheless, several controversies persist on technical aspects, interpretation and clinical decision-making based on values derived from this monitoring technique. The aim of this review is to summarize the physiological bases of esophageal pressure monitoring, discussing the pros and cons of its clinical applications and different interpretations in critically ill patients undergoing invasive and non-invasive respiratory support.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
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Chow JWY, Al-Bassam W, Yanase F, O'Brien Z, Bassam A, Hadzakis S, Chaba A, Maeda A, Bellomo R, Serpa Neto A. P0.1 During Pressure Support Ventilation. Am J Respir Crit Care Med 2024; 209:590-592. [PMID: 37991405 DOI: 10.1164/rccm.202307-1314le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023] Open
Affiliation(s)
- Joanna W Y Chow
- Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Wisam Al-Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | | | - Zachary O'Brien
- Austin Health and
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Ahmad Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Stefanos Hadzakis
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | | | | | - Rinaldo Bellomo
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; and
| | - Ary Serpa Neto
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Roshon M, Khandhar PB, Biniwale M, Ramanathan R, Frazier TP, Xu F, Zhang L, Guan X, Wenling D, Lambermont B. Evaluation of the Puritan Bennett™ 980 Ventilator System Safety and Performance in the Real-World Setting. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2024; 17:37-45. [PMID: 38282718 PMCID: PMC10821633 DOI: 10.2147/mder.s433900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/12/2024] [Indexed: 01/30/2024] Open
Abstract
Purpose Mechanical ventilation is a life-supporting intervention but is associated with known risks and complications. To improve the efficacy and safety profile of mechanical ventilation, manufacturers have developed advanced ventilator settings, modes, and alarm strategies to optimize ventilation for patient needs while avoiding complications. However, there is little real-world data published on the deployment of ventilator technology. The main objective of this study was to assess the clinical safety and performance of the Puritan Bennett™ 980 Ventilator System (PB980) using real-world clinical data collected from a diverse, global patient population. Methods This was a multi-center, post-market registry study that included nine sites: four in the United States of America, one in Europe, and four in China. Patients were enrolled into the registry if they were intended to be treated with a PB980. Data collection began at the start of ventilation and continued until extubation off the ventilator or up to seven days of ventilation, whichever occurred first. Subjects were divided by age into three categories: infants (0-365 days), pediatric (1-17 years), and adult (18 years and older). The primary outcome was device-related complication rate. Results Two-hundred-and-eleven subjects were enrolled (41 infants, 48 pediatric, and 122 adults). Sixteen deaths, unrelated to device deficiency, occurred during the data collection timeframe (relative frequency: 7.58, 95% CI: 4.40, 12.0). Only one device-related adverse event was reported (relative frequency: 0.47% 95% CI: 0.01%, 2.61%). Conclusion Ventilation by the PB980 was delivered safely in this multi-center observational study, which included a diverse sample of patients with broad ventilatory needs.
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Affiliation(s)
- Michael Roshon
- Department of Emergency Medicine, Penrose-St. Francis Health Services, Colorado, Springs, CO, USA
| | - Paras B Khandhar
- Pediatric Critical Care Medicine, Beaumont Children’s Hospital, Royal Oak, MI, USA
| | - Manoj Biniwale
- Division of Neonatology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Rangasamy Ramanathan
- Division of Neonatology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - T Patrick Frazier
- Department of Medicine, University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, AL, USA
| | - Feng Xu
- Department of Intensive Care, Children’s Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xiangdong Guan
- Department of Critical Care Medicine, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Dai Wenling
- Department of Critical Care Medicine, Yancheng First People’s Hospital, Yancheng, People’s Republic of China
| | - Bernard Lambermont
- Department of Intensive Care, University Hospital of Liege, Liege, Belgium
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Ide Y, Urushibata N, Takayama W, Hondo K, Aiboshi J, Otomo Y. Clinical characteristics of pneumothorax and pneumomediastinum in mechanical ventilated patients with coronavirus disease 2019: a case series. J Med Case Rep 2024; 18:7. [PMID: 38166996 PMCID: PMC10759624 DOI: 10.1186/s13256-023-04281-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Pneumothorax (PTX) and pneumomediastinum (PM) have been reported as potential complications in patients with coronavirus disease 2019 (COVID-19); however, their risk factors and etiology remain unknown. Herein, we investigated the clinical characteristics of mechanically ventilated patients with COVID-19 with PTX or PM. METHODS We examined patients with severe COVID-19 requiring mechanical ventilation who were admitted to the intensive care unit of a tertiary-level emergency medical center in Tokyo, Japan between April 1, 2020. and October 31, 2021. We collected and analyzed the clinical characteristics of the patients who presented with either PTX or PM during mechanical ventilation. RESULTS During the study period, a total of 165 patients required mechanical ventilation, and 15 patients with PTX/PM during mechanical ventilation were selected. Three patients with obvious causes were excluded, and the remaining 12 patients were analyzed (7.3%). The mortality rate in these patients was as high as 50%, demonstrating the difficulty of treatment in the presence of PTX/PM. PTX/PM occurred 14.5 days after intubation. A peak pressure of > 30 cmH2O was only apparent in one patient, suggesting that high positive pressure ventilation may be less involved than mentioned in the literature. In addition, the inspiratory effort was not strong in our group of patients. (P0.1 was 2.1 cm H2O [1.0-3.8]). CONCLUSION Various factors are associated with the development of PTX/PM in patients on mechanical ventilation for COVID-19. We did not find a strong correlation between PTM/PM and barotrauma or strong inspiratory efforts, which have been identified as potential causes in previous studies.
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Affiliation(s)
- Yohei Ide
- Trauma and Acute Critical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
| | - Nao Urushibata
- Trauma and Acute Critical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan.
| | - Wataru Takayama
- Trauma and Acute Critical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
| | - Kenichi Hondo
- Trauma and Acute Critical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
| | - Junichi Aiboshi
- Trauma and Acute Critical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Center, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
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Wang WZ, Ying LJ, Liu WD, Zhang P, Li SF. Findings of ventilator-measured P0.1 in assessing respiratory drive in patients with severe ARDS. Technol Health Care 2024; 32:719-726. [PMID: 37393453 DOI: 10.3233/thc-230096] [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: 07/03/2023]
Abstract
BACKGROUND Providers should adjust the depth of sedation to promote lung-protective ventilation in patients with severe ARDS. This recommendation was based on the assumption that the depth of sedation could be used to assess respiratory drive. OBJECTIVE To assess the association between respiratory drive and sedation in patients with severe ARDS by using ventilator-measured P0.1 and RASS score. METHODS Loss of spontaneous breathing was observed within 48 h of mechanical ventilation in patients with severe ARDS, and spontaneous breathing returned after 48 hours. P0.1 was measured by ventilator every 12 ± 2 hours, and the RASS score was measured synchronously. RESULTS The RASS score was moderately correlated with P0.1 (R𝑆𝑝𝑒𝑎𝑟𝑚𝑎𝑛, 0.570; 95% CI, 0.475 to 0.637; p= 0.00). However, only patients with a RASS score of -5 were considered to have no excessive respiratory drive, but there was a risk for loss of spontaneous breathing. A P0.1 exceeding 3.5 cm H2O in patients with other RASS scores indicated an increase in respiratory drive. CONCLUSION RASS score has little clinical significance in evaluating respiratory drive in severe ARDS. P0.1 should be evaluated by ventilator when adjusting the depth of sedation to promote lung-protective ventilation.
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Olímpio Júnior H, Camilo GB, Marques JA, Xavier RS, Santos CE, Lopes AJ. Effects of transcutaneous electrical diaphragmatic stimulation in critically ill elderly patients: a randomized controlled trial. Physiother Theory Pract 2023:1-10. [PMID: 38044840 DOI: 10.1080/09593985.2023.2289053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/25/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Elderly patients under invasive mechanical ventilation (IMV) are more susceptible to muscle weakness. In the out-of-hospital environment, there are benefits to transcutaneous electrical diaphragmatic stimulation (TEDS), which is an easy-to-apply and low-cost technique. OBJECTIVE To evaluate the effect of TEDS on respiratory muscle strength, diaphragm thickness (DT), and IMV time in critically ill elderly patients. METHODS This was a randomized controlled trial in which patients were divided into an experimental group (EG) and a control group (CG). TEDS started 24 h after orotracheal intubation and lasted until the end of weaning. Both groups underwent the following assessments during the spontaneous breathing test after weaning from mechanical ventilation (MV): measurement of respiratory muscle strength by pressure gauge, analysis of DT by lung ultrasound, and extubation failure prevention checklist. RESULTS There were 23 participants in the EG and 21 in the CG. The median age was 66 (60-79) years. The mean values of the diaphragmatic thickening index in the EG and CG participants were 99.13 ± 26.75 and 66.88 ± 31.77, respectively (p = .001, Cohen's d = 1.094). The mean values of maximum inspiratory pressure in the EG and CG were 22.04 ± 3.41 and 19.34 ± 4.23 cmH2O, respectively (p = .005, Cohen's d = 0.698). The Tobin index and the integrative weaning index were similar between groups (p = .584 and p = .102, respectively). The duration of MV in the EG and CG was 6.28 ± 2.68 and 9.21 ± 2.76 days, respectively (p = .001, Cohen's d = -1.075). CONCLUSION Critically ill elderly patients receiving TEDS had shorter MV time, greater inspiratory muscle strength, and greater diaphragmatic contraction capacity according to their thickness fraction.
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Affiliation(s)
- Hebert Olímpio Júnior
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Gustavo Bittencourt Camilo
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
- Faculty of Medical and Health Sciences of Juiz de Fora (SUPREMA), Minas Gerais, Brazil
| | | | - Rosemere Saldanha Xavier
- Local Development Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
| | - Carlos Eduardo Santos
- Rehabilitation Sciences Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
- Local Development Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
- Rehabilitation Sciences Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
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Ito Y, Herrera MG, Hotz JC, Kyogoku M, Newth CJL, Bhalla AK, Takeuchi M, Khemani RG. Estimation of inspiratory effort using airway occlusion maneuvers in ventilated children: a secondary analysis of an ongoing randomized trial testing a lung and diaphragm protective ventilation strategy. Crit Care 2023; 27:466. [PMID: 38031116 PMCID: PMC10685539 DOI: 10.1186/s13054-023-04754-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Monitoring respiratory effort in ventilated patients is important to balance lung and diaphragm protection. Esophageal manometry remains the gold standard for monitoring respiratory effort but is invasive and requires expertise for its measurement and interpretation. Airway pressures during occlusion maneuvers may provide an alternative, although pediatric data are limited. We sought to determine the correlation between change in esophageal pressure during tidal breathing (∆Pes) and airway pressure measured during three airway occlusion maneuvers: (1) expiratory occlusion pressure (Pocc), (2) airway occlusion pressure (P0.1), and (3) respiratory muscle pressure index (PMI) in children. We also sought to explore pediatric threshold values for these pressures to detect excessive or insufficient respiratory effort. METHODS Secondary analysis of physiologic data from children between 1 month and 18 years of age with acute respiratory distress syndrome enrolled in an ongoing randomized clinical trial testing a lung and diaphragm protective ventilation strategy (REDvent, R01HL124666). ∆Pes, Pocc, P0.1, and PMI were measured. Repeated measure correlations were used to investigate correlation coefficients between ∆Pes and the three measures, and linear regression equations were generated to identify potential therapeutic thresholds. RESULTS There were 653 inspiratory and 713 expiratory holds from 97 patients. Pocc had the strongest correlation with ∆Pes (r = 0.68), followed by PMI (r = 0.60) and P0.1 (r = 0.42). ∆Pes could be reliably estimated using the regression equation ∆Pes = 0.66 [Formula: see text] Pocc (R2 = 0.82), with Pocc cut-points having high specificity and moderate sensitivity to detect respective ∆Pes thresholds for high and low respiratory effort. There were minimal differences in the relationship between Pocc and ∆Pes based on age (infant, child, adolescent) or mode of ventilation (SIMV versus Pressure Support), although these differences were more apparent with P0.1 and PMI. CONCLUSIONS Airway occlusion maneuvers may be appropriate alternatives to esophageal pressure measurement to estimate the inspiratory effort in children, and Pocc represents the most promising target. TRIAL REGISTRATION NCT03266016; August 23, 2017.
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Affiliation(s)
- Yukie Ito
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Matías G Herrera
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Intensive Care, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina
| | - Justin C Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
| | - Miyako Kyogoku
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Muneyuki Takeuchi
- Department of Intensive Care, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, USA.
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA.
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10
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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.
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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.
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11
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Katayama S, Tonai K, Nunomiya S. Bias and Precision of Continuous P 0.1 Measurement by Various Ventilators: A Simulation Study. Respir Care 2023; 68:1393-1399. [PMID: 37221083 PMCID: PMC10506633 DOI: 10.4187/respcare.10755] [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: 05/25/2023]
Abstract
BACKGROUND Most ventilators measure airway occlusion pressure (occlusion P0.1) by occluding the breathing circuit; however, some ventilators can predict P0.1 for each breath without occlusion. Nevertheless, few studies have verified the accuracy of continuous P0.1 measurement. The aim of this study was to evaluate the accuracy of continuous P0.1 measurement compared with that of occlusion methods for various ventilators using a lung simulator. METHODS A total of 42 breathing patterns were validated using a lung simulator in combination with 7 different inspiratory muscular pressures and 3 different rise rates to simulate normal and obstructed lungs. PB980 and Dräger V500 ventilators were used to obtain occlusion P0.1 measurements. The occlusion maneuver was performed on the ventilator, and a corresponding reference P0.1 was recorded from the ASL5000 breathing simulator simultaneously. Hamilton-C6, Hamilton-G5, and Servo-U ventilators were used to obtain sustained P0.1 measurements (continuous P0.1). The reference P0.1 measured with the simulator was analyzed by using a Bland-Altman plot. RESULTS The 2 lung mechanical models capable of measuring occlusion P0.1 yielded values equivalent to reference P0.1 (bias and precision values were 0.51 and 1.06, respectively, for the Dräger V500, and were 0.54 and 0.91, respectively, for the PB980). Continuous P0.1 for the Hamilton-C6 was underestimated in both the normal and obstructive models (bias and precision values were -2.13 and 1.91, respectively), whereas continuous P0.1 for the Servo-U was underestimated only in the obstructive model (bias and precision values were -0.86 and 1.76, respectively). Continuous P0.1 for the Hamilton-G5 was mostly similar to but less accurate than occlusion P0.1 (bias and precision values were 1.62 and 2.06, respectively). CONCLUSIONS The accuracy of continuous P0.1 measurements varies based on the characteristics of the ventilator and should be interpreted by considering the characteristics of each system. Moreover, measurements obtained with an occluded circuit could be desirable for determining the true P0.1.
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Affiliation(s)
- Shinshu Katayama
- Intensive Care Section, Emergency and Critical Care/General Intensive Care Center, Jichi Medical University Hospital, Shimotsuke, Tochigi, Japan.
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Ken Tonai
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Shin Nunomiya
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
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12
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Chen H, Liang M, He Y, Teboul JL, Sun Q, Xie J, Yang Y, Qiu H, Liu L. Inspiratory effort impacts the accuracy of pulse pressure variations for fluid responsiveness prediction in mechanically ventilated patients with spontaneous breathing activity: a prospective cohort study. Ann Intensive Care 2023; 13:72. [PMID: 37592166 PMCID: PMC10435426 DOI: 10.1186/s13613-023-01167-0] [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: 02/16/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Pulse pressure variation (PPV) is unreliable in predicting fluid responsiveness (FR) in patients receiving mechanical ventilation with spontaneous breathing activity. Whether PPV can be valuable for predicting FR in patients with low inspiratory effort is unknown. We aimed to investigate whether PPV can be valuable in patients with low inspiratory effort. METHODS This prospective study was conducted in an intensive care unit at a university hospital and included acute circulatory failure patients receiving volume-controlled ventilation with spontaneous breathing activity. Hemodynamic measurements were collected before and after a fluid challenge. The degree of inspiratory effort was assessed using airway occlusion pressure (P0.1) and airway pressure swing during a whole breath occlusion (ΔPocc) before fluid challenge. Patients were classified as fluid responders if their cardiac output increased by ≥ 10%. Areas under receiver operating characteristic (AUROC) curves and gray zone approach were used to assess the predictive performance of PPV. RESULTS Among the 189 included patients, 53 (28.0%) were defined as responders. A PPV > 9.5% enabled to predict FR with an AUROC of 0.79 (0.67-0.83) in the whole population. The predictive performance of PPV differed significantly in groups stratified by the median value of P0.1 (P0.1 < 1.5 cmH2O and P0.1 ≥ 1.5 cmH2O), but not in groups stratified by the median value of ΔPocc (ΔPocc < - 9.8 cmH2O and ΔPocc ≥ - 9.8 cmH2O). Specifically, in patients with P0.1 < 1.5 cmH2O, PPV was associated with an AUROC of 0.90 (0.82-0.99) compared with 0.68 (0.57-0.79) otherwise (p = 0.0016). The cut-off values of PPV were 10.5% and 9.5%, respectively. Besides, patients with P0.1 < 1.5 cmH2O had a narrow gray zone (10.5-11.5%) compared to patients with P0.1 ≥ 1.5 cmH2O (8.5-16.5%). CONCLUSIONS PPV is reliable in predicting FR in patients who received controlled ventilation with low spontaneous effort, defined as P0.1 < 1.5 cmH2O. Trial registration NCT04802668. Registered 6 February 2021, https://clinicaltrials.gov/ct2/show/record/NCT04802668.
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Affiliation(s)
- Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, No. 899 Pinghai Road, Suzhou, 215000 People’s Republic of China
| | - Meihao Liang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, Changsha central hospital, University of South China, No. 161, South Shaoshan Road, Changsha, 410000 Hunan People’s Republic of China
| | - Yuanchao He
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
- Department of Critical Care Medicine, Wuhan first hospital of Hubei Province, No 215 Zhongshan Avenue, Qiaokou District, Wuhan, 430000 People’s Republic of China
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, Université Paris-Saclay, AP-HP, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Jianfen Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009 People’s Republic of China
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Jonkman AH, Telias I, Spinelli E, Akoumianaki E, Piquilloud L. The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects. Eur Respir Rev 2023; 32:220186. [PMID: 37197768 PMCID: PMC10189643 DOI: 10.1183/16000617.0186-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/22/2023] [Indexed: 05/19/2023] Open
Abstract
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure (P oes) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, P oes monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using P oes measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of P oes-guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital-Unity Health Toronto, Toronto, ON, Canada
| | - Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evangelia Akoumianaki
- Adult Intensive Care Unit, University Hospital of Heraklion, Heraklion, Greece
- Medical School, University of Crete, Heraklion, Greece
| | - Lise Piquilloud
- Adult Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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14
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Spinelli E, Pesenti A, Slobod D, Fornari C, Fumagalli R, Grasselli G, Volta CA, Foti G, Navalesi P, Knafelj R, Pelosi P, Mancebo J, Brochard L, Mauri T. Clinical risk factors for increased respiratory drive in intubated hypoxemic patients. Crit Care 2023; 27:138. [PMID: 37041553 PMCID: PMC10088111 DOI: 10.1186/s13054-023-04402-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/14/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND There is very limited evidence identifying factors that increase respiratory drive in hypoxemic intubated patients. Most physiological determinants of respiratory drive cannot be directly assessed at the bedside (e.g., neural inputs from chemo- or mechano-receptors), but clinical risk factors commonly measured in intubated patients could be correlated with increased drive. We aimed to identify clinical risk factors independently associated with increased respiratory drive in intubated hypoxemic patients. METHODS We analyzed the physiological dataset from a multicenter trial on intubated hypoxemic patients on pressure support (PS). Patients with simultaneous assessment of the inspiratory drop in airway pressure at 0.1-s during an occlusion (P0.1) and risk factors for increased respiratory drive on day 1 were included. We evaluated the independent correlation of the following clinical risk factors for increased drive with P0.1: severity of lung injury (unilateral vs. bilateral pulmonary infiltrates, PaO2/FiO2, ventilatory ratio); arterial blood gases (PaO2, PaCO2 and pHa); sedation (RASS score and drug type); SOFA score; arterial lactate; ventilation settings (PEEP, level of PS, addition of sigh breaths). RESULTS Two-hundred seventeen patients were included. Clinical risk factors independently correlated with higher P0.1 were bilateral infiltrates (increase ratio [IR] 1.233, 95%CI 1.047-1.451, p = 0.012); lower PaO2/FiO2 (IR 0.998, 95%CI 0.997-0.999, p = 0.004); higher ventilatory ratio (IR 1.538, 95%CI 1.267-1.867, p < 0.001); lower pHa (IR 0.104, 95%CI 0.024-0.464, p = 0.003). Higher PEEP was correlated with lower P0.1 (IR 0.951, 95%CI 0.921-0.982, p = 0.002), while sedation depth and drugs were not associated with P0.1. CONCLUSIONS Independent clinical risk factors for higher respiratory drive in intubated hypoxemic patients include the extent of lung edema and of ventilation-perfusion mismatch, lower pHa, and lower PEEP, while sedation strategy does not affect drive. These data underline the multifactorial nature of increased respiratory drive.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Critical Care Medicine, McGill University, Montreal, QC, Canada
| | - Carla Fornari
- Research Centre On Public Health, University of Milano - Bicocca, Monza, Italy
| | - Roberto Fumagalli
- Anesthesia and Critical Care Service 1, Niguarda Hospital, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carlo Alberto Volta
- Morphology, Surgery and Experimental Medicine, Anesthesia and Intensive Care Unit, University of Ferrara, Ferrara, Italy
| | - Giuseppe Foti
- Anesthesia and Critical Care, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medicine - DIMED, Padua University Hospital, University of Padua, Padua, Italy
| | - Rihard Knafelj
- Center for Internal Intensive Medicine (MICU), University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Jordi Mancebo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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15
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Roshdy A. Respiratory Monitoring During Mechanical Ventilation: The Present and the Future. J Intensive Care Med 2023; 38:407-417. [PMID: 36734248 DOI: 10.1177/08850666231153371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increased application of mechanical ventilation, the recognition of its harms and the interest in individualization raised the need for an effective monitoring. An increasing number of monitoring tools and modalities were introduced over the past 2 decades with growing insight into asynchrony, lung and chest wall mechanics, respiratory effort and drive. They should be used in a complementary rather than a standalone way. A sound strategy can guide a reduction in adverse effects like ventilator-induced lung injury, ventilator-induced diaphragm dysfunction, patient-ventilator asynchrony and helps early weaning from the ventilator. However, the diversity, complexity, lack of expertise, and associated cost make formulating the appropriate monitoring strategy a challenge for clinicians. Most often, a big amount of data is fed to the clinicians making interpretation difficult. Therefore, it is fundamental for intensivists to be aware of the principle, advantages, and limits of each tool. This analytic review includes a simplified narrative of the commonly used basic and advanced respiratory monitors along with their limits and future prospective.
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Affiliation(s)
- Ashraf Roshdy
- Critical Care Medicine Department, Faculty of Medicine, 54562Alexandria University, Alexandria, Egypt.,Critical Care Unit, North Middlesex University Hospital, London, UK
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16
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van Diepen A, Bakkes THGF, De Bie AJR, Turco S, Bouwman RA, Woerlee PH, Mischi M. Evaluation of the accuracy of established patient inspiratory effort estimation methods during mechanical support ventilation. Heliyon 2023; 9:e13610. [PMID: 36852019 PMCID: PMC9958297 DOI: 10.1016/j.heliyon.2023.e13610] [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: 11/02/2022] [Revised: 12/13/2022] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
There is a clinical need for monitoring inspiratory effort to prevent lung- and diaphragm injury in patients who receive supportive mechanical ventilation in an Intensive Care Unit. Different pressure-based techniques are available to estimate this inspiratory effort at the bedside, but the accuracy of their effort estimation is uncertain since they are all based on a simplified linear model of the respiratory system, which omits gas compressibility of air, and the viscoelasticity and nonlinearities of the respiratory system. The aim of this in-silico study was to provide an overview of the pressure-based estimation techniques and to evaluate their accuracy using a more sophisticated model of the respiratory system and ventilator. The influence of the following parameters on the accuracy of the pressure-based estimation techniques was evaluated using the in-silico model: 1) the patient's respiratory mechanics 2) PEEP and the inspiratory pressure of the ventilator 3) gas compressibility of air 4) viscoelasticity of the respiratory system 5) the strength of the inspiratory effort. The best-performing technique in terms of accuracy was the whole breath occlusion. The average error and maximum error were the lowest for all patient archetypes. We found that the error was related to the expansion of gas in the breathing set and lungs and respiratory compliance. However, concerns exist that other factors not included in the model, such as a changed muscle-force relation during an occlusion, might influence the true accuracy. The estimation techniques based on the esophageal pressure showed an error related to the viscoelastic element in the model which leads to a higher error than the occlusion. The error of the esophageal pressure-based techniques is therefore highly dependent on the pathology of the patient and the settings of the ventilator and might change over time while a patient recovers or becomes more ill.
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Affiliation(s)
- A van Diepen
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - T H G F Bakkes
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - A J R De Bie
- Catharina Hospital, Michelangelolaan 2, Eindhoven, 5623 EJ, Noord-Brabant, the Netherlands
| | - S Turco
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - R A Bouwman
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands.,Catharina Hospital, Michelangelolaan 2, Eindhoven, 5623 EJ, Noord-Brabant, the Netherlands
| | - P H Woerlee
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
| | - M Mischi
- Department of Electrical Engineering, Technische Universiteit Eindhoven, De Zaale, Eindhoven, 5612AZ, Noord-Brabant, the Netherlands
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17
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Takane R, Nakajima M, Miwa M, Kaszynski RH, Nakano T, Goto H, Takeuchi M. Breath-by-breath P0.1 measured on quasi-occlusion via Hamilton C6 may result in underestimation of respiratory drive and inspiratory effort. Crit Care 2022; 26:403. [PMID: 36567319 PMCID: PMC9790810 DOI: 10.1186/s13054-022-04286-5] [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: 09/07/2022] [Accepted: 12/17/2022] [Indexed: 12/27/2022] Open
Abstract
We aimed to identify the threshold for P0.1 in a breath-by-breath manner measured by the Hamilton C6 on quasi-occlusion for high respiratory drive and inspiratory effort. In this prospective observational study, we analyzed the relationships between airway P0.1 on quasi-occlusion and esophageal pressure (esophageal P0.1 and esophageal pressure swing). We also conducted a linear regression analysis and derived the threshold of airway P0.1 on quasi-occlusion for high respiratory drive and inspiratory effort. We found that airway P0.1 measured on quasi-occlusion had a strong positive correlation with esophageal P0.1 measured on quasi-occlusion and esophageal pressure swing, respectively. Additionally, the P0.1 threshold for high respiratory drive and inspiratory effort were calculated at approximately 1.0 cmH2O from the regression equations. Our calculations suggest a lower threshold of airway P0.1 measured by the Hamilton C6 on quasi-occlusion than that which has been previously reported.
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Affiliation(s)
- Ryo Takane
- grid.417093.80000 0000 9912 5284Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, 2−34−10, Ebisu, Shibuya-Ku, Tokyo, 150-0013 Japan
| | - Mikio Nakajima
- grid.417093.80000 0000 9912 5284Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, 2−34−10, Ebisu, Shibuya-Ku, Tokyo, 150-0013 Japan
| | - Maki Miwa
- grid.417093.80000 0000 9912 5284Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, 2−34−10, Ebisu, Shibuya-Ku, Tokyo, 150-0013 Japan
| | - Richard H. Kaszynski
- grid.417093.80000 0000 9912 5284Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, 2−34−10, Ebisu, Shibuya-Ku, Tokyo, 150-0013 Japan
| | - Tomotsugu Nakano
- grid.417093.80000 0000 9912 5284Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, 2−34−10, Ebisu, Shibuya-Ku, Tokyo, 150-0013 Japan
| | - Hideaki Goto
- grid.417093.80000 0000 9912 5284Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, 2−34−10, Ebisu, Shibuya-Ku, Tokyo, 150-0013 Japan
| | - Muneyuki Takeuchi
- grid.416629.e0000 0004 0377 2137Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
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18
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Lee HY, Lee J, Lee SM. Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial. Crit Care 2022; 26:402. [PMID: 36564808 PMCID: PMC9783722 DOI: 10.1186/s13054-022-04281-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A spontaneous breathing trial (SBT) is used to determine whether patients are ready for extubation, but the best method for choosing the SBT strategy remains controversial. We investigated the effect of high-flow oxygen versus T-piece ventilation strategies during SBT on rates of weaning failure among patients receiving mechanical ventilation. METHODS This randomized clinical trial was conducted from June 2019 through January 2022 among patients receiving mechanical ventilation for ≥ 12 h who fulfilled the weaning readiness criteria at a single-center medical intensive care unit. Patients were randomized to undergo either T-piece SBT or high-flow oxygen SBT. The primary outcome was weaning failure on day 2, and the secondary outcomes were weaning failure on day 7, ICU and hospital length of stay, and ICU and in-hospital morality. RESULTS Of 108 patients (mean age, 67.0 ± 11.1 years; 64.8% men), 54 received T-piece SBT and 54 received high-flow oxygen SBT. Weaning failure on day 2 occurred in 5 patients (9.3%) in the T-piece group and 3 patients (5.6%) in the high-flow group (difference, 3.7% [95% CI, - 6.1-13.6]; p = 0.713). Weaning failure on day 7 occurred in 13 patients (24.1%) in the T-piece group and 7 patients (13.0%) in the high-flow group (difference, 11.1% [95% CI, - 3.4-25.6]; p = 0.215). A post hoc subgroup analysis showed that high-flow oxygen SBT was significantly associated with a lower rate of weaning failure on day 7 (OR, 0.17 [95% CI, 0.04-0.78]) among those patients intubated because of respiratory failure (p for interaction = 0.020). The ICU and hospital length of stay and mortality rates did not differ significantly between the two groups. During the study, no serious adverse events were recorded. CONCLUSIONS Among patients receiving mechanical ventilation, high-flow oxygen SBT did not significantly reduce the risk of weaning failure compared with T-piece SBT. However, the study may have been underpowered to detect a clinically important treatment effect for the comparison of high-flow oxygen SBT versus T-piece SBT, and a higher percentage of patients with simple weaning and a lower weaning failure rate than expected should be considered when interpreting the findings. Clinical trial registration This trial was registered with ClinicalTrials.gov (number NCT03929328) on April 26, 2019.
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Affiliation(s)
- Hong Yeul Lee
- grid.412484.f0000 0001 0302 820XDepartment of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinwoo Lee
- grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Republic of Korea
| | - Sang-Min Lee
- grid.412484.f0000 0001 0302 820XDepartment of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea ,grid.412484.f0000 0001 0302 820XDivision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Republic of Korea
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19
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Ríos-Castro F, González-Seguel F, Molina J. Respiratory drive, inspiratory effort, and work of breathing: review of definitions and non-invasive monitoring tools for intensive care ventilators during pandemic times. Medwave 2022; 22:e8724. [DOI: 10.5867/medwave.2022.03.002550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/28/2022] [Indexed: 11/27/2022] Open
Abstract
Technological advances in mechanical ventilation have been essential to increasing the survival rate in intensive care units. Usually, patients needing mechanical ventilation use controlled ventilation to override the patient’s respiratory muscles and favor lung protection. Weaning from mechanical ventilation implies a transition towards spontaneous breathing, mainly using assisted mechanical ventilation. In this transition, the challenge for clinicians is to avoid under and over assistance and minimize excessive respiratory effort and iatrogenic diaphragmatic and lung damage. Esophageal balloon monitoring allows objective measurements of respiratory muscle activity in real time, but there are still limitations to its routine application in intensive care unit patients using mechanical ventilation. Like the esophageal balloon, respiratory muscle electromyography and diaphragmatic ultrasound are minimally invasive tools requiring specific training that monitor respiratory muscle activity. Particularly during the coronavirus disease pandemic, non invasive tools available on mechanical ventilators to monitor respiratory drive, inspiratory effort, and work of breathing have been extended to individualize mechanical ventilation based on patient’s needs. This review aims to identify the conceptual definitions of respiratory drive, inspiratory effort, and work of breathing and to identify non invasive maneuvers available on intensive care ventilators to measure these parameters. The literature highlights that although respiratory drive, inspiratory effort, and work of breathing are intuitive concepts, even distinguished authors disagree on their definitions.
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20
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Flow Index accurately identifies breaths with low or high inspiratory effort during pressure support ventilation. Crit Care 2021; 25:427. [PMID: 34911541 PMCID: PMC8672539 DOI: 10.1186/s13054-021-03855-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/03/2021] [Indexed: 01/19/2023] Open
Abstract
Background Flow Index, a numerical expression of the shape of the inspiratory flow-time waveform recorded during pressure support ventilation, is associated with patient inspiratory effort. The aim of this study was to assess the accuracy of Flow Index in detecting high or low inspiratory effort during pressure support ventilation and to establish cutoff values for the Flow index to identify these conditions. The secondary aim was to compare the performance of Flow index,of breathing pattern parameters and of airway occlusion pressure (P0.1) in detecting high or low inspiratory effort during pressure support ventilation. Methods Data from 24 subjects was included in the analysis, accounting for a total of 702 breaths. Breaths with high inspiratory effort were defined by a pressure developed by inspiratory muscles (Pmusc) greater than 10 cmH2O while breaths with low inspiratory effort were defined by a Pmusc lower than 5 cmH2O. The areas under the receiver operating characteristic curves of Flow Index and respiratory rate, tidal volume,respiratory rate over tidal volume and P0.1 were analyzed and compared to identify breaths with low or high inspiratory effort. Results Pmusc, P0.1, Pressure Time Product and Flow Index differed between breaths with high, low and intermediate inspiratory effort, while RR, RR/VT and VT/kg of IBW did not differ in a statistically significant way. A Flow index higher than 4.5 identified breaths with high inspiratory effort [AUC 0.89 (CI 95% 0.85–0.93)], a Flow Index lower than 2.6 identified breaths with low inspiratory effort [AUC 0.80 (CI 95% 0.76–0.83)]. Conclusions Flow Index is accurate in detecting high and low spontaneous inspiratory effort during pressure support ventilation. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03855-4.
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21
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Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation. Crit Care Med 2021; 49:2090-2101. [PMID: 34115638 PMCID: PMC8602777 DOI: 10.1097/ccm.0000000000005113] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In mechanically ventilated patients, deep sedation is often assumed to induce "respirolysis," that is, lyse spontaneous respiratory effort, whereas light sedation is often assumed to preserve spontaneous effort. This study was conducted to determine validity of these common assumptions, evaluating the association of respiratory drive with sedation depth and ventilator-free days in acute respiratory failure. DESIGN Prospective cohort study. SETTING Patients were enrolled during 2 month-long periods in 2016-2017 from five ICUs representing medical, surgical, and cardiac specialties at a U.S. academic hospital. PATIENTS Eligible patients were critically ill adults receiving invasive ventilation initiated no more than 36 hours before enrollment. Patients with neuromuscular disease compromising respiratory function or expiratory flow limitation were excluded. INTERVENTIONS Respiratory drive was measured via P0.1, the change in airway pressure during a 0.1-second airway occlusion at initiation of patient inspiratory effort, every 12 ± 3 hours for 3 days. Sedation depth was evaluated via the Richmond Agitation-Sedation Scale. Analyses evaluated the association of P0.1 with Richmond Agitation-Sedation Scale (primary outcome) and ventilator-free days. MEASUREMENTS AND MAIN RESULTS Fifty-six patients undergoing 197 bedside evaluations across five ICUs were included. P0.1 ranged between 0 and 13.3 cm H2O (median [interquartile range], 0.1 cm H2O [0.0-1.3 cm H2O]). P0.1 was not significantly correlated with the Richmond Agitation-Sedation Scale (RSpearman, 0.02; 95% CI, -0.12 to 0.16; p = 0.80). Considering P0.1 terciles (range less than 0.2, 0.2-1.0, and greater than 1.0 cm H2O), patients in the middle tercile had significantly more ventilator-free days than the lowest tercile (incidence rate ratio, 0.78; 95% CI, 0.65-0.93; p < 0.01) or highest tercile (incidence rate ratio, 0.58; 95% CI, 0.48-0.70; p < 0.01). CONCLUSIONS Sedation depth is not a reliable marker of respiratory drive during critical illness. Respiratory drive can be low, moderate, or high across the range of routinely targeted sedation depth.
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22
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Savary D, Lesimple A, Beloncle F, Morin F, Templier F, Broc A, Brochard L, Richard JC, Mercat A. Reliability and limits of transport-ventilators to safely ventilate severe patients in special surge situations. Ann Intensive Care 2020; 10:166. [PMID: 33296045 PMCID: PMC7724620 DOI: 10.1186/s13613-020-00782-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/25/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Intensive Care Units (ICU) have sometimes been overwhelmed by the surge of COVID-19 patients. Extending ICU capacity can be limited by the lack of air and oxygen pressure sources available. Transport ventilators requiring only one O2 source may be used in such places. OBJECTIVE To evaluate the performances of four transport ventilators and an ICU ventilator in simulated severe respiratory conditions. MATERIALS AND METHODS Two pneumatic transport ventilators, (Oxylog 3000, Draeger; Osiris 3, Air Liquide Medical Systems), two turbine transport ventilators (Elisee 350, ResMed; Monnal T60, Air Liquide Medical Systems) and an ICU ventilator (Engström Carestation-GE Healthcare) were evaluated on a Michigan test lung. We tested each ventilator with different set volumes (Vtset = 350, 450, 550 ml) and compliances (20 or 50 ml/cmH2O) and a resistance of 15 cmH2O/l/s based on values described in COVID-19 Acute Respiratory Distress Syndrome. Volume error (percentage of Vtset) with P0.1 of 4 cmH2O and trigger delay during assist-control ventilation simulating spontaneous breathing activity with P0.1 of 4 cmH2O and 8 cmH2O were measured. RESULTS Grouping all conditions, the volume error was 2.9 ± 2.2% for Engström Carestation; 3.6 ± 3.9% for Osiris 3; 2.5 ± 2.1% for Oxylog 3000; 5.4 ± 2.7% for Monnal T60 and 8.8 ± 4.8% for Elisee 350. Grouping all conditions (P0.1 of 4 cmH2O and 8 cmH2O), trigger delay was 50 ± 11 ms, 71 ± 8 ms, 132 ± 22 ms, 60 ± 12 and 67 ± 6 ms for Engström Carestation, Osiris 3, Oxylog 3000, Monnal T60 and Elisee 350, respectively. CONCLUSIONS In surge situations such as COVID-19 pandemic, transport ventilators may be used to accurately control delivered volumes in locations, where only oxygen pressure supply is available. Performances regarding triggering function are acceptable for three out of the four transport ventilators tested.
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Affiliation(s)
- Dominique Savary
- Emergency Department, University Hospital of Angers, 4, Rue Larrey, 49933, Angers Cedex 9, France.
- Inserm, EHESP, University of Rennes, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, 49000, Angers, France.
| | - Arnaud Lesimple
- CNRS, INSERM 1083, MITOVASC, Université d'Angers, Angers, France
- Med2Lab, ALMS, Antony, France
| | - François Beloncle
- Critical Care Department, Angers University Hospital, Angers, France
| | - François Morin
- Emergency Department, University Hospital of Angers, 4, Rue Larrey, 49933, Angers Cedex 9, France
| | - François Templier
- Emergency Department, University Hospital of Angers, 4, Rue Larrey, 49933, Angers Cedex 9, France
| | - Alexandre Broc
- The Telecom-Physic-Strasbourg, Strasbourg University, Strasbourg , France
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Christophe Richard
- Critical Care Department, Angers University Hospital, Angers, France
- INSERM, UMR 955 Eq 13, Toronto, Canada
| | - Alain Mercat
- Critical Care Department, Angers University Hospital, Angers, France
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23
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Esnault P, Cardinale M, Hraiech S, Goutorbe P, Baumstrack K, Prud'homme E, Bordes J, Forel JM, Meaudre E, Papazian L, Guervilly C. High Respiratory Drive and Excessive Respiratory Efforts Predict Relapse of Respiratory Failure in Critically Ill Patients with COVID-19. Am J Respir Crit Care Med 2020; 202:1173-1178. [PMID: 32755309 PMCID: PMC7560807 DOI: 10.1164/rccm.202005-1582le] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
| | | | - Sami Hraiech
- Assistance Public-Hôpitaux de Marseille (APHM) Marseille, France.,Aix-Marseille University Marseille, France
| | | | | | | | - Julien Bordes
- Sainte Anne Military Hospital Toulon, France.,Ecole du Val-de-Grâce Paris, France
| | - Jean-Marie Forel
- Aix-Marseille University Marseille, France.,APHM Marseille, France and
| | - Eric Meaudre
- Sainte Anne Military Hospital Toulon, France.,Ecole du Val-de-Grâce Paris, France
| | - Laurent Papazian
- Aix-Marseille University Marseille, France.,APHM Marseille, France and
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24
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Telias I, Junhasavasdikul D, Rittayamai N, Piquilloud L, Chen L, Ferguson ND, Goligher EC, Brochard L. Airway Occlusion Pressure As an Estimate of Respiratory Drive and Inspiratory Effort during Assisted Ventilation. Am J Respir Crit Care Med 2020; 201:1086-1098. [PMID: 32097569 DOI: 10.1164/rccm.201907-1425oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Rationale: Monitoring and controlling respiratory drive and effort may help to minimize lung and diaphragm injury. Airway occlusion pressure (P0.1) is a noninvasive measure of respiratory drive.Objectives: To determine 1) the validity of "ventilator" P0.1 (P0.1vent) displayed on the screen as a measure of drive, 2) the ability of P0.1 to detect potentially injurious levels of effort, and 3) how P0.1vent displayed by different ventilators compares to a "reference" P0.1 (P0.1ref) measured from airway pressure recording during an occlusion.Methods: Analysis of three studies in patients, one in healthy subjects, under assisted ventilation, and a bench study with six ventilators. P0.1vent was validated against measures of drive (electrical activity of the diaphragm and muscular pressure over time) and P0.1ref. Performance of P0.1ref and P0.1vent to detect predefined potentially injurious effort was tested using derivation and validation datasets using esophageal pressure-time product as the reference standard.Measurements and Main Results: P0.1vent correlated well with measures of drive and with the esophageal pressure-time product (within-subjects R2 = 0.8). P0.1ref >3.5 cm H2O was 80% sensitive and 77% specific for detecting high effort (≥200 cm H2O ⋅ s ⋅ min-1); P0.1ref ≤1.0 cm H2O was 100% sensitive and 92% specific for low effort (≤50 cm H2O ⋅ s ⋅ min-1). The area under the receiver operating characteristics curve for P0.1vent to detect potentially high and low effort were 0.81 and 0.92, respectively. Bench experiments showed a low mean bias for P0.1vent compared with P0.1ref for most ventilators but precision varied; in patients, precision was lower. Ventilators estimating P0.1vent without occlusions could underestimate P0.1ref.Conclusions: P0.1 is a reliable bedside tool to assess respiratory drive and detect potentially injurious inspiratory effort.
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Affiliation(s)
- Irene Telias
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Detajin Junhasavasdikul
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Faculty of Medicine Ramathibodi Hospital and
| | - Nuttapol Rittayamai
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lise Piquilloud
- Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Lausanne, Switzerland; and
| | - Lu Chen
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine and.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine and.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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