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Shahn Z, Jung B, Talmor D, Kennedy EH, Lehman LWH, Baedorf-Kassis E. The impact of aggressive and conservative propensity for initiation of neuromuscular blockade in mechanically ventilated patients with hypoxemic respiratory failure. J Crit Care 2024; 82:154803. [PMID: 38552450 PMCID: PMC11139559 DOI: 10.1016/j.jcrc.2024.154803] [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: 07/14/2023] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Neuromuscular blockade (NMB) in ventilated patients may cause benefit or harm. We applied "incremental interventions" to determine the impact of altering NMB initiation aggressiveness. METHODS Retrospective cohort study of ventilated patients with PaO2/FiO2 ratio < 150 mmHg and PEEP≥ 8cmH2O from the Medical Information Mart of Intensive Care IV database (MIMIC-IV version 1.0) estimating the effect of incremental interventions on in-hospital mortality and ventilator-free days, modifying hourly propensity for NMB initiation to be aggressive or conservative relative to usual care, adjusting for confounding with inverse probability weighting. RESULTS 5221 patients were included (13.3% initiated on NMB). Incremental interventions estimated a strong effect on NMB usage: 5-fold higher hourly odds of initiation increased usage to 36.5% (CI = [34.3%,38.7%]) and 5-fold lower odds decreased usage to 3.8% (CI = [3.3%,4.3%]). Aggressive and conservative strategies demonstrated a U-shaped mortality relationship. 5-fold higher or lower propensity increased in-hospital mortality by 2.6% (0.95 CI = [1.5%,3.7%]) or 1.3% (0.95 CI = [0.1%,2.5%]) respectively. In secondary analysis of a healthier patient cohort, results were similar, however conservative strategies also improved ventilator-free days. INTERPRETATION Aggressive or conservative initiation of NMB may worsen mortality. In healthier populations, marginally conservative NMB initiation strategies may lead to increased ventilator free days with minimal impact on mortality.
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Affiliation(s)
- Zach Shahn
- MIT-IBM Watson AI Lab, Cambridge, MA, United States of America; CUNY Graduate School of Public Health and Health Policy, New York City, NY, United States of America
| | - Boris Jung
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital, Montpellier University, Montpellier, France; Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America
| | - Daniel Talmor
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America
| | - Edward H Kennedy
- Department of Statistics & Data Science, Carnegie Mellon University, Pittsburgh, PA 15213, United States of America
| | - Li-Wei H Lehman
- MIT-IBM Watson AI Lab, Cambridge, MA, United States of America; Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, 02142, United States of America
| | - Elias Baedorf-Kassis
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, United States of America.
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2
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Marongiu I, Slobod D, Leali M, Spinelli E, Mauri T. Clinical and Experimental Evidence for Patient Self-Inflicted Lung Injury (P-SILI) and Bedside Monitoring. J Clin Med 2024; 13:4018. [PMID: 39064059 PMCID: PMC11278124 DOI: 10.3390/jcm13144018] [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: 06/17/2024] [Revised: 07/01/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Patient self-inflicted lung injury (P-SILI) is a major challenge for the ICU physician: although spontaneous breathing is associated with physiological benefits, in patients with acute respiratory distress syndrome (ARDS), the risk of uncontrolled inspiratory effort leading to additional injury needs to be assessed to avoid delayed intubation and increased mortality. In the present review, we analyze the available clinical and experimental evidence supporting the existence of lung injury caused by uncontrolled high inspiratory effort, we discuss the pathophysiological mechanisms by which increased effort causes P-SILI, and, finally, we consider the measurements and interpretation of bedside physiological measures of increased drive that should alert the clinician. The data presented in this review could help to recognize injurious respiratory patterns that may trigger P-SILI and to prevent it.
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Affiliation(s)
- Ines Marongiu
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, QC H4A 3J1, Canada
| | - Marco Leali
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.M.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
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Liu W, Chi Y, Zhao Y, He H, Long Y, Zhao Z. Occurrence of pendelluft during ventilator weaning with T piece correlated with increased mortality in difficult-to-wean patients. J Intensive Care 2024; 12:23. [PMID: 38915067 PMCID: PMC11194869 DOI: 10.1186/s40560-024-00737-z] [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: 03/07/2024] [Accepted: 06/14/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Difficult-to-wean patients, typically identified as those failing the initial spontaneous breathing trial (SBT), face elevated mortality rates. Pendelluft, frequently observed in patients experiencing SBT failure, can be conveniently detected through bedside monitoring with electrical impedance tomography (EIT). This study aimed to explore the impact of pendelluft during SBT on difficult-to-wean patients. METHODS This retrospective observational study included difficult-to-wean patients undergoing spontaneous T piece breathing, during which EIT data were collected. Pendelluft occurrence was defined when its amplitude exceeded 2.5% of global tidal impedance variation. Physiological parameters during SBT were retrospectively retrieved from the EIT Examination Report Form. Other clinical data including mechanical ventilation duration, length of ICU stay, length of hospital stay, and 28-day mortality were retrieved from patient records in the hospital information system for each subject. RESULTS Pendelluft was observed in 72 (70.4%) of the 108 included patients, with 16 (14.8%) experiencing mortality by day 28. The pendelluft group exhibited significantly higher mortality (19.7% vs. 3.1%, p = 0.035), longer median mechanical ventilation duration [9 (5-15) vs. 7 (5-11) days, p = 0.041] and shorter ventilator-free days at day 28 [18 (4-22) vs. 20 (16-23) days, p = 0.043]. The presence of pendellfut was independently associated with increased mortality at day 28 (OR = 10.50, 95% confidence interval 1.21-90.99, p = 0.033). CONCLUSIONS Pendelluft occurred in 70.4% of difficult-to-wean patients undergoing T piece spontaneous breathing. Pendelluft was associated with worse clinical outcomes, including prolonged mechanical ventilation and increased mortality in this population. Our findings underscore the significance of monitoring pendelluft using EIT during SBT for difficult-to-wean patients.
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Affiliation(s)
- Wanglin Liu
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yi Chi
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yutong Zhao
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
- Department of Critical Care Medicine, The First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Huaiwu He
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Yun Long
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Zhanqi Zhao
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
- School of Biomedical Engineering, Guangzhou Medical University, No. 1 Xinzao Rd. Panyu District, Guangzhou, China.
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany.
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Simonte R, Cammarota G, Vetrugno L, De Robertis E, Longhini F, Spadaro S. Advanced Respiratory Monitoring during Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:2541. [PMID: 38731069 PMCID: PMC11084162 DOI: 10.3390/jcm13092541] [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: 03/17/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Advanced respiratory monitoring encompasses a diverse range of mini- or noninvasive tools used to evaluate various aspects of respiratory function in patients experiencing acute respiratory failure, including those requiring extracorporeal membrane oxygenation (ECMO) support. Among these techniques, key modalities include esophageal pressure measurement (including derived pressures), lung and respiratory muscle ultrasounds, electrical impedance tomography, the monitoring of diaphragm electrical activity, and assessment of flow index. These tools play a critical role in assessing essential parameters such as lung recruitment and overdistention, lung aeration and morphology, ventilation/perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator synchrony. In contrast to conventional methods, advanced respiratory monitoring offers a deeper understanding of pathological changes in lung aeration caused by underlying diseases. Moreover, it allows for meticulous tracking of responses to therapeutic interventions, aiding in the development of personalized respiratory support strategies aimed at preserving lung function and respiratory muscle integrity. The integration of advanced respiratory monitoring represents a significant advancement in the clinical management of acute respiratory failure. It serves as a cornerstone in scenarios where treatment strategies rely on tailored approaches, empowering clinicians to make informed decisions about intervention selection and adjustment. By enabling real-time assessment and modification of respiratory support, advanced monitoring not only optimizes care for patients with acute respiratory distress syndrome but also contributes to improved outcomes and enhanced patient safety.
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Affiliation(s)
- Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Università della Magna Graecia, 88100 Catanzaro, Italy
- Anesthesia and Intensive Care Unit, “R. Dulbecco” University Hospital, 88100 Catanzaro, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44100 Ferrara, Italy;
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Gaertner VD, Büchler VL, Waldmann A, Bassler D, Rüegger CM. Deciphering Mechanisms of Respiratory Fetal-to-Neonatal Transition in Very Preterm Infants. Am J Respir Crit Care Med 2024; 209:738-747. [PMID: 38032260 DOI: 10.1164/rccm.202306-1021oc] [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: 06/13/2023] [Accepted: 11/30/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: The respiratory mechanisms of a successful transition of preterm infants after birth are largely unknown. Objectives: To describe intrapulmonary gas flows during different breathing patterns directly after birth. Methods: Analysis of electrical impedance tomography data from a previous randomized trial in preterm infants at 26-32 weeks gestational age. Electrical impedance tomography data for individual breaths were extracted, and lung volumes as well as ventilation distribution were calculated for end of inspiration, end of expiratory braking and/or holding maneuver, and end of expiration. Measurements and Main Results: Overall, 10,348 breaths from 33 infants were analyzed. We identified three distinct breath types within the first 10 minutes after birth: tidal breathing (44% of all breaths; sinusoidal breathing without expiratory disruption), braking (50%; expiratory brake with a short duration), and holding (6%; expiratory brake with a long duration). Only after holding breaths did end-expiratory lung volume increase: Median (interquartile range [IQR]) = 2.0 AU/kg (0.6 to 4.3), 0.0 (-1.0 to 1.1), and 0.0 (-1.1 to 0.4), respectively; P < 0.001]. This was mediated by intrathoracic air redistribution to the left and non-gravity-dependent parts of the lung through pendelluft gas flows during braking and/or holding maneuvers. Conclusions: Respiratory transition in preterm infants is characterized by unique breathing patterns. Holding breaths contribute to early lung aeration after birth in preterm infants. This is facilitated by air redistribution during braking/holding maneuvers through pendelluft flow, which may prevent lung liquid reflux in this highly adaptive situation. This study deciphers mechanisms for a successful fetal-to-neonatal transition and increases our pathophysiological understanding of this unique moment in life. Clinical trial registered with www.clinicaltrials.gov (NCT04315636).
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
- Division of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Vanessa L Büchler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Andreas Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
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Kneyber MCJ, Cheifetz IM. Mechanical ventilation during pediatric extracorporeal life support. Curr Opin Pediatr 2023; 35:596-602. [PMID: 37497765 DOI: 10.1097/mop.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW To discuss the role of ventilator induced lung injury (VILI) and patient self-inflicted lung injury in ventilated children supported on extracorporeal membrane oxygenation (ECMO). RECENT FINDINGS While extracorporeal life support is used routinely used every day around the globe to support neonatal, pediatric, and adult patients with refractory cardiac and/or respiratory failure, the optimal approach to mechanical ventilation, especially for those with acute respiratory distress syndrome (ARDS), remains unknown and controversial. Given the lack of definitive data in this population, one must rely on available evidence in those with ARDS not supported with ECMO and extrapolate adult observations. Ventilatory management should include, as a minimum standard, limiting inspiratory and driving pressures, providing a sufficient level of positive end-expiratory pressure, and setting a low rate to reduce mechanical power. Allowing for spontaneous breathing and use of pulmonary specific ancillary treatment modalities must be individualized, while balancing the risk and benefits. Future studies delineating the best strategies for optimizing MV during pediatric extracorporeal life support are much needed. SUMMARY Future investigations will hopefully provide the needed evidence and better understanding of the overall goal of reducing mechanical ventilation intensity to decrease risk for VILI and promote lung recovery for those supported with ECMO.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen
- Critical care, Anesthesiology, Peri-operative & Emergency medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Lassola S, Miori S, Sanna A, Menegoni I, De Rosa S, Bellani G, Umbrello M. Assessment of Inspiratory Effort in Spontaneously Breathing COVID-19 ARDS Patients Undergoing Helmet CPAP: A Comparison between Esophageal, Transdiaphragmatic and Central Venous Pressure Swing. Diagnostics (Basel) 2023; 13:diagnostics13111965. [PMID: 37296817 DOI: 10.3390/diagnostics13111965] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION The clinical features of COVID-19 are highly variable. It has been speculated that the progression across COVID-19 may be triggered by excessive inspiratory drive activation. The aim of the present study was to assess whether the tidal swing in central venous pressure (ΔCVP) is a reliable estimate of inspiratory effort. METHODS Thirty critically ill patients with COVID-19 ARDS underwent a PEEP trial (0-5-10 cmH2O) during helmet CPAP. Esophageal (ΔPes) and transdiaphragmatic (ΔPdi) pressure swings were measured as indices of inspiratory effort. ΔCVP was assessed via a standard venous catheter. A low and a high inspiratory effort were defined as ΔPes ≤ 10 and >15 cmH2O, respectively. RESULTS During the PEEP trial, no significant changes in ΔPes (11 [6-16] vs. 11 [7-15] vs. 12 [8-16] cmH2O, p = 0.652) and in ΔCVP (12 [7-17] vs. 11.5 [7-16] vs. 11.5 [8-15] cmH2O, p = 0.918) were detected. ΔCVP was significantly associated with ΔPes (marginal R2 0.87, p < 0.001). ΔCVP recognized both low (AUC-ROC curve 0.89 [0.84-0.96]) and high inspiratory efforts (AUC-ROC curve 0.98 [0.96-1]). CONCLUSIONS ΔCVP is an easily available a reliable surrogate of ΔPes and can detect a low or a high inspiratory effort. This study provides a useful bedside tool to monitor the inspiratory effort of spontaneously breathing COVID-19 patients.
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Affiliation(s)
- Sergio Lassola
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Sara Miori
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Andrea Sanna
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Ilaria Menegoni
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Silvia De Rosa
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
- Centre for Medical Sciences-CISMed, University of Trento, Via S. Maria Maddalena 1, 38122 Trento, Italy
| | - Giacomo Bellani
- Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
- Centre for Medical Sciences-CISMed, University of Trento, Via S. Maria Maddalena 1, 38122 Trento, Italy
| | - Michele Umbrello
- Anesthesia and Intensive Care 2, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo-Polo Universitario, 20148 Milano, Italy
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Koopman AA, van Dijk J, Oppersma E, Blokpoel RGT, Kneyber MCJ. Surface electromyography to quantify neuro-respiratory drive and neuro-mechanical coupling in mechanically ventilated children. Respir Res 2023; 24:77. [PMID: 36915106 PMCID: PMC10010013 DOI: 10.1186/s12931-023-02374-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND The patient's neuro-respiratory drive, measured as electrical activity of the diaphragm (EAdi), quantifies the mechanical load on the respiratory muscles. It correlates with respiratory effort but requires a dedicated esophageal catheter. Transcutaneous (surface) monitoring of respiratory muscle electromyographic (sEMG) signals may be considered a suitable alternative to EAdi because of its non-invasive character, with the additional benefit that it allows for simultaneously monitoring of other respiratory muscles. We therefore sought to study the neuro-respiratory drive and timing of inspiratory muscles using sEMG in a cohort of children enrolled in a pediatric ventilation liberation trial. The neuro-mechanical coupling, relating the pressure generated by the inspiratory muscles to the sEMG signals of these muscles, was also calculated. METHODS This is a secondary analysis of data from a randomized cross-over trial in ventilated patients aged < 5 years. sEMG recordings of the diaphragm and parasternal intercostal muscles (ICM), esophageal pressure tracings and ventilator scalars were simultaneously recorded during continuous spontaneous ventilation and pressure controlled-intermittent mandatory ventilation, and at three levels of pressure support. Neuro-respiratory drive, timing of diaphragm and ICM relative to the mechanical ventilator's inspiration and neuro-mechanical coupling were quantified. RESULTS Twenty-nine patients were included (median age: 5.9 months). In response to decreasing pressure support, both amplitude of sEMG (diaphragm: p = 0.001 and ICM: p = 0.002) and neuro-mechanical efficiency indices increased (diaphragm: p = 0.05 and ICM: p < 0.001). Poor correlations between neuro-respiratory drive and respiratory effort were found, with R2: 0.088 [0.021-0.152]. CONCLUSIONS sEMG allows for the quantification of the electrical activity of the diaphragm and ICM in mechanically ventilated children. Both neuro-respiratory drive and neuro-mechanical efficiency increased in response to lower inspiratory assistance. There was poor correlation between neuro-respiratory drive and respiratory effort. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05254691. Registered 24 February 2022, registered retrospectively.
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Affiliation(s)
- Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Eline Oppersma
- Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
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Abstract
Advanced respiratory monitoring involves several mini- or noninvasive tools, applicable at bedside, focused on assessing lung aeration and morphology, lung recruitment and overdistention, ventilation-perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator asynchrony, in dealing with acute respiratory failure. Compared to a conventional approach, advanced respiratory monitoring has the potential to provide more insights into the pathologic modifications of lung aeration induced by the underlying disease, follow the response to therapies, and support clinicians in setting up a respiratory support strategy aimed at protecting the lung and respiratory muscles. Thus, in the clinical management of the acute respiratory failure, advanced respiratory monitoring could play a key role when a therapeutic strategy, relying on individualization of the treatments, is adopted.
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10
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Shahn Z, Choudhri A, Jung B, Talmor D, Lehman LWH, Baedorf-Kassis E. Effects of aggressive and conservative strategies for mechanical ventilation liberation. J Crit Care 2023; 76:154275. [PMID: 36796189 DOI: 10.1016/j.jcrc.2023.154275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/17/2023] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND The optimal approach for transitioning from strict lung protective ventilation to support modes of ventilation when patients determine their own respiratory rate and tidal volume remains unclear. While aggressive liberation from lung protective settings could expedite extubation and prevent harm from prolonged ventilation and sedation, conservative liberation could prevent lung injury from spontaneous breathing. RESEARCH QUESTION Should physicians take a more aggressive or conservative approach to liberation? METHODS Retrospective cohort study of mechanically ventilated patients from the Medical Information Mart for Intensive Care IV database (MIMIC-IV version 1.0) estimating effects of incremental interventions modifying the propensity for liberation to be more aggressive or conservative relative to usual care, with adjustment for confounding via inverse probability weighting. Outcomes included in-hospital mortality, ventilator free days, and ICU free days. Analysis was performed on the entire cohort as well as subgroups differentiated by PaO2/FiO2 ratio, and SOFA. RESULTS 7433 patients were included. Strategies multiplying the odds of a first liberation relative to usual care at each hour had a large impact on time to first liberation attempt (43 h under usual care, 24 h (0.95 CI = [23,25]) with an aggressive strategy doubling liberation odds, and 74 h (0.95 CI = [69,78]) under a conservative strategy halving liberation odds). In the full cohort, we estimated aggressive liberation increased ICU-free days by 0.9 days (0.95 CI = [0.8,1.0]) and ventilator free days by 0.82 days (0.95 CI = [0.67,0.97]), but had minimal effect on mortality (only a 0.3% (0.95 CI = [-0.2%,0.8%]) difference between minimum and maximum rates). With baseline SOFA≥ 12 (n = 1355), aggressive liberation moderately increased mortality (58.5% [0.95 CI = (55.7%,61.2%)]) compared with conservative liberation (55.1% [0.95 CI = (51.6%,58.6%)]). INTERPRETATION Aggressive liberation may improve ventilator free and ICU free days with little impact on mortality in patients with SOFA score < 12. Trials are needed.
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Affiliation(s)
- Zach Shahn
- IBM Research, Yorktown Heights, NY 10598, USA; MIT-IBM Watson AI Lab, Cambridge, MA, USA; CUNY School of Public Health, New York City, New York, USA.
| | - Aman Choudhri
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Boris Jung
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital, Montpellier University, Montpellier, France; Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Daniel Talmor
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Li-Wei H Lehman
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA; MIT-IBM Watson AI Lab, Cambridge, MA, USA
| | - Elias Baedorf-Kassis
- Department of Anesthesia, Pain and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA; Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
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11
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Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2023; 11:197-212. [PMID: 36566767 PMCID: PMC10880453 DOI: 10.1016/s2213-2600(22)00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine, University of Groningen, Groningen, Netherlands.
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mary K Dahmer
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montreal, QC, Canada
| | - Jocelyn Grunwell
- Department of Pediatrics, Division of Critical Care, Emory University, Atlanta, GA, USA
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Bhushan H Katira
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics (Critical Care), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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13
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Vedrenne-Cloquet M, Khirani S, Khemani R, Lesage F, Oualha M, Renolleau S, Chiumello D, Demoule A, Fauroux B. Pleural and transpulmonary pressures to tailor protective ventilation in children. Thorax 2023; 78:97-105. [PMID: 35803726 DOI: 10.1136/thorax-2021-218538] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 06/12/2022] [Indexed: 02/07/2023]
Abstract
This review aims to: (1) describe the rationale of pleural (PPL) and transpulmonary (PL) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on PL in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (PES) and PL measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. PL corresponds to the difference between airway pressure and PPL Oesophageal manometry allows measurement of PES, a good surrogate of PPL, to estimate PL directly at the bedside. Lung stress is the PL, while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with PL and PPL being key components. PL-targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory PL (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory PL value close to zero; (2) Protective ventilation based on end-inspiratory PL (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20-25 cmH2O; (3) PPL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) PPL or PL measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, PPL and PL measurements may help to characterise how changes in PEEP affect PPL and potentially haemodynamics. In the PICU, PPL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of PPL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, PES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate PPL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. PPL and PL monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of PL and multimodal respiratory monitoring may be worth to be evaluated in the future.
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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France .,Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sonia Khirani
- Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France.,ASV Santé, Genevilliers, France
| | - Robinder Khemani
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Fabrice Lesage
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Mehdi Oualha
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sylvain Renolleau
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Davide Chiumello
- Dipartimento di Anestesia, Rianimazione e Terapia del Dolore, Fondazione, IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alexandre Demoule
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, Sorbonne Université, INSERM, Paris, France
| | - Brigitte Fauroux
- Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
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Zainol NM, Damanhuri NS, Othman NA, Chiew YS, Nor MBM, Muhammad Z, Chase JG. Estimating the incidence of spontaneous breathing effort of mechanically ventilated patients using a non-linear auto regressive (NARX) model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 220:106835. [PMID: 35512627 PMCID: PMC9754157 DOI: 10.1016/j.cmpb.2022.106835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/04/2022] [Accepted: 04/21/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Mechanical ventilation (MV) provides breathing support for acute respiratory distress syndrome (ARDS) patients in the intensive care unit, but is difficult to optimize. Too much, or too little of pressure or volume support can cause further ventilator-induced lung injury, increasing length of MV, cost and mortality. Patient-specific respiratory mechanics can help optimize MV settings. However, model-based estimation of respiratory mechanics is less accurate when patient exhibit un-modeled spontaneous breathing (SB) efforts on top of ventilator support. This study aims to estimate and quantify SB efforts by reconstructing the unaltered passive mechanics airway pressure using NARX model. METHODS Non-linear autoregressive (NARX) model is used to reconstruct missing airway pressure due to the presence of spontaneous breathing effort in mv patients. Then, the incidence of SB patients is estimated. The study uses a total of 10,000 breathing cycles collected from 10 ARDS patients from IIUM Hospital in Kuantan, Malaysia. In this study, there are 2 different ratios of training and validating methods. Firstly, the initial ratio used is 60:40 which indicates 600 breath cycles for training and remaining 400 breath cycles used for testing. Then, the ratio is varied using 70:30 ratio for training and testing data. RESULTS AND DISCUSSION The mean residual error between original airway pressure and reconstructed airway pressure is denoted as the magnitude of effort. The median and interquartile range of mean residual error for both ratio are 0.0557 [0.0230 - 0.0874] and 0.0534 [0.0219 - 0.0870] respectively for all patients. The results also show that Patient 2 has the highest percentage of SB incidence and Patient 10 with the lowest percentage of SB incidence which proved that NARX model is able to perform for both higher incidence of SB effort or when there is a lack of SB effort. CONCLUSION This model is able to produce the SB incidence rate based on 10% threshold. Hence, the proposed NARX model is potentially useful to estimate and identify patient-specific SB effort, which has the potential to further assist clinical decisions and optimize MV settings.
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Affiliation(s)
- Nurhidayah Mohd Zainol
- Centre for Electrical Engineering Studies, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh Campus, 13500 Pulau Pinang, Malaysia
| | - Nor Salwa Damanhuri
- Centre for Electrical Engineering Studies, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh Campus, 13500 Pulau Pinang, Malaysia.
| | - Nor Azlan Othman
- Centre for Electrical Engineering Studies, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh Campus, 13500 Pulau Pinang, Malaysia
| | - Yeong Shiong Chiew
- School of Engineering, Monash University Malaysia, Bandar Sunway 47500, Malaysia
| | - Mohd Basri Mat Nor
- Department of Anaesthesiology and Intensive Care, Kulliyah of Medicine, International Islamic University of Malaysia, Kuantan 25200, Malaysia
| | - Zuraida Muhammad
- Centre for Electrical Engineering Studies, Universiti Teknologi MARA, Cawangan Pulau Pinang, Permatang Pauh Campus, 13500 Pulau Pinang, Malaysia
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch 8041, New Zealand
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Tonelli R, Bruzzi G, Manicardi L, Tabbì L, Fantini R, Castaniere I, Andrisani D, Gozzi F, Pellegrino MR, Trentacosti F, Dall’Ara L, Busani S, Franceschini E, Baroncini S, Manco G, Meschiari M, Mussini C, Girardis M, Beghè B, Marchioni A, Clini E. Risk Factors for Pulmonary Air Leak and Clinical Prognosis in Patients With COVID-19 Related Acute Respiratory Failure: A Retrospective Matched Control Study. Front Med (Lausanne) 2022; 9:848639. [PMID: 35433732 PMCID: PMC9008271 DOI: 10.3389/fmed.2022.848639] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background The role of excessive inspiratory effort in promoting alveolar and pleural rupture resulting in air leak (AL) in patients with SARS-CoV-2 induced acute respiratory failure (ARF) while on spontaneous breathing is undetermined. Methods Among all patients with COVID-19 related ARF admitted to a respiratory intensive care unit (RICU) and receiving non-invasive respiratory support, those developing an AL were and matched 1:1 [by means of PaO2/FiO2 ratio, age, body mass index-BMI and subsequent organ failure assessment (SOFA)] with a comparable population who did not (NAL group). Esophageal pressure (ΔPes) and dynamic transpulmonary pressure (ΔPL) swings were compared between groups. Risk factors affecting AL onset were evaluated. The composite outcome of ventilator-free-days (VFD) at day 28 (including ETI, mortality, tracheostomy) was compared between groups. Results Air leak and NAL groups (n = 28) showed similar ΔPes, whereas AL had higher ΔPL (20 [16–21] and 17 [11–20], p = 0.01, respectively). Higher ΔPL (OR = 1.5 95%CI[1–1.8], p = 0.01), positive end-expiratory pressure (OR = 2.4 95%CI[1.2–5.9], p = 0.04) and pressure support (OR = 1.8 95%CI[1.1–3.5], p = 0.03), D-dimer on admission (OR = 2.1 95%CI[1.3–9.8], p = 0.03), and features suggestive of consolidation on computed tomography scan (OR = 3.8 95%CI[1.1–15], p = 0.04) were all significantly associated with AL. A lower VFD score resulted in a higher risk (HR = 3.7 95%CI [1.2–11.3], p = 0.01) in the AL group compared with NAL. RICU stay and 90-day mortality were also higher in the AL group compared with NAL. Conclusion In spontaneously breathing patients with COVID-19 related ARF, higher levels of ΔPL, blood D-dimer, NIV delivery pressures and a consolidative lung pattern were associated with AL onset.
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Affiliation(s)
- Roberto Tonelli
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Bruzzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Linda Manicardi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Dario Andrisani
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Filippo Gozzi
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Rosaria Pellegrino
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Fabiana Trentacosti
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Lorenzo Dall’Ara
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Stefano Busani
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | | | - Serena Baroncini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Gianrocco Manco
- Department of Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Cristina Mussini
- Infectious Diseases Unit, University Hospital of Modena, Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Bianca Beghè
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
| | - Alessandro Marchioni
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
- *Correspondence: Alessandro Marchioni,
| | - Enrico Clini
- Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena Reggio Emilia, Modena, Italy
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Fabo C, Oszlanyi A, Lantos J, Rarosi F, Horvath T, Barta Z, Nemeth T, Szabo Z. Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review. Front Surg 2022; 8:818456. [PMID: 35223971 PMCID: PMC8873170 DOI: 10.3389/fsurg.2021.818456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background In the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS). Methods We performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms. Results Based on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential. Conclusion NITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.
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Affiliation(s)
- Csongor Fabo
- Department of Anesthesiology and Intensive Care, University of Szeged, Szeged, Hungary
| | - Adam Oszlanyi
- Department of Cardiac Surgery, Zala County St. Raphael Hospital, Zalaegerszeg, Hungary
| | - Judit Lantos
- Department of Neurology, Bács- Kiskun County Hospital, Kecskemét, Hungary
| | - Ferenc Rarosi
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | | | - Zsanett Barta
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Tibor Nemeth
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Zsolt Szabo
- Ars Medica Laser Surgery Hospital, Budapest, Hungary
- *Correspondence: Zsolt Szabo
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Biasucci DG, Buonsenso D, Piano A, Bonadia N, Vargas J, Settanni D, Bocci MG, Grieco DL, Carnicelli A, Scoppettuolo G, Eleuteri D, DE Pascale G, Pennisi MA, Franceschi F, Antonelli M. Lung ultrasound predicts non-invasive ventilation outcome in COVID-19 acute respiratory failure: a pilot study. Minerva Anestesiol 2021; 87:1006-1016. [PMID: 34263580 DOI: 10.23736/s0375-9393.21.15188-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this study is to determine relationships between lung aeration assessed by lung ultrasound (LUS) with non-invasive ventilation (NIMV) outcome, intensive care unit (ICU) admission and mechanical ventilation (MV) needs in COVID-19 respiratory failure. METHODS A cohort of adult patients with COVID-19 respiratory failure underwent LUS during initial assessment. A simplified LUS protocol consisting in scanning six areas, three for each side, was adopted. A score from 0 to 3 was assigned to each area. Comprehensive LUS score (LUSsc) was calculated as the sum of the score in all areas. LUSsc, the amount of involved sonographic lung areas (LUSq), the number of lung quadrants radiographically infiltrated and the degree of oxygenation impairment at admission (SpO<inf>2</inf>/FiO2 ratio) were compared to NIMV Outcome, MV needs and ICU admission. RESULTS Among 85 patients prospectively included in the analysis, 49 of 61 needed MV. LUSsc and LUSq were higher in patients who required MV (median 12 [IQR 8-14] and median 6 [IQR 4-6], respectively) than in those who did not (6 [IQR 2-9] and 3 [IQR 1-5], respectively), both P<0.001. NIMV trial failed in 26 patients out 36. LUSsc and LUSq were significantly higher in patients who failed NIMV than in those who did not. From ROC analysis, LUSsc ≥12 and LUSq ≥5 gave the best cut-off values for NIMV failure prediction (AUC=0.95, 95%CI 0.83-0.99 and AUC=0.81, 95% CI 0.65-0.91, respectively). CONCLUSIONS Our data suggest LUS as a possible tool for identifying patients who are likely to require MV and ICU admission or to fail a NIMV trial.
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Affiliation(s)
- Daniele G Biasucci
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Alfonso Piano
- Emergency Room, "A. Gemelli" University Hospital Foundation IRCCS, Rome, Italy
| | - Nicola Bonadia
- Emergency Medicine, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Joel Vargas
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Donatella Settanni
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Maria G Bocci
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Domenico L Grieco
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Annamaria Carnicelli
- Emergency Medicine, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Giancarlo Scoppettuolo
- Infectious Diseases Unit, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Davide Eleuteri
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Gennaro DE Pascale
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Mariano A Pennisi
- Shock and Trauma Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Massimo Antonelli
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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Yu X, Gu S, Li M, Zhan Q. Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration. Front Med (Lausanne) 2021; 8:682526. [PMID: 34277659 PMCID: PMC8282255 DOI: 10.3389/fmed.2021.682526] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/01/2021] [Indexed: 01/18/2023] Open
Abstract
With the goal of protecting injured lungs and extrapulmonary organs, venovenous extracorporeal membrane oxygenation (VV-ECMO) has been increasingly adopted as a rescue therapy for patients with severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation failed to provide effective oxygenation and decarbonation. In recent years, it has become a promising approach to respiratory support for awake, non-intubated, spontaneously breathing patients with respiratory failure, referred to as awake ECMO, to avoid possible detrimental effects associated with intubation, mechanical ventilation, and the adjunctive therapies. However, several complex clinical issues should be taken into consideration when initiating and implementing awake ECMO, such as selecting potential patients who appeared to benefit most; techniques to facilitating cannulation and maintain stable ECMO blood flow; approaches to manage pain, agitation, and delirium; and approaches to monitor and modulate respiratory drive. It is worth mentioning that there had also been some inherent disadvantages and limitations of awake ECMO compared to the conventional combination of ECMO and invasive mechanical ventilation. Here, we review the use of ECMO in awake, spontaneously breathing patients with severe ARDS, highlighting the issues involving bedside clinical practice, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.
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Affiliation(s)
- Xin Yu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Sichao Gu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
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19
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Amirfarzan H, Cereda M, Gaulton TG, Leissner KB, Cortegiani A, Schumann R, Gregoretti C. Use of Helmet CPAP in COVID-19 - A practical review. Pulmonology 2021; 27:413-422. [PMID: 33583765 PMCID: PMC7849604 DOI: 10.1016/j.pulmoe.2021.01.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 01/15/2023] Open
Abstract
Helmet CPAP (H-CPAP) has been recommended in many guidelines as a noninvasive respiratory support during COVID-19 pandemic in many countries around the world. It has the least amount of particle dispersion and air contamination among all noninvasive devices and may mitigate the ICU bed shortage during a COVID surge as well as a decreased need for intubation/mechanical ventilation. It can be attached to many oxygen delivery sources. The MaxVenturi setup is preferred as it allows for natural humidification, low noise burden, and easy transition to HFNC during breaks and it is the recommended transport set-up. The patients can safely be proned with the helmet. It can also be used to wean the patients from invasive mechanical ventilation. Our article reviews in depth the pathophysiology of COVID-19 ARDS, provides rationale of using H-CPAP, suggests a respiratory failure algorithm, guides through its setup and discusses the issues and concerns around using it.
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Affiliation(s)
- H Amirfarzan
- Tufts University School of Medicine, VA Boston Healthcare System, Anesthesiology and Perioperative Medicine, United States.
| | - M Cereda
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St, Dulles Bldg, Floor 7, Philadelphia, PA 19104, United States.
| | - T G Gaulton
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St, Dulles Bldg, Floor 7, Philadelphia, PA 19104, United States.
| | - K B Leissner
- Harvard Medical School, VA Boston Healthcare System, Anesthesiology and Perioperative Medicine, United States.
| | - A Cortegiani
- Departmentof Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy.
| | - R Schumann
- Tufts University School of Medicine, VA Boston Healthcare System, Anesthesiology and Perioperative Medicine, United States.
| | - C Gregoretti
- Departmentof Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Fondazione 'Giglio', Cefalù, Italy.
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20
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Cruces P, Retamal J, Hurtado DE, Erranz B, Iturrieta P, González C, Díaz F. A physiological approach to understand the role of respiratory effort in the progression of lung injury in SARS-CoV-2 infection. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:494. [PMID: 32778136 PMCID: PMC7416996 DOI: 10.1186/s13054-020-03197-7] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/22/2020] [Indexed: 12/16/2022]
Abstract
Deterioration of lung function during the first week of COVID-19 has been observed when patients remain with insufficient respiratory support. Patient self-inflicted lung injury (P-SILI) is theorized as the responsible, but there is not robust experimental and clinical data to support it. Given the limited understanding of P-SILI, we describe the physiological basis of P-SILI and we show experimental data to comprehend the role of regional strain and heterogeneity in lung injury due to increased work of breathing. In addition, we discuss the current approach to respiratory support for COVID-19 under this point of view.
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Affiliation(s)
- Pablo Cruces
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile.,Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile.,Instituto de Ingeniería Biológica y Médica, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel E Hurtado
- Department of Structural and Geotechnical Engineering, School of Engineering Pontificia Universidad Católica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile.,Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile
| | - Benjamín Erranz
- Centro de Medicina Regenerativa, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Pablo Iturrieta
- Department of Structural and Geotechnical Engineering, School of Engineering Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos González
- Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile. .,Unidad de Paciente Crítico Pediátrico, Hospital Clínico La Florida Dra. Eloísa Díaz Insunza, Santiago, Chile. .,Instituto de Ciencias e Innovacion en Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile.
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21
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Hurtado DE, Erranz B, Lillo F, Sarabia-Vallejos M, Iturrieta P, Morales F, Blaha K, Medina T, Diaz F, Cruces P. Progression of regional lung strain and heterogeneity in lung injury: assessing the evolution under spontaneous breathing and mechanical ventilation. Ann Intensive Care 2020; 10:107. [PMID: 32761387 PMCID: PMC7407426 DOI: 10.1186/s13613-020-00725-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Protective mechanical ventilation (MV) aims at limiting global lung deformation and has been associated with better clinical outcomes in acute respiratory distress syndrome (ARDS) patients. In ARDS lungs without MV support, the mechanisms and evolution of lung tissue deformation remain understudied. In this work, we quantify the progression and heterogeneity of regional strain in injured lungs under spontaneous breathing and under MV. METHODS Lung injury was induced by lung lavage in murine subjects, followed by 3 h of spontaneous breathing (SB-group) or 3 h of low Vt mechanical ventilation (MV-group). Micro-CT images were acquired in all subjects at the beginning and at the end of the ventilation stage following induction of lung injury. Regional strain, strain progression and strain heterogeneity were computed from image-based biomechanical analysis. Three-dimensional regional strain maps were constructed, from which a region-of-interest (ROI) analysis was performed for the regional strain, the strain progression, and the strain heterogeneity. RESULTS After 3 h of ventilation, regional strain levels were significantly higher in 43.7% of the ROIs in the SB-group. Significant increase in regional strain was found in 1.2% of the ROIs in the MV-group. Progression of regional strain was found in 100% of the ROIs in the SB-group, whereas the MV-group displayed strain progression in 1.2% of the ROIs. Progression in regional strain heterogeneity was found in 23.4% of the ROIs in the SB-group, while the MV-group resulted in 4.7% of the ROIs showing significant changes. Deformation progression is concurrent with an increase of non-aerated compartment in SB-group (from 13.3% ± 1.6% to 37.5% ± 3.1%), being higher in ventral regions of the lung. CONCLUSIONS Spontaneous breathing in lung injury promotes regional strain and strain heterogeneity progression. In contrast, low Vt MV prevents regional strain and heterogeneity progression in injured lungs.
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Affiliation(s)
- Daniel E Hurtado
- Department of Structural and Geotechnical Engineering, School of Engineering Pontificia, Universidad Católica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile.,Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile
| | - Benjamín Erranz
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Felipe Lillo
- Centro de Investigación de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mauricio Sarabia-Vallejos
- Department of Structural and Geotechnical Engineering, School of Engineering Pontificia, Universidad Católica de Chile, Santiago, Chile
| | - Pablo Iturrieta
- Department of Structural and Geotechnical Engineering, School of Engineering Pontificia, Universidad Católica de Chile, Santiago, Chile
| | - Felipe Morales
- Centro de Investigación de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Katherine Blaha
- Pediatric Critical Care Unit, Clínica Alemana de Santiago, Santiago, Chile
| | - Tania Medina
- Pediatric Intensive Care Unit, Hospital El Carmen de Maipú, Santiago, Chile
| | - Franco Diaz
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile.,Pediatric Critical Care Unit, Clínica Alemana de Santiago, Santiago, Chile
| | - Pablo Cruces
- Centro de Investigación de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile. .,Pediatric Intensive Care Unit, Hospital El Carmen de Maipú, Santiago, Chile.
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22
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Rossi FS, Costa ELV, Iope DDM, Pacce PHD, Cestaro C, Braz LZ, Bousso A, Amato MBP. Pendelluft Detection Using Electrical Impedance Tomography in an Infant. Keep Those Images in Mind. Am J Respir Crit Care Med 2020; 200:1427-1429. [PMID: 31260637 DOI: 10.1164/rccm.201902-0461im] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Felipe S Rossi
- Materno-Infantil Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo L V Costa
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil; and
| | | | | | | | - Luisa Z Braz
- Materno-Infantil Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Albert Bousso
- Materno-Infantil Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo B P Amato
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil; and
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23
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Arunachalam GR, Chiew YS, Tan CP, Ralib AM, Nor MBM. Patient asynchrony modelling during controlled mechanical ventilation therapy. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 183:105103. [PMID: 31606559 DOI: 10.1016/j.cmpb.2019.105103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/30/2019] [Accepted: 09/30/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Mechanical ventilation therapy of respiratory failure patients can be guided by monitoring patient-specific respiratory mechanics. However, the patient's spontaneous breathing effort during controlled ventilation changes airway pressure waveform and thus affects the model-based identification of patient-specific respiratory mechanics parameters. This study develops a model to estimate respiratory mechanics in the presence of patient effort. METHODS Gaussian effort model (GEM) is a derivative of the single-compartment model with basis function. GEM model uses a linear combination of basis functions to model the nonlinear pressure waveform of spontaneous breathing patients. The GEM model estimates respiratory mechanics such as Elastance and Resistance along with the magnitudes of basis functions, which accounts for patient inspiratory effort. RESULTS AND DISCUSSION The GEM model was tested using both simulated data and a retrospective observational clinical trial patient data. GEM model fitting to the original airway pressure waveform is better than any existing models when reverse triggering asynchrony is present. The fitting error of GEM model was less than 10% for both simulated data and clinical trial patient data. CONCLUSION GEM can capture the respiratory mechanics in the presence of patient effect in volume control ventilation mode and also can be used to assess patient-ventilator interaction. This model determines basis functions magnitudes, which can be used to simulate any waveform of patient effort pressure for future studies. The estimation of parameter identification GEM model can further be improved by constraining the parameters within a physiologically plausible range during least-square nonlinear regression.
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Affiliation(s)
| | | | - Chee Pin Tan
- School of Engineering, Monash University, Subang Jaya, Malaysia
| | - Azrina Mohd Ralib
- Department of Intensive Care, International Islamic University Malaysia Medical Centre, Kuantan, Malaysia
| | - Mohd Basri Mat Nor
- Department of Intensive Care, International Islamic University Malaysia Medical Centre, Kuantan, Malaysia
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24
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Silva PL, Gama de Abreu M. Regional distribution of transpulmonary pressure. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:385. [PMID: 30460259 DOI: 10.21037/atm.2018.10.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The pressure across the lung, so-called transpulmonary pressure (PL), represents the main force acting toward to provide lung movement. During mechanical ventilation, PL is provided by respiratory system pressurization, using specific ventilator setting settled by the operator, such as: tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), and inspiratory airway flow. Once PL is developed throughout the lungs, its distribution is heterogeneous, being explained by the elastic properties of the lungs and pleural pressure gradient. There are different methods of PL calculation, each one with importance and some limitations. Among the most known, it can be quoted: (I) direct measurement of PL; (II) elastance derived method at end-inspiration of PL; (III) transpulmonary driving pressure. Recent studies using pleural sensors in large animal models as also in human cadaver have added new and important information about PL heterogeneous distribution across the lungs. Due to this heterogeneous distribution, lung damage could happen in specific areas of the lung. In addition, it is widely accepted that high PL can cause lung damage, however the way it is delivered, whether it's compressible or tensile, may also further damage despite the values of PL achieved. According to heterogeneous distribution of PL across the lungs, the interstitium and lymphatic vessels may also interplay to disseminate lung inflammation toward peripheral organs through thoracic lymph tracts. Thus, it is conceivable that juxta-diaphragmatic area associated strong efforts leading to high values of PL may be a source of dissemination of inflammatory cells, large molecules, and plasma contents able to perpetuate inflammation in distal organs.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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25
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de Vries H, Jonkman A, Shi ZH, Spoelstra-de Man A, Heunks L. Assessing breathing effort in mechanical ventilation: physiology and clinical implications. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:387. [PMID: 30460261 DOI: 10.21037/atm.2018.05.53] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent studies have shown both beneficial and detrimental effects of patient breathing effort in mechanical ventilation. Quantification of breathing effort may allow the clinician to titrate ventilator support to physiological levels of respiratory muscle activity. In this review we will describe the physiological background and methodological issues of the most frequently used methods to quantify breathing effort, including esophageal pressure measurement, the work of breathing, the pressure-time-product, electromyography and ultrasound. We will also discuss the level of breathing effort that may be considered optimal during mechanical ventilation at different stages of critical illness.
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Affiliation(s)
- Heder de Vries
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Angélique Spoelstra-de Man
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
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26
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Staub LJ, Mazzali Biscaro RR, Velho GV, Reis C, Maurici R. A 59-Year-Old Man With ARDS Receiving “Protective” Ventilation. Chest 2018; 153:e67-e70. [DOI: 10.1016/j.chest.2017.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/11/2017] [Accepted: 10/31/2017] [Indexed: 10/17/2022] Open
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27
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Roshdy A, Katira BH, Kuebler WM, Kavanagh BP. Vascular-induced lung injury: another advocate for personalized ARDS management : Discussion on "Inspiratory preload obliteration may injure lungs via cyclical 'on-off' vascular flow". Intensive Care Med 2018; 44:540-541. [PMID: 29450595 DOI: 10.1007/s00134-018-5077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Ashraf Roshdy
- Critical Care Unit, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Road, Woolwich, London, SE18 4QH, UK. .,Critical Care Medicine, Alexandria University, Alexandria, Egypt.
| | - B H Katira
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - W M Kuebler
- Institute of Physiology, Charité-Universitätsmedizin, Berlin, Germany
| | - B P Kavanagh
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Canada.,Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
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28
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Gudmundsson M, Perchiazzi G, Pellegrini M, Vena A, Hedenstierna G, Rylander C. Atelectasis is inversely proportional to transpulmonary pressure during weaning from ventilator support in a large animal model. Acta Anaesthesiol Scand 2018; 62:94-104. [PMID: 29058315 DOI: 10.1111/aas.13015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/22/2017] [Accepted: 09/30/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND In mechanically ventilated, lung injured, patients without spontaneous breathing effort, atelectasis with shunt and desaturation may appear suddenly when ventilator pressures are decreased. It is not known how such a formation of atelectasis is related to transpulmonary pressure (PL ) during weaning from mechanical ventilation when the spontaneous breathing effort is increased. If the relation between PL and atelectasis were known, monitoring of PL might help to avoid formation of atelectasis and cyclic collapse during weaning. The main purpose of this study was to determine the relation between PL and atelectasis in an experimental model representing weaning from mechanical ventilation. METHODS Dynamic transverse computed tomography scans were acquired in ten anaesthetized, surfactant-depleted pigs with preserved spontaneous breathing, as ventilator support was lowered by sequentially reducing inspiratory pressure and positive end expiratory pressure in steps. The volumes of gas and atelectasis in the lungs were correlated with PL obtained using oesophageal pressure recordings. Work of breathing (WOB) was assessed from Campbell diagrams. RESULTS Gradual decrease in PL in both end-expiration and end-inspiration caused a proportional increase in atelectasis and decrease in the gas content (linear mixed model with an autoregressive correlation matrix; P < 0.001) as the WOB increased. However, cyclic alveolar collapse during tidal ventilation did not increase significantly. CONCLUSION We found a proportional correlation between atelectasis and PL during the 'weaning process' in experimental mild lung injury. If confirmed in the clinical setting, a gradual tapering of ventilator support can be recommended for weaning without risk of sudden formation of atelectasis.
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Affiliation(s)
- M. Gudmundsson
- Department of Anaesthesiology and Intensive Care Medicine; Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - G. Perchiazzi
- Hedenstierna Laboratory; Institute of Medical Sciences; Uppsala University; Uppsala Sweden
| | - M. Pellegrini
- Hedenstierna Laboratory; Institute of Medical Sciences; Uppsala University; Uppsala Sweden
| | - A. Vena
- Department of Emergency and Organ Transplant; Bari University; Bari Italy
| | - G. Hedenstierna
- Hedenstierna Laboratory; Institute of Medical Sciences; Uppsala University; Uppsala Sweden
| | - C. Rylander
- Department of Anaesthesiology and Intensive Care Medicine; Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Hedenstierna Laboratory; Institute of Medical Sciences; Uppsala University; Uppsala Sweden
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29
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Mauri T, Cambiaghi B, Spinelli E, Langer T, Grasselli G. Spontaneous breathing: a double-edged sword to handle with care. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:292. [PMID: 28828367 DOI: 10.21037/atm.2017.06.55] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) patients, spontaneous breathing is associated with multiple physiologic benefits: it prevents muscles atrophy, avoids paralysis, decreases sedation needs and is associated with improved hemodynamics. On the other hand, in the presence of uncontrolled inspiratory effort, severe lung injury and asynchronies, spontaneous ventilation might also worsen lung edema, induce diaphragm dysfunction and lead to muscles exhaustion and prolonged weaning. In the present review article, we present physiologic mechanisms driving spontaneous breathing, with emphasis on how to implement basic and advanced respiratory monitoring to assess lung protection during spontaneous assisted ventilation. Then, key benefits and risks associated with spontaneous ventilation are described. Finally, we propose some clinical means to promote protective spontaneous breathing at the bedside. In summary, early switch to spontaneous assisted breathing of acutely hypoxemic patients is more respectful of physiology and might yield several advantages. Nonetheless, risk of additional lung injury is not completely avoided during spontaneous breathing and careful monitoring of target physiologic variables such as tidal volume (Vt) and driving transpulmonary pressure should be applied routinely. In clinical practice, multiple interventions such as extracorporeal CO2 removal exist to maintain inspiratory effort, Vt and driving transpulmonary pressure within safe limits but more studies are needed to assess their long-term efficacy.
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Affiliation(s)
- Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Cambiaghi
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Thomas Langer
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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30
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Lopes FA, de Souza LAM, Bernardi JTN, Rocha CE, de Figueiredo LC, Agostini APRDA, Dragosavac D, Faez DCDS. Pendelluft diagnosed from ventilator weaning indexes obtained through bioelectrical impedance tomography: a case report. SAO PAULO MED J 2017; 135:302-308. [PMID: 28380204 PMCID: PMC10019837 DOI: 10.1590/1516-3180.2016.025514102016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 11/22/2022] Open
Abstract
CONTEXT: Today, through major technological advances in diagnostic resources within medicine, evaluation and monitoring of clinical parameters at the patient's bedside in intensive care units (ICUs) has become possible. CASE REPORT: This case report presents results and interpretations from predictive mechanical ventilation weaning indexes obtained through monitoring using chest electrical bioimpedance tomography. These indexes included maximum inspiratory pressure, maximum expiratory pressure, shallow breathing index and spontaneous breathing test. These were correlated with variations in tidal volume variables, respiratory rate, mean arterial pressure and peripheral oxygen saturation. Regarding the air distribution behavior in the pulmonary parenchyma, the patient showed the pendelluft phenomenon. Pendelluft occurs due to the time constant (product of the airways resistance and compliance) asymmetry between adjacent lung. CONCLUSION: Bioelectrical impedance tomography can help in weaning from mechanical ventilation, as in the case presented here. Pendelluft was defined as a limitation during the weaning tests.
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Affiliation(s)
- Fabiana Aparecida Lopes
- BSc. Physiotherapist at the Adult Intensive Care Unit, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | | | - Juliana Tavares Neves Bernardi
- BSc. Physiotherapist at the Adult Intensive Care Unit, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Carlos Eduardo Rocha
- BSc. Physiotherapist at the Adult Intensive Care Unit, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | - Luciana Castilho de Figueiredo
- MSc, PhD. Physiotherapist at Adult Intensive Care Unit, Hospital das Clínicas, and Supervisor of Chest Physiotherapy Training Course, Adult Intensive Care Unit, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
| | | | - Desanka Dragosavac
- MD, PhD. Coordinator, Adult Intensive Care Unit, Hospital das Clínicas, Universidade Estadual de Campinas (UNICAMP), Campinas (SP), Brazil.
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31
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Doorduin J, Nollet JL, Roesthuis LH, van Hees HWH, Brochard LJ, Sinderby CA, van der Hoeven JG, Heunks LMA. Partial Neuromuscular Blockade during Partial Ventilatory Support in Sedated Patients with High Tidal Volumes. Am J Respir Crit Care Med 2017; 195:1033-1042. [DOI: 10.1164/rccm.201605-1016oc] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
| | | | | | | | - Laurent J. Brochard
- Department of Critical Care Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada; and
- Keenan Research Centre for Biomedical Science, Toronto, Ontario, Canada
| | - Christer A. Sinderby
- Department of Critical Care Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada; and
- Keenan Research Centre for Biomedical Science, Toronto, Ontario, Canada
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32
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Conservative oxygen therapy in mechanically ventilated patients following cardiac arrest: A retrospective nested cohort study. Resuscitation 2015; 101:108-14. [PMID: 26718090 DOI: 10.1016/j.resuscitation.2015.11.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/26/2015] [Accepted: 11/30/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND In mechanically ventilated (MV) cardiac arrest (CA) survivors admitted to the intensive care unit (ICU) avoidance of hypoxia is considered crucial. However, avoidance of hyperoxia may also be important. A conservative approach to oxygen therapy may reduce exposure to both. METHODS We evaluated the introduction of conservative oxygen therapy (target SpO2 88-92% using the lowest FiO2) during MV for resuscitated CA patients admitted to the ICU. RESULTS We studied 912 arterial blood gas (ABG) datasets: 448 ABGs from 50 'conventional' and 464 ABGs from 50 'conservative' oxygen therapy patients. Compared to the conventional group, conservative group patients had significantly lower PaO2 values and FiO2 exposure (p<0.001, respectively); more received MV in a spontaneous ventilation mode (18% vs 2%; p=0.001) and more were exposed to a FiO2 of 0.21 (19 vs 0 patients, p=0.001). Additionally, according to mean PaO2, more conservative group patients were classified as normoxaemic (36 vs 16 patients, p<0.01) and fewer as hyperoxaemic (14 vs 33 patients, p<0.01). Finally, ICU length of stay was significantly shorter for conservative group patients (p=0.04). There was no difference in the proportion of survivors discharged from hospital with good neurological outcome (14/23 vs 12/22 patients, p=0.67). CONCLUSIONS Our findings provide preliminary support for the feasibility and physiological safety of conservative oxygen therapy in patients admitted to ICU for MV support after cardiac arrest (Trial registration, NCT01684124).
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Hall MB, Johnston DR, Barth P. Positive Pressure Bronchoscopy Technique: Case Report. Ann Otol Rhinol Laryngol 2015; 125:165-8. [PMID: 26307070 DOI: 10.1177/0003489415602265] [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: 11/17/2022]
Abstract
OBJECTIVE Foreign body aspiration into the tracheobronchial tree continues to be a challenging problem for otolaryngologists. This is especially true in patients with poor pulmonary reserve. METHODS We describe a novel technique in which an endotracheal sheathed bronchoscope is used as a means to provide positive pressure ventilation simultaneously during foreign body extraction. RESULTS This new technique afforded the bronchoscopist more time during retrieval of the foreign body where previous attempts were limited by rapid desaturations and the overall nature of the foreign body. CONCLUSION The endotracheal sheathed bronchoscope is a safe and efficacious technique for challenging airway foreign bodies complicated by a patient's limited pulmonary reserve.
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Affiliation(s)
- Michael B Hall
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Deleware, USA Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Douglas R Johnston
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Deleware, USA Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Patrick Barth
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Deleware, USA
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