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Parhar KKS, Doig C. Caution-Do Not Attempt This at Home. Airway Pressure Release Ventilation Should Not Routinely Be Used in Patients With or at Risk of Acute Respiratory Distress Syndrome Outside of a Clinical Trial. Crit Care Med 2024; 52:1451-1457. [PMID: 36661571 DOI: 10.1097/ccm.0000000000005776] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Ken Kuljit S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, ICU Administration - Ground Floor - McCaig Tower, Foothills Medical Center, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Christopher Doig
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, ICU Administration - Ground Floor - McCaig Tower, Foothills Medical Center, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Ille A, Nilsson C, Sjödin C, Daham S, Persson P, Svensson CJ. Airway pressure release ventilation (APRV) versus pressure support ventilation (PSV)-A prospective intervention trial comparing haemodynamic parameters in intensive care patients. Acta Anaesthesiol Scand 2024; 68:932-939. [PMID: 38764089 DOI: 10.1111/aas.14434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND AND AIM Assisted mechanical ventilation may alter the pressure profile in the thorax compared to normal breathing, which can affect the blood flow to and from the heart. Studies suggest that in patients with severe lung disease, airway pressure release ventilation (APRV) may be haemodynamically beneficial compared to other ventilator settings. The primary aim of this study was to investigate if APRV affects cardiac index in intubated intensive care patients without severe lung disease when compared to pressure support ventilation (PSV). The secondary aim comprised potential changes in other haemodynamic and ventilatory parameters. METHODS Twenty patients were enrolled in the intensive care unit (ICU) at Sahlgrenska University Hospital. Eligible patients met the inclusion criteria; 18 years of age or above, intubated and mechanically ventilated, triggering and stable on PSV mode, with indwelling haemodynamic monitoring via a pulse-induced continuous cardiac output (PiCCO) catheter. The study protocol started with a 30-min interval on PSV mode, followed by a 30-min interval on APRV mode, and finally a 30-min interval back on PSV mode. At the end of each interval, PiCCO outputs, ventilator outputs, arterial and venous blood gas analyses, heart rate and central venous pressure were recorded and compared between modes. RESULTS There was no significant difference in cardiac index (3.42 vs. 3.39 L/min/m2) between PSV and APRV, but a significant increase in central venous pressure (+1.0 mmHg, p = .027). Furthermore, we found a significant reduction in peak airway pressure (-3.16 cmH2O, p < .01) and an increase in mean airway pressure (+2.1 cmH2O, p < .01). No statistically significant change was found in oxygenation index (partial pressure of O2 [pO2]/fraction of inspired oxygen) nor in other secondary outcomes when comparing PSV and APRV. There was no significant association between global end-diastolic volume index and cardiac index (R2 = 0.0089) or central venous pressure (R2 = 0.278). All parameters returned to baseline after switching the ventilator mode back to PSV. CONCLUSION We could not detect any changes in cardiac index in ICU patients without severe lung disease during APRV compared to PSV mode, despite lower peak airway pressure and increased mean airway pressure.
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Affiliation(s)
- Alexandru Ille
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carl Nilsson
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carl Sjödin
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Shanay Daham
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Per Persson
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carl Johan Svensson
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Zhou Y, Cheng J, Zhu S, Dong M, Lv Y, Jing X, Kang Y. Early pathophysiology-driven airway pressure release ventilation versus low tidal volume ventilation strategy for patients with moderate-severe ARDS: study protocol for a randomized, multicenter, controlled trial. BMC Pulm Med 2024; 24:252. [PMID: 38783268 PMCID: PMC11112826 DOI: 10.1186/s12890-024-03065-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Conventional Mechanical ventilation modes used for individuals suffering from acute respiratory distress syndrome have the potential to exacerbate lung injury through regional alveolar overinflation and/or repetitive alveolar collapse with shearing, known as atelectrauma. Animal studies have demonstrated that airway pressure release ventilation (APRV) offers distinct advantages over conventional mechanical ventilation modes. However, the methodologies for implementing APRV vary widely, and the findings from clinical studies remain controversial. This study (APRVplus trial), aims to assess the impact of an early pathophysiology-driven APRV ventilation approach compared to a low tidal volume ventilation (LTV) strategy on the prognosis of patients with moderate to severe ARDS. METHODS The APRVplus trial is a prospective, multicenter, randomized clinical trial, building upon our prior single-center study, to enroll 840 patients from at least 35 hospitals in China. This investigation plans to compare the early pathophysiology-driven APRV ventilation approach with the control intervention of LTV lung-protective ventilation. The primary outcome measure will be all-cause mortality at 28 days after randomization in the intensive care units (ICU). Secondary outcome measures will include assessments of oxygenation, and physiology parameters at baseline, as well as on days 1, 2, and 3. Additionally, clinical outcomes such as ventilator-free days at 28 days, duration of ICU and hospital stay, ICU and hospital mortality, and the occurrence of adverse events will be evaluated. TRIAL ETHICS AND DISSEMINATION The research project has obtained approval from the Ethics Committee of West China Hospital of Sichuan University (2019-337). Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION The study was registered at Clinical Trials.gov (NCT03549910) on June 8, 2018.
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Affiliation(s)
- Yongfang Zhou
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China.
| | - Jiangli Cheng
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Shuo Zhu
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Meiling Dong
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Yinxia Lv
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Xiaorong Jing
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China.
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Lutz MR, Charlamb J, Kenna JR, Smith A, Glatt SJ, Araos JD, Andrews PL, Habashi NM, Nieman GF, Ghosh AJ. Inconsistent Methods Used to Set Airway Pressure Release Ventilation in Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Regression Analysis. J Clin Med 2024; 13:2690. [PMID: 38731219 PMCID: PMC11084500 DOI: 10.3390/jcm13092690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/15/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Airway pressure release ventilation (APRV) is a protective mechanical ventilation mode for patients with acute respiratory distress syndrome (ARDS) that theoretically may reduce ventilator-induced lung injury (VILI) and ARDS-related mortality. However, there is no standard method to set and adjust the APRV mode shown to be optimal. Therefore, we performed a meta-regression analysis to evaluate how the four individual APRV settings impacted the outcome in these patients. Methods: Studies investigating the use of the APRV mode for ARDS patients were searched from electronic databases. We tested individual settings, including (1) high airway pressure (PHigh); (2) low airway pressure (PLow); (3) time at high airway pressure (THigh); and (4) time at low pressure (TLow) for association with PaO2/FiO2 ratio and ICU length of stay. Results: There was no significant difference in PaO2/FiO2 ratio between the groups in any of the four settings (PHigh difference -12.0 [95% CI -100.4, 86.4]; PLow difference 54.3 [95% CI -52.6, 161.1]; TLow difference -27.19 [95% CI -127.0, 72.6]; THigh difference -51.4 [95% CI -170.3, 67.5]). There was high heterogeneity across all parameters (PhHgh I2 = 99.46%, PLow I2 = 99.16%, TLow I2 = 99.31%, THigh I2 = 99.29%). Conclusions: None of the four individual APRV settings independently were associated with differences in outcome. A holistic approach, analyzing all settings in combination, may improve APRV efficacy since it is known that small differences in ventilator settings can significantly alter mortality. Future clinical trials should set and adjust APRV based on the best current scientific evidence available.
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Affiliation(s)
- Mark R. Lutz
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, USA (J.C.); (J.R.K.)
| | - Jacob Charlamb
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, USA (J.C.); (J.R.K.)
| | - Joshua R. Kenna
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, USA (J.C.); (J.R.K.)
| | - Abigail Smith
- Health Sciences Library, SUNY Upstate Medical University, Syracuse, NY 13210, USA;
| | - Stephen J. Glatt
- Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY 13210, USA
- Department of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY 13210, USA
- Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | - Joaquin D. Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA;
| | - Penny L. Andrews
- Department of Critical Care, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA
| | - Nader M. Habashi
- Department of Critical Care, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, USA (J.C.); (J.R.K.)
| | - Auyon J. Ghosh
- Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA;
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Camporota L, Rose L, Andrews PL, Nieman GF, Habashi NM. Airway pressure release ventilation for lung protection in acute respiratory distress syndrome: an alternative way to recruit the lungs. Curr Opin Crit Care 2024; 30:76-84. [PMID: 38085878 DOI: 10.1097/mcc.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW Airway pressure release ventilation (APRV) is a modality of ventilation in which high inspiratory continuous positive airway pressure (CPAP) alternates with brief releases. In this review, we will discuss the rationale for APRV as a lung protective strategy and then provide a practical introduction to initiating APRV using the time-controlled adaptive ventilation (TCAV) method. RECENT FINDINGS APRV using the TCAV method uses an extended inspiratory time and brief expiratory release to first stabilize and then gradually recruit collapsed lung (over hours/days), by progressively 'ratcheting' open a small volume of collapsed tissue with each breath. The brief expiratory release acts as a 'brake' preventing newly recruited units from re-collapsing, reversing the main drivers of ventilator-induced lung injury (VILI). The precise timing of each release is based on analysis of expiratory flow and is set to achieve termination of expiratory flow at 75% of the peak expiratory flow. Optimization of the release time reflects the changes in elastance and, therefore, is personalized (i.e. conforms to individual patient pathophysiology), and adaptive (i.e. responds to changes in elastance over time). SUMMARY APRV using the TCAV method is a paradigm shift in protective lung ventilation, which primarily aims to stabilize the lung and gradually reopen collapsed tissue to achieve lung homogeneity eliminating the main mechanistic drivers of VILI.
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Affiliation(s)
- Luigi Camporota
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences
| | - Louise Rose
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust
- Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, UK
| | - Penny L Andrews
- Department of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Gary F Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York, USA
| | - Nader M Habashi
- Department of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Aldhahir AM, Alqarni AA, Madkhali MA, Madkhali HH, Bakri AA, Shawany MA, Alasimi AH, Alsulayyim AS, Alqahtani JS, Alyami MM, Alghamdi SM, Alqarni OA, Hakamy A. Awareness and practice of airway pressure release ventilation mode in acute respiratory distress syndrome patients among nurses in Saudi Arabia. BMC Nurs 2024; 23:79. [PMID: 38291421 PMCID: PMC10826023 DOI: 10.1186/s12912-024-01763-w] [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: 10/21/2023] [Accepted: 01/24/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND This study aimed to assess the knowledge and current practice of using the airway pressure release ventilation (APRV) mode with acute respiratory distress syndrome (ARDS) patients and identify barriers to not using this mode of ventilation among nurses who work in critical areas in Saudi Arabia. METHODS Between December 2022 and April 2023, a cross-sectional online survey was disseminated to nurses working in critical care areas in Saudi Arabia. The characteristics of the respondents were analyzed using descriptive statistics. Percentages and frequencies were used to report categorical variables. RESULTS Overall, 1,002 nurses responded to the online survey, of whom 592 (59.1%) were female. Only 248 (24.7%) nurses had ever used APRV mode, whereas only 229 (22.8%) received training on APRV mode. Moreover, 602 (60.0%) nurses did not know whether APRV was utilized in their hospital. Additionally, 658 (65.6%) nurses did not know whether APRV mode was managed using a standard protocol. Prone positioning was the highest recommended intervention by 444 (43.8%) when a conventional MV failed to improve oxygenation in patients with ARDS. 323 (32.2%) respondents stated that the P-high should be set equal to the plateau pressure on a conventional ventilator, while 400 (39.9%) said that the P-low should match PEEP from a conventional ventilator. Almost half of the respondents (446, 44.5%) stated that the T-high should be set between 4 and 6 s, while 415 (41.4%) said that the T-low should be set at 0.4 to 0.8 s. Over half of the nurses (540, 53.9%) thought that the maximum allowed tidal volume during the release phase should be 4-6 ml/kg. Moreover, 475 (47.4%) believed that the maximum allowed P-high setting should be 35 cm H2O. One-third of the responders (329, 32.8%) stated that when weaning patients with ARDS while in APRV mode, the P-high should be reduced gradually to reach a target of 10 cm H2O. However, 444 (44.3%) thought that the T-high should be gradually increased to reach a target of 10 s. Half of the responders (556, 55.5%) felt that the criteria to switch the patient to continuous positive airway pressure (CPAP) were for the patient to have an FiO2 ≤ 0.4, P-high ≤ 10 cm H2O, and T-high ≥ 10 s. Lack of training was the most common barrier to not using APRV by 615 (61.4%). CONCLUSION The majority of nurses who work in critical care units have not received sufficient training in APRV mode. A significant discrepancy was observed regarding the clinical application and management of APRV parameters. Inadequate training was the most frequently reported barrier to the use of APRV in patients with ARDS.
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Affiliation(s)
- Abdulelah M Aldhahir
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia.
| | - Abdullah A Alqarni
- Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
- Respiratory Therapy Unit, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mohammed A Madkhali
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Hussain H Madkhali
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Abdullah A Bakri
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Mohammad A Shawany
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Ahmed H Alasimi
- Department of Respiratory Therapy, Georgia State University, Atlanta, GA, USA
| | - Abdullah S Alsulayyim
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Jaber S Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Mohammed M Alyami
- Respiratory Therapy Department, Batterjee Medical College, Khamis Mushait, Saudi Arabia
| | - Saeed M Alghamdi
- Clinical Technology Department, Respiratory Care Program, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Omar A Alqarni
- Clinical Technology Department, Respiratory Care Program, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ali Hakamy
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
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Al-Khalisy H, Nieman GF, Kollisch-Singule M, Andrews P, Camporota L, Shiber J, Manougian T, Satalin J, Blair S, Ghosh A, Herrmann J, Kaczka DW, Gaver DP, Bates JHT, Habashi NM. Time-Controlled Adaptive Ventilation (TCAV): a personalized strategy for lung protection. Respir Res 2024; 25:37. [PMID: 38238778 PMCID: PMC10797864 DOI: 10.1186/s12931-023-02615-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/25/2023] [Indexed: 01/22/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) alters the dynamics of lung inflation during mechanical ventilation. Repetitive alveolar collapse and expansion (RACE) predisposes the lung to ventilator-induced lung injury (VILI). Two broad approaches are currently used to minimize VILI: (1) low tidal volume (LVT) with low-moderate positive end-expiratory pressure (PEEP); and (2) open lung approach (OLA). The LVT approach attempts to protect already open lung tissue from overdistension, while simultaneously resting collapsed tissue by excluding it from the cycle of mechanical ventilation. By contrast, the OLA attempts to reinflate potentially recruitable lung, usually over a period of seconds to minutes using higher PEEP used to prevent progressive loss of end-expiratory lung volume (EELV) and RACE. However, even with these protective strategies, clinical studies have shown that ARDS-related mortality remains unacceptably high with a scarcity of effective interventions over the last two decades. One of the main limitations these varied interventions demonstrate to benefit is the observed clinical and pathologic heterogeneity in ARDS. We have developed an alternative ventilation strategy known as the Time Controlled Adaptive Ventilation (TCAV) method of applying the Airway Pressure Release Ventilation (APRV) mode, which takes advantage of the heterogeneous time- and pressure-dependent collapse and reopening of lung units. The TCAV method is a closed-loop system where the expiratory duration personalizes VT and EELV. Personalization of TCAV is informed and tuned with changes in respiratory system compliance (CRS) measured by the slope of the expiratory flow curve during passive exhalation. Two potentially beneficial features of TCAV are: (i) the expiratory duration is personalized to a given patient's lung physiology, which promotes alveolar stabilization by halting the progressive collapse of alveoli, thereby minimizing the time for the reopened lung to collapse again in the next expiration, and (ii) an extended inspiratory phase at a fixed inflation pressure after alveolar stabilization gradually reopens a small amount of tissue with each breath. Subsequently, densely collapsed regions are slowly ratcheted open over a period of hours, or even days. Thus, TCAV has the potential to minimize VILI, reducing ARDS-related morbidity and mortality.
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Affiliation(s)
| | - Gary F Nieman
- SUNY Upstate Medical University, 750 E. Adams St., Syracuse, NY, 13210, USA
| | | | - Penny Andrews
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joseph Shiber
- University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Joshua Satalin
- SUNY Upstate Medical University, 750 E. Adams St., Syracuse, NY, 13210, USA.
| | - Sarah Blair
- SUNY Upstate Medical University, 750 E. Adams St., Syracuse, NY, 13210, USA
| | - Auyon Ghosh
- SUNY Upstate Medical University, 750 E. Adams St., Syracuse, NY, 13210, USA
| | | | | | | | | | - Nader M Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
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Cruz AF, Herrmann J, Ramcharran H, Kollisch-Singule M, Tawhai MH, Bates JHT, Nieman GF, Kaczka DW. Sustained vs. Intratidal Recruitment in the Injured Lung During Airway Pressure Release Ventilation: A Computational Modeling Perspective. Mil Med 2023; 188:141-148. [PMID: 37948236 DOI: 10.1093/milmed/usad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/03/2023] [Accepted: 02/14/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION During mechanical ventilation, cyclic recruitment and derecruitment (R/D) of alveoli result in focal points of heterogeneous stress throughout the lung. In the acutely injured lung, the rates at which alveoli can be recruited or derecruited may also be altered, requiring longer times at higher pressure levels to be recruited during inspiration, but shorter times at lower pressure levels to minimize collapse during exhalation. In this study, we used a computational model to simulate the effects of airway pressure release ventilation (APRV) on acinar recruitment, with varying inspiratory pressure levels and durations of exhalation. MATERIALS AND METHODS The computational model consisted of a ventilator pressure source, a distensible breathing circuit, an endotracheal tube, and a porcine lung consisting of recruited and derecruited zones, as well as a transitional zone capable of intratidal R/D. Lung injury was simulated by modifying each acinus with an inflation-dependent surface tension. APRV was simulated for an inhalation duration (Thigh) of 4.0 seconds, inspiratory pressures (Phigh) of 28 and 40 cmH2O, and exhalation durations (Tlow) ranging from 0.2 to 1.5 seconds. RESULTS Both sustained acinar recruitment and intratidal R/D within the subtree were consistently higher for Phigh of 40 cmH2O vs. 28 cmH2O, regardless of Tlow. Increasing Tlow was associated with decreasing sustained acinar recruitment, but increasing intratidal R/D, within the subtree. Increasing Tlow was associated with decreasing elastance of both the total respiratory system and transitional subtree of the model. CONCLUSIONS Our computational model demonstrates the confounding effects of cyclic R/D, sustained recruitment, and parenchymal strain stiffening on estimates of total lung elastance during APRV. Increasing inspiratory pressures leads to not only more sustained recruitment of unstable acini but also more intratidal R/D. Our model indicates that higher inspiratory pressures should be used in conjunction with shorter exhalation times, to avoid increasing intratidal R/D.
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Affiliation(s)
- Andrea F Cruz
- Department of Anesthesia, University of Iowa, Iowa City, IA 52242, USA
| | - Jacob Herrmann
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Harry Ramcharran
- Department of Surgery, SUNY Upstate Medical Center, Syracuse, NY 13210, USA
| | | | - Merryn H Tawhai
- Department of Bioengineering, University of Auckland, Auckland 1124, New Zealand
| | - Jason H T Bates
- Department of Medicine, University of Vermont, Burlington, VT 05405, USA
| | - Gary F Nieman
- Department of Surgery, SUNY Upstate Medical Center, Syracuse, NY 13210, USA
| | - David W Kaczka
- Department of Anesthesia, University of Iowa, Iowa City, IA 52242, USA
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
- Department of Radiology, University of Iowa, Iowa City, IA 52242, USA
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Pan C, Chen Y, Zhou Y. A Fast-Track Respiratory Protocol for High Cervical Spine Injury: A Case Report. J Trauma Nurs 2023; 30:357-363. [PMID: 37937878 PMCID: PMC10681283 DOI: 10.1097/jtn.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Cervical spinal cord injury can greatly affect pulmonary function, resulting in complications, including respiratory failure with prolonged mechanical ventilation, ultimately leading to increased mortality and high health care costs. Weaning from mechanical ventilation is particularly challenging in patients with complete high spinal cord injury. CASE PRESENTATION We present the case of a 42-year-old man who suffered a complete cervical 5-6 spinal cord injury following a rollover motor vehicle crash and subsequently developed postoperative pneumonia and severe hypoxemic respiratory failure. He received a novel approach to fast-track respiratory care, including early and aggressive secretion clearance management, moderate pressure level of airway pressure release ventilation, timely transition to spontaneous mode, early tracheostomy and humane care, and high-flow oxygenation via tracheotomy after weaning off the ventilator. As a result, the patient experienced significant improvement in pulmonary function and was successfully liberated from the ventilator within a 2-week period. CONCLUSION This case highlights the potential effectiveness of fast-track respiratory care in promoting lung function restoration and expediting liberation from mechanical ventilation in patients with severe hypoxemic respiratory failure following a complete cervical spinal cord injury. However, further research is warranted to validate these findings and expand our understanding in this area.
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Affiliation(s)
- Caixue Pan
- Departments of Respiratory Care (Mr Pan and Ms Zhou) and Critical Care Medicine (Dr Chen), West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yao Chen
- Departments of Respiratory Care (Mr Pan and Ms Zhou) and Critical Care Medicine (Dr Chen), West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yongfang Zhou
- Departments of Respiratory Care (Mr Pan and Ms Zhou) and Critical Care Medicine (Dr Chen), West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Shu B, Zhang Y, Ren Q, Zheng X, Zhang Y, Liu Q, Li S, Chen J, Chen Y, Duan G, Huang H. Optimal positive end-expiratory pressure titration of intraoperative mechanical ventilation in different operative positions of female patients under general anesthesia. Heliyon 2023; 9:e20552. [PMID: 37822628 PMCID: PMC10562915 DOI: 10.1016/j.heliyon.2023.e20552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
Objective This study aimed to compare the effectiveness and safety of different titrated methods used to determine individual positive end-expiratory pressure (PEEP) for intraoperative mechanical ventilation in female patients undergoing general anesthesia in different operative positions, and provide reference ranges of optimal PEEP values based on the titration. Methods A total of 123 female patients who underwent elective open abdominal surgery under general anesthesia were included in this study. After endotracheal intubation, patients' body position was adjusted to the supine position, Trendelenburg positions at 10° and 20° respectively. PEEP was titrated from 20 cmH2O to 4 cmH2O, decreasing by 2 cmH2O every 1 min. Electrical impedance tomography (EIT), hemodynamic and respiratory mechanics parameters were continuously monitored and recorded. Optimal PEEP values and reference ranges were respectively calculated based on optimal EIT parameters, mean arterial pressure (MAP), and lung dynamic compliance (Cdyn). Results EIT-guided optimal PEEP was found to have higher values than those of the MAP-guided and Cdyn-guided methods for all three body positions (P < 0.001), and it was observed to more significantly inhibit hemodynamics (P < 0.05). The variable coefficients of EIT-guided optimal PEEP values were smaller than those of the other two methods, and this technique could provide better ventilation uniformity for dorsal/ventral lung fields and better balance for pulmonary atelectasis/collapse. The 95% reference ranges of EIT-guided optimal PEEP values were 4.6-13.8 cmH2O, 7.0-15.0 cmH2O and 8.6-17.0 cmH2O for the supine position, Trendelenburg 10°, and Trendelenburg 20° positions, respectively. Conclusion EIT-guided optimal PEEP titration was found to be a superior method for lung protective ventilation in different operative positions under general anesthesia. The calculated reference ranges of PEEP values based on the EIT-guided method can be used as a reference for intraoperative mechanical ventilation.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qian Ren
- Department of Anesthesiology, Chongqing University Three Gorges Hospital, Chongqing, 404000, China
| | - Xuemei Zheng
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yamei Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qi Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Shiqi Li
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Jie Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yuanjing Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - He Huang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
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Nieman GF, Kaczka DW, Andrews PL, Ghosh A, Al-Khalisy H, Camporota L, Satalin J, Herrmann J, Habashi NM. First Stabilize and then Gradually Recruit: A Paradigm Shift in Protective Mechanical Ventilation for Acute Lung Injury. J Clin Med 2023; 12:4633. [PMID: 37510748 PMCID: PMC10380509 DOI: 10.3390/jcm12144633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is associated with a heterogeneous pattern of injury throughout the lung parenchyma that alters regional alveolar opening and collapse time constants. Such heterogeneity leads to atelectasis and repetitive alveolar collapse and expansion (RACE). The net effect is a progressive loss of lung volume with secondary ventilator-induced lung injury (VILI). Previous concepts of ARDS pathophysiology envisioned a two-compartment system: a small amount of normally aerated lung tissue in the non-dependent regions (termed "baby lung"); and a collapsed and edematous tissue in dependent regions. Based on such compartmentalization, two protective ventilation strategies have been developed: (1) a "protective lung approach" (PLA), designed to reduce overdistension in the remaining aerated compartment using a low tidal volume; and (2) an "open lung approach" (OLA), which first attempts to open the collapsed lung tissue over a short time frame (seconds or minutes) with an initial recruitment maneuver, and then stabilize newly recruited tissue using titrated positive end-expiratory pressure (PEEP). A more recent understanding of ARDS pathophysiology identifies regional alveolar instability and collapse (i.e., hidden micro-atelectasis) in both lung compartments as a primary VILI mechanism. Based on this understanding, we propose an alternative strategy to ventilating the injured lung, which we term a "stabilize lung approach" (SLA). The SLA is designed to immediately stabilize the lung and reduce RACE while gradually reopening collapsed tissue over hours or days. At the core of SLA is time-controlled adaptive ventilation (TCAV), a method to adjust the parameters of the airway pressure release ventilation (APRV) modality. Since the acutely injured lung at any given airway pressure requires more time for alveolar recruitment and less time for alveolar collapse, SLA adjusts inspiratory and expiratory durations and inflation pressure levels. The TCAV method SLA reverses the open first and stabilize second OLA method by: (i) immediately stabilizing lung tissue using a very brief exhalation time (≤0.5 s), so that alveoli simply do not have sufficient time to collapse. The exhalation duration is personalized and adaptive to individual respiratory mechanical properties (i.e., elastic recoil); and (ii) gradually recruiting collapsed lung tissue using an inflate and brake ratchet combined with an extended inspiratory duration (4-6 s) method. Translational animal studies, clinical statistical analysis, and case reports support the use of TCAV as an efficacious lung protective strategy.
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Affiliation(s)
- Gary F. Nieman
- Department of Surgery, Upstate Medical University, Syracuse, NY 13210, USA;
| | - David W. Kaczka
- Departments of Anesthesia, Radiology and Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Penny L. Andrews
- Department of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201, USA
| | - Auyon Ghosh
- Department of Medicine, Upstate Medical University, Syracuse, NY 13210, USA
| | - Hassan Al-Khalisy
- Brody School of Medicine, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, King’s Partners, St Thomas’ Hospital, London SE1 7EH, UK
| | - Joshua Satalin
- Department of Surgery, Upstate Medical University, Syracuse, NY 13210, USA;
| | - Jacob Herrmann
- Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Nader M. Habashi
- Department of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201, USA
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12
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Roshdy A, Elsayed AS, Saleh AS. Airway Pressure Release Ventilation for Acute Respiratory Failure Due to Coronavirus Disease 2019: A Systematic Review and Meta-Analysis. J Intensive Care Med 2023; 38:160-168. [PMID: 35733377 DOI: 10.1177/08850666221109779] [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] [Indexed: 12/16/2022]
Abstract
Objective: To explore the evidence surrounding the use of Airway Pressure Release Ventilation (APRV) in patients with coronavirus disease 2019 (COVID-19). Methods: A Systematic electronic search of PUBMED, EMBASE, and the WHO COVID-19 database. We also searched the grey literature via Google and preprint servers (medRxive and research square). Eligible studies included randomised controlled trials and observational studies comparing APRV to conventional mechanical ventilation (CMV) in adults with acute hypoxemic respiratory failure due to COVID-19 and reporting at least one of the following outcomes; in-hospital mortality, ventilator free days (VFDs), ICU length of stay (LOS), changes in gas exchange parameters, and barotrauma. Two authors independently screened and selected articles for inclusion and extracted data in a pre-specified form. Results: Of 181 articles screened, seven studies (one randomised controlled trial, two cohort studies, and four before-after studies) were included comprising 354 patients. APRV was initiated at a mean of 1.2-13 days after intubation. APRV wasn't associated with improved mortality compared to CMV (relative risk [RR], 1.20; 95% CI 0.70-2.05; I2, 61%) neither better VFDs (ratio of means [RoM], 0.80; 95% CI, 0.52-1.24; I2, 0%) nor ICU LOS (RoM, 1.10; 95% CI, 0.79-1.51; I2, 57%). Compared to CMV, APRV was associated with a 33% increase in PaO2/FiO2 ratio (RoM, 1.33; 95% CI, 1.21-1.48; I2, 29%) and a 9% decrease in PaCO2 (RoM, 1.09; 95% CI, 1.02-1.15; I2, 0%). There was no significant increased risk of barotrauma compared to CMV (RR, 1.55; 95% CI, 0.60-4.00; I2, 0%). Conclusions: In adult patients with COVID-19 requiring mechanical ventilation, APRV is associated with improved gas exchange but not mortality nor VFDs when compared with CMV. The results were limited by high uncertainty given the low quality of the available studies and limited number of patients. Adequately powered and well-designed clinical trials to define the role of APRV in COVID-19 patients are still needed. Registration: PROSPERO; CRD42021291234.
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Affiliation(s)
- Ashraf Roshdy
- Critical Care Medicine Department, Faculty of Medicine, 54562Alexandria University, Alexandria, Egypt.,Intensive Care Unit, 156506William Harvey Hospital, East Kent Hospitals University NHS Foundation Trust, Kent, UK
| | - Ahmad Samy Elsayed
- Intensive Care Unit, 37841King Fahd Military Medical Complex, Dhahran, Saudi Arabia
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13
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Inflammatory biomarkers and pendelluft magnitude in ards patients transitioning from controlled to partial support ventilation. Sci Rep 2022; 12:20233. [PMID: 36418386 PMCID: PMC9684576 DOI: 10.1038/s41598-022-24412-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022] Open
Abstract
The transition from controlled to partial support ventilation is a challenge in acute respiratory distress syndrome (ARDS) patients due to the risks of patient-self-inflicted lung injury. The magnitude of tidal volume (VT) and intrapulmonary dyssynchrony (pendelluft) are suggested mechanisms of lung injury. We conducted a prospective, observational, physiological study in a tertiary academic intensive care unit. ARDS patients transitioning from controlled to partial support ventilation were included. On these, we evaluated the association between changes in inflammatory biomarkers and esophageal pressure swing (ΔPes), transpulmonary driving pressure (ΔPL), VT, and pendelluft. Pendelluft was defined as the percentage of the tidal volume that moves from the non-dependent to the dependent lung region during inspiration, and its frequency at different thresholds (- 15, - 20 and - 25%) was also registered. Blood concentrations of inflammatory biomarkers (IL-6, IL-8, TNF-α, ANGPT2, RAGE, IL-18, Caspase-1) were measured before (T0) and after 4-h (T4) of partial support ventilation. Pendelluft, ΔPes, ΔPL and VT were recorded. Nine out of twenty-four patients (37.5%) showed a pendelluft mean ≥ 10%. The mean values of ΔPes, ΔPL, and VT were - 8.4 [- 6.7; - 10.2] cmH2O, 15.2 [12.3-16.5] cmH2O and 8.1 [7.3-8.9] m/kg PBW, respectively. Significant associations were observed between the frequency of high-magnitude pendelluft and IL-8, IL-18, and Caspase-1 changes (T0/T4 ratio). These results suggest that the frequency of high magnitude pendelluft may be a potential determinant of inflammatory response related to inspiratory efforts in ARDS patients transitioning to partial support ventilation. Future studies are needed to confirm these results.
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14
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Herrmann J, Kollisch-Singule M, Satalin J, Nieman GF, Kaczka DW. Assessment of Heterogeneity in Lung Structure and Function During Mechanical Ventilation: A Review of Methodologies. JOURNAL OF ENGINEERING AND SCIENCE IN MEDICAL DIAGNOSTICS AND THERAPY 2022; 5:040801. [PMID: 35832339 PMCID: PMC9132008 DOI: 10.1115/1.4054386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/13/2022] [Indexed: 06/15/2023]
Abstract
The mammalian lung is characterized by heterogeneity in both its structure and function, by incorporating an asymmetric branching airway tree optimized for maintenance of efficient ventilation, perfusion, and gas exchange. Despite potential benefits of naturally occurring heterogeneity in the lungs, there may also be detrimental effects arising from pathologic processes, which may result in deficiencies in gas transport and exchange. Regardless of etiology, pathologic heterogeneity results in the maldistribution of regional ventilation and perfusion, impairments in gas exchange, and increased work of breathing. In extreme situations, heterogeneity may result in respiratory failure, necessitating support with a mechanical ventilator. This review will present a summary of measurement techniques for assessing and quantifying heterogeneity in respiratory system structure and function during mechanical ventilation. These methods have been grouped according to four broad categories: (1) inverse modeling of heterogeneous mechanical function; (2) capnography and washout techniques to measure heterogeneity of gas transport; (3) measurements of heterogeneous deformation on the surface of the lung; and finally (4) imaging techniques used to observe spatially-distributed ventilation or regional deformation. Each technique varies with regard to spatial and temporal resolution, degrees of invasiveness, risks posed to patients, as well as suitability for clinical implementation. Nonetheless, each technique provides a unique perspective on the manifestations and consequences of mechanical heterogeneity in the diseased lung.
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Affiliation(s)
- Jacob Herrmann
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242
| | | | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210
| | - David W. Kaczka
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242; Department of Anesthesia, University of Iowa, Iowa City, IA 52242; Department of Radiology, University of Iowa, Iowa City, IA 52242
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15
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Nieman G, Kollisch-Singule M, Ramcharran H, Satalin J, Blair S, Gatto LA, Andrews P, Ghosh A, Kaczka DW, Gaver D, Bates J, Habashi NM. Unshrinking the baby lung to calm the VILI vortex. Crit Care 2022; 26:242. [PMID: 35934707 PMCID: PMC9357329 DOI: 10.1186/s13054-022-04105-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/12/2022] [Indexed: 02/07/2023] Open
Abstract
A hallmark of ARDS is progressive shrinking of the ‘baby lung,’ now referred to as the ventilator-induced lung injury (VILI) ‘vortex.’ Reducing the risk of the VILI vortex is the goal of current ventilation strategies; unfortunately, this goal has not been achieved nor has mortality been reduced. However, the temporal aspects of a mechanical breath have not been considered. A brief expiration prevents alveolar collapse, and an extended inspiration can recruit the atelectatic lung over hours. Time-controlled adaptive ventilation (TCAV) is a novel ventilator approach to achieve these goals, since it considers many of the temporal aspects of dynamic lung mechanics.
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Affiliation(s)
- Gary Nieman
- Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate, 750 East Adams St., Syracuse, NY, 13210, USA
| | - Michaela Kollisch-Singule
- Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate, 750 East Adams St., Syracuse, NY, 13210, USA
| | - Harry Ramcharran
- Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate, 750 East Adams St., Syracuse, NY, 13210, USA
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate, 750 East Adams St., Syracuse, NY, 13210, USA.
| | - Sarah Blair
- Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate, 750 East Adams St., Syracuse, NY, 13210, USA
| | - Louis A Gatto
- Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate, 750 East Adams St., Syracuse, NY, 13210, USA
| | - Penny Andrews
- Department of Medicine, University of Maryland, Baltimore, MD, USA
| | - Auyon Ghosh
- Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate, 750 East Adams St., Syracuse, NY, 13210, USA
| | - David W Kaczka
- Departments of Anesthesia, Biomedical Engineering, and Radiology, University of Iowa, Iowa City, IA, USA
| | - Donald Gaver
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA
| | - Jason Bates
- Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Nader M Habashi
- Department of Medicine, University of Maryland, Baltimore, MD, USA
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16
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Andrews P, Shiber J, Madden M, Nieman GF, Camporota L, Habashi NM. Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal. Front Physiol 2022; 13:928562. [PMID: 35957991 PMCID: PMC9358044 DOI: 10.3389/fphys.2022.928562] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/21/2022] [Indexed: 12/16/2022] Open
Abstract
In the pursuit of science, competitive ideas and debate are necessary means to attain knowledge and expose our ignorance. To quote Murray Gell-Mann (1969 Nobel Prize laureate in Physics): "Scientific orthodoxy kills truth". In mechanical ventilation, the goal is to provide the best approach to support patients with respiratory failure until the underlying disease resolves, while minimizing iatrogenic damage. This compromise characterizes the philosophy behind the concept of "lung protective" ventilation. Unfortunately, inadequacies of the current conceptual model-that focuses exclusively on a nominal value of low tidal volume and promotes shrinking of the "baby lung" - is reflected in the high mortality rate of patients with moderate and severe acute respiratory distress syndrome. These data call for exploration and investigation of competitive models evaluated thoroughly through a scientific process. Airway Pressure Release Ventilation (APRV) is one of the most studied yet controversial modes of mechanical ventilation that shows promise in experimental and clinical data. Over the last 3 decades APRV has evolved from a rescue strategy to a preemptive lung injury prevention approach with potential to stabilize the lung and restore alveolar homogeneity. However, several obstacles have so far impeded the evaluation of APRV's clinical efficacy in large, randomized trials. For instance, there is no universally accepted standardized method of setting APRV and thus, it is not established whether its effects on clinical outcomes are due to the ventilator mode per se or the method applied. In addition, one distinctive issue that hinders proper scientific evaluation of APRV is the ubiquitous presence of myths and misconceptions repeatedly presented in the literature. In this review we discuss some of these misleading notions and present data to advance scientific discourse around the uses and misuses of APRV in the current literature.
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Affiliation(s)
- Penny Andrews
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph Shiber
- University of Florida College of Medicine, Jacksonville, FL, United States
| | - Maria Madden
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, United Kingdom
| | - Nader M. Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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17
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Cheng J, Yang J, Ma A, Dong M, Yang J, Wang P, Xue Y, Zhou Y, Kang Y. The Effects of Airway Pressure Release Ventilation on Pulmonary Permeability in Severe Acute Respiratory Distress Syndrome Pig Models. Front Physiol 2022; 13:927507. [PMID: 35936889 PMCID: PMC9354663 DOI: 10.3389/fphys.2022.927507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of the study was to compare the effects of APRV and LTV ventilation on pulmonary permeability in severe ARDS.Methods: Mini Bama adult pigs were randomized into the APRV group (n = 5) and LTV group (n = 5). A severe ARDS animal model was induced by the whole lung saline lavage. Pigs were ventilated and monitored continuously for 48 h.Results: Compared with the LTV group, CStat was significantly better (p < 0.05), and the PaO2/FiO2 ratio showed a trend to be higher throughout the period of the experiment in the APRV group. The extravascular lung water index and pulmonary vascular permeability index showed a trend to be lower in the APRV group. APRV also significantly mitigates lung histopathologic injury determined by the lung histopathological injury score (p < 0.05) and gross pathological changes of lung tissues. The protein contents of occludin (p < 0.05), claudin-5 (p < 0.05), E-cadherin (p < 0.05), and VE-cadherin (p < 0.05) in the middle lobe of the right lung were higher in the APRV group than in the LTV group; among them, the contents of occludin (p < 0.05) and E-cadherin (p < 0.05) of the whole lung were higher in the APRV group. Transmission electron microscopy showed that alveolar–capillary barrier damage was more severe in the middle lobe of lungs in the LTV group.Conclusion: In comparison with LTV, APRV could preserve the alveolar–capillary barrier architecture, mitigate lung histopathologic injury, increase the expression of cell junction protein, improve respiratory system compliance, and showed a trend to reduce extravascular lung water and improve oxygenation. These findings indicated that APRV might lead to more profound beneficial effects on the integrity of the alveolar–capillary barrier architecture and on the expression of biomarkers related to pulmonary permeability.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yan Kang
- *Correspondence: Yongfang Zhou, ; Yan Kang,
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18
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Airway Pressure Release Ventilation. Emerg Med Clin North Am 2022; 40:489-501. [DOI: 10.1016/j.emc.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Comparison of Airway Pressure Release Ventilation to High-Frequency Oscillatory Ventilation in Neonates with Refractory Respiratory Failure. Int J Pediatr 2022; 2022:7864280. [PMID: 35546962 PMCID: PMC9085362 DOI: 10.1155/2022/7864280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background Airway pressure release ventilation (APRV) is a relatively new mode of ventilation in neonates. We hypothesize that APRV is an effective rescue mode in infants failing conventional ventilation and it is comparable in survival rates to rescue with high-frequency oscillatory ventilation (HFOV). Methods This is a 6-year retrospective cohort study of infants that failed synchronized intermittent mandatory ventilation (SIMV) and were rescued with either APRV or HFOV. For comparison, we divided infants into two groups (28-37 and >37 weeks) based on their corrected gestational age (CGA) at failure of SIMV. Results Ninety infants were included in the study. Infants rescued with APRV (n = 46) had similar survival rates to those rescued with HFOV (n = 44)—28-37 weeks CGA (APRV 78% vs. HFOV 84%, p = 0.68) and >37 weeks CGA (APRV 76% vs. HFOV 72%, p = 0.74). Use of APRV was not associated with an increase in pneumothorax (APRV 0% and HFOV 10%, p = 0.31, in 28-37 weeks CGA, and APRV 0% and HFOV 4%, p = 0.22, in >37 weeks CGA). Conclusion APRV can be effectively used to rescue infants with refractory respiratory failure on SIMV. When compared to HFOV, rescue with APRV is not associated with an increase in mortality or pneumothorax.
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A Ventilator Mode Cannot Set Itself, Nor Can It Be Solely Responsible for Outcomes. Crit Care Med 2022; 50:695-699. [PMID: 35311779 DOI: 10.1097/ccm.0000000000005403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Cheng J, Ma A, Dong M, Zhou Y, Wang B, Xue Y, Wang P, Yang J, Kang Y. Does airway pressure release ventilation offer new hope for treating acute respiratory distress syndrome? JOURNAL OF INTENSIVE MEDICINE 2022; 2:241-248. [PMID: 36785647 PMCID: PMC8958099 DOI: 10.1016/j.jointm.2022.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/30/2022] [Accepted: 02/16/2022] [Indexed: 01/01/2023]
Abstract
Mechanical ventilation (MV) is an essential life support method for patients with acute respiratory distress syndrome (ARDS), which is one of the most common critical illnesses with high mortality in the intensive care unit (ICU). A lung-protective ventilation strategy based on low tidal volume (LTV) has been recommended since a few years; however, as this did not result in a significant decrease of ARDS-related mortality, a more optimal ventilation mode was required. Airway pressure release ventilation (APRV) is an old method defined as a continuous positive airway pressure (CPAP) with a brief intermittent release phase based on the open lung concept; it also perfectly fits the ARDS treatment principle. Despite this, APRV has not been widely used in the past, rather only as a rescue measure for ARDS patients who are difficult to oxygenate. Over recent years, with an increased understanding of the pathophysiology of ARDS, APRV has been reproposed to improve patient prognosis. Nevertheless, this mode is still not routinely used in ARDS patients given its vague definition and complexity. Consequently, in this paper, we summarize the studies that used APRV in ARDS, including adults, children, and animals, to illustrate the settings of parameters, effectiveness in the population, safety (especially in children), incidence, and mechanism of ventilator-induced lung injury (VILI) and effects on extrapulmonary organs. Finally, we found that APRV is likely associated with improvement in ARDS outcomes, and does not increase injury to the lungs and other organs, thereby indicating that personalized APRV settings may be the new hope for ARDS treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Jing Yang
- Corresponding authors: Yan Kang and Jing Yang, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Yan Kang
- Corresponding authors: Yan Kang and Jing Yang, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
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22
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Kollisch-Singule M, Ramcharran H, Satalin J, Blair S, Gatto LA, Andrews PL, Habashi NM, Nieman GF, Bougatef A. Mechanical Ventilation in Pediatric and Neonatal Patients. Front Physiol 2022; 12:805620. [PMID: 35369685 PMCID: PMC8969224 DOI: 10.3389/fphys.2021.805620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/15/2021] [Indexed: 11/30/2022] Open
Abstract
Pediatric acute respiratory distress syndrome (PARDS) remains a significant cause of morbidity and mortality, with mortality rates as high as 50% in children with severe PARDS. Despite this, pediatric lung injury and mechanical ventilation has been poorly studied, with the majority of investigations being observational or retrospective and with only a few randomized controlled trials to guide intensivists. The most recent and universally accepted guidelines for pediatric lung injury are based on consensus opinion rather than objective data. Therefore, most neonatal and pediatric mechanical ventilation practices have been arbitrarily adapted from adult protocols, neglecting the differences in lung pathophysiology, response to injury, and co-morbidities among the three groups. Low tidal volume ventilation has been generally accepted for pediatric patients, even in the absence of supporting evidence. No target tidal volume range has consistently been associated with outcomes, and compliance with delivering specific tidal volume ranges has been poor. Similarly, optimal PEEP has not been well-studied, with a general acceptance of higher levels of FiO2 and less aggressive PEEP titration as compared with adults. Other modes of ventilation including airway pressure release ventilation and high frequency ventilation have not been studied in a systematic fashion and there is too little evidence to recommend supporting or refraining from their use. There have been no consistent outcomes among studies in determining optimal modes or methods of setting them. In this review, the studies performed to date on mechanical ventilation strategies in neonatal and pediatric populations will be analyzed. There may not be a single optimal mechanical ventilation approach, where the best method may simply be one that allows for a personalized approach with settings adapted to the individual patient and disease pathophysiology. The challenges and barriers to conducting well-powered and robust multi-institutional studies will also be addressed, as well as reconsidering outcome measures and study design.
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Affiliation(s)
| | - Harry Ramcharran
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
- *Correspondence: Joshua Satalin,
| | - Sarah Blair
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Louis A. Gatto
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Penny L. Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Nader M. Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Adel Bougatef
- Independent Researcher, San Antonio, TX, United States
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23
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Miller AG, Bartle RM, Feldman A, Mallory P, Reyes E, Scott B, Rotta AT. A narrative review of advanced ventilator modes in the pediatric intensive care unit. Transl Pediatr 2021; 10:2700-2719. [PMID: 34765495 PMCID: PMC8578787 DOI: 10.21037/tp-20-332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Renee M Bartle
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandra Feldman
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Palen Mallory
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Edith Reyes
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Briana Scott
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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25
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Herrmann J, Gerard SE, Shao W, Xin Y, Cereda M, Reinhardt JM, Christensen GE, Hoffman EA, Kaczka DW. Effects of Lung Injury on Regional Aeration and Expiratory Time Constants: Insights From Four-Dimensional Computed Tomography Image Registration. Front Physiol 2021; 12:707119. [PMID: 34393824 PMCID: PMC8355819 DOI: 10.3389/fphys.2021.707119] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 06/30/2021] [Indexed: 11/13/2022] Open
Abstract
Rationale: Intratidal changes in regional lung aeration, as assessed with dynamic four-dimensional computed tomography (CT; 4DCT), may indicate the processes of recruitment and derecruitment, thus portending atelectrauma during mechanical ventilation. In this study, we characterized the time constants associated with deaeration during the expiratory phase of pressure-controlled ventilation in pigs before and after acute lung injury using respiratory-gated 4DCT and image registration. Methods: Eleven pigs were mechanically ventilated in pressure-controlled mode under baseline conditions and following an oleic acid model of acute lung injury. Dynamic 4DCT scans were acquired without interrupting ventilation. Automated segmentation of lung parenchyma was obtained by a convolutional neural network. Respiratory structures were aligned using 4D image registration. Exponential regression was performed on the time-varying CT density in each aligned voxel during exhalation, resulting in regional estimates of intratidal aeration change and deaeration time constants. Regressions were also performed for regional and total exhaled gas volume changes. Results: Normally and poorly aerated lung regions demonstrated the largest median intratidal aeration changes during exhalation, compared to minimal changes within hyper- and non-aerated regions. Following lung injury, median time constants throughout normally aerated regions within each subject were greater than respective values for poorly aerated regions. However, parametric response mapping revealed an association between larger intratidal aeration changes and slower time constants. Lower aeration and faster time constants were observed for the dependent lung regions in the supine position. Regional gas volume changes exhibited faster time constants compared to regional density time constants, as well as better correspondence to total exhaled volume time constants. Conclusion: Mechanical time constants based on exhaled gas volume underestimate regional aeration time constants. After lung injury, poorly aerated regions experience larger intratidal changes in aeration over shorter time scales compared to normally aerated regions. However, the largest intratidal aeration changes occur over the longest time scales within poorly aerated regions. These dynamic 4DCT imaging data provide supporting evidence for the susceptibility of poorly aerated regions to ventilator-induced lung injury, and for the functional benefits of short exhalation times during mechanical ventilation of injured lungs.
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Affiliation(s)
- Jacob Herrmann
- Department of Biomedical Engineering, Boston University, Boston, MA, United States
| | - Sarah E Gerard
- Department of Radiology, University of Iowa, Iowa City, IA, United States
| | - Wei Shao
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Joseph M Reinhardt
- Department of Radiology, University of Iowa, Iowa City, IA, United States.,Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States
| | - Gary E Christensen
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA, United States.,Department of Radiation Oncology, University of Iowa, Iowa City, IA, United States
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, IA, United States.,Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States.,Department of Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - David W Kaczka
- Department of Radiology, University of Iowa, Iowa City, IA, United States.,Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States.,Department of Anesthesia, University of Iowa, Iowa City, IA, United States
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26
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Othman F, Alsagami N, Alharbi R, Almuammer Y, Alshahrani S, Ismaeil T. The efficacy of airway pressure release ventilation in acute respiratory distress syndrome adult patients: A meta-analysis of clinical trials. Ann Thorac Med 2021; 16:245-252. [PMID: 34484439 PMCID: PMC8388564 DOI: 10.4103/atm.atm_475_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/13/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To recruit poorly ventilated lung areas by providing active and adequate oxygenation is a core aspect of treating patients with acute respiratory distress syndrome (ARDS). The airway pressure release ventilation (APRV) mode is increasingly accepted as a means of supporting patients with ARDS. This study aimed to determine whether the APRV mode is effective in improving oxygenation, compared to conventional ventilation, in adult ARDS patients. METHODS We conducted the study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched for clinical trials in PubMed, Embase, Web of Science, and the Cochrane Library until April 2019. We included all studies comparing APRV and other conventional mechanical ventilation modes for adult ARDS patients. Our primary outcome was oxygenation status (defined as the day 3 PaO2/FiO2 ratio). The secondary outcomes were the length of stay (LOS) in the intensive care unit (ICU) and mortality. Sensitivity analyses were performed including studies with conventional low-tidal volume ventilation as a comparator ventilation strategy. RESULTS We included six clinical trials enrolling a total of 375 patients. The day 3 PaO2/FiO2 was reported in all the studies, and it was significantly higher in patients receiving APRV (mean difference [MD] 51.9 mmHg, 95% confidence intervals (CI) 8.2-95.5, P = 0.02, I 2= 92%). There was no significant difference in mortality between APRV and the other conventional ventilator modes (risk difference 0.07, 95% CI: -0.01-0.15, P = 0.08, I 20%). The point estimate for the effect of APRV on the LOS in ICU indicated a significant reduction in the ICU LOS for the APRV group compared to the counter group (MD 3.1 days, 95% CI 0.4-5.9, P = 0.02, I 2= 53%). CONCLUSION In this study, using the APRV mode may improve oxygenation on day 3 and contribute to reducing the LOS in ICU. However, it is difficult to draw a clinical message about APRV, and well-designed clinical trials are required to investigate this issue.
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Affiliation(s)
- Fatmah Othman
- Department of Research, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Noura Alsagami
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reem Alharbi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yara Almuammer
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shatha Alshahrani
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Taha Ismaeil
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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27
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Time-Controlled Adaptive Ventilation Versus Volume-Controlled Ventilation in Experimental Pneumonia. Crit Care Med 2021; 49:140-150. [PMID: 33060501 DOI: 10.1097/ccm.0000000000004675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We hypothesized that a time-controlled adaptive ventilation strategy would open and stabilize alveoli by controlling inspiratory and expiratory duration. Time-controlled adaptive ventilation was compared with volume-controlled ventilation at the same levels of mean airway pressure and positive end-release pressure (time-controlled adaptive ventilation)/positive end-expiratory pressure (volume-controlled ventilation) in a Pseudomonas aeruginosa-induced pneumonia model. DESIGN Animal study. SETTING Laboratory investigation. SUBJECTS Twenty-one Wistar rats. INTERVENTIONS Twenty-four hours after pneumonia induction, Wistar rats (n = 7) were ventilated with time-controlled adaptive ventilation (tidal volume = 8 mL/kg, airway pressure release ventilation for a Thigh = 0.75-0.85 s, release pressure (Plow) set at 0 cm H2O, and generating a positive end-release pressure = 1.6 cm H2O applied for Tlow = 0.11-0.14 s). The expiratory flow was terminated at 75% of the expiratory flow peak. An additional 14 animals were ventilated using volume-controlled ventilation, maintaining similar time-controlled adaptive ventilation levels of positive end-release pressure (positive end-expiratory pressure=1.6 cm H2O) and mean airway pressure = 10 cm H2O. Additional nonventilated animals (n = 7) were used for analysis of molecular biology markers. MEASUREMENTS AND MAIN RESULTS After 1 hour of mechanical ventilation, the heterogeneity score, the expression of pro-inflammatory biomarkers interleukin-6 and cytokine-induced neutrophil chemoattractant-1 in lung tissue were significantly lower in the time-controlled adaptive ventilation than volume-controlled ventilation with similar mean airway pressure groups (p = 0.008, p = 0.011, and p = 0.011, respectively). Epithelial cell integrity, measured by E-cadherin tissue expression, was higher in time-controlled adaptive ventilation than volume-controlled ventilation with similar mean airway pressure (p = 0.004). Time-controlled adaptive ventilation animals had bacteremia counts lower than volume-controlled ventilation with similar mean airway pressure animals, while time-controlled adaptive ventilation and volume-controlled ventilation with similar positive end-release pressure animals had similar colony-forming unit counts. In addition, lung edema and cytokine-induced neutrophil chemoattractant-1 gene expression were more reduced in time-controlled adaptive ventilation than volume-controlled ventilation with similar positive end-release pressure groups. CONCLUSIONS In the model of pneumonia used herein, at the same tidal volume and mean airway pressure, time-controlled adaptive ventilation, compared with volume-controlled ventilation, was associated with less lung damage and bacteremia and reduced gene expression of mediators associated with inflammation.
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Janssen M, Meeder JHJ, Seghers L, den Uil CA. Time controlled adaptive ventilation™ as conservative treatment of destroyed lung: an alternative to lung transplantation. BMC Pulm Med 2021; 21:176. [PMID: 34022829 PMCID: PMC8140588 DOI: 10.1186/s12890-021-01545-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/16/2021] [Indexed: 02/06/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) often requires controlled ventilation, yielding high mechanical power and possibly further injury. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be used as a bridge to recovery, however, if this fails the end result is destroyed lung parenchyma. This condition is fatal and the only remaining alternative is lung transplantation. In the case study presented in this paper, lung transplantation was not an option given the critically ill state and the presence of HLA antibodies. Airway pressure release ventilation (APRV) may be valuable in ARDS, but APRV settings recommended in various patient and clinical studies are inconsistent. The Time Controlled Adaptive Ventilation (TCAV™) method is the most studied technique to set and adjust the APRV mode and uses an extended continuous positive airway pressure (CPAP) Phase in combination with a very brief Release Phase. In addition, the TCAV™ method settings are personalized and adaptive based on changes in lung pathophysiology. We used the TCAV™ method in a case of severe ARDS, which enabled us to open, stabilize and slowly heal the severely damaged lung parenchyma. Case presentation A 43-year-old woman presented with Staphylococcus Aureus necrotizing pneumonia. Progressive respiratory failure necessitated invasive mechanical ventilation and VV-ECMO. Mechanical ventilation (MV) was ultimately discontinued because lung protective settings resulted in trivial tidal volumes. She was referred to our academic transplant center for bilateral lung transplantation after the remaining infection had been cleared. We initiated the TCAV™ method in order to stabilize the lung parenchyma and to promote tissue recovery. This strategy was challenged by the presence of a large bronchopleural fistula, however, APRV enabled weaning from VV-ECMO and mechanical ventilation. After two months, following nearly complete surgical closure of the remaining bronchopleural fistulas, the patient was readmitted to ICU where she had early postoperative complications. Since other ventilation modes resulted in significant atelectasis and hypercapnia, APRV was restarted. The patient was then again weaned from MV. Conclusions The TCAV™ method can be useful to wean challenging patients with severe ARDS and might contribute to lung recovery. In this particular case, a lung transplantation was circumvented.
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Affiliation(s)
- Malou Janssen
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center, Dr Molewaterplein 40, Room Rg 626, 3015 GD, Rotterdam, The Netherlands.
| | - J Han J Meeder
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center, Dr Molewaterplein 40, Room Rg 626, 3015 GD, Rotterdam, The Netherlands
| | - Leonard Seghers
- Department of Pulmonary Medicine, Transplant Center, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Corstiaan A den Uil
- Department of Intensive Care Medicine, Erasmus MC, University Medical Center, Dr Molewaterplein 40, Room Rg 626, 3015 GD, Rotterdam, The Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, The Netherlands
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29
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Shah A, Dave S, Galvagno S, George K, Menne AR, Haase DJ, McCormick B, Rector R, Dahi S, Madathil RJ, Deatrick KB, Ghoreishi M, Gammie JS, Kaczorowski DJ, Scalea TM, Menaker J, Herr D, Tabatabai A, Krause E. A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management. MEMBRANES 2021; 11:306. [PMID: 33919390 PMCID: PMC8143287 DOI: 10.3390/membranes11050306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/15/2021] [Accepted: 04/17/2021] [Indexed: 01/14/2023]
Abstract
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.
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Affiliation(s)
- Aakash Shah
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Sagar Dave
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Samuel Galvagno
- Program in Trauma, Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Kristen George
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Ashley R. Menne
- Program in Trauma, Department of Emergency Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (A.R.M.); (D.J.H.)
| | - Daniel J. Haase
- Program in Trauma, Department of Emergency Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (A.R.M.); (D.J.H.)
| | - Brian McCormick
- Perfusion Services, University of Maryland Medical Center, Baltimore, MD 21201, USA; (B.M.); (R.R.)
| | - Raymond Rector
- Perfusion Services, University of Maryland Medical Center, Baltimore, MD 21201, USA; (B.M.); (R.R.)
| | - Siamak Dahi
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Ronson J. Madathil
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Kristopher B. Deatrick
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Mehrdad Ghoreishi
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - James S. Gammie
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - David J. Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Thomas M. Scalea
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Jay Menaker
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA 94143, USA;
| | - Daniel Herr
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Ali Tabatabai
- Program in Trauma, Department of Medicine, Division of Pulmonary and Critical Care, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Eric Krause
- Department of Surgery, Division of Thoracic Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
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Cavaliere GA, Jasani GN, Gordon D, Lawner BJ. Difficulty Ventilating: A Case Report on Ventilation Considerations of an Intubated Asthmatic Undergoing Air Medical Critical Care Transport. Air Med J 2020; 40:135-138. [PMID: 33637279 DOI: 10.1016/j.amj.2020.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 11/25/2022]
Abstract
The air medical transport of intubated patients is a high-risk mission that requires preplanning before helicopter launch. This case describes a scenario in which the helicopter emergency medical services (HEMS) team was unable to ventilate a patient because of the mechanical limitations of the transport ventilator. The HEMS mission was ultimately aborted, and the patient had to be transported by a ground crew equipped with a hospital-based ventilator. In addition to the optimal medical management of the patient in status asthmaticus, critical care transport crews must be familiar with the treatment of patients exhibiting extremely high peak airway pressures. Specifically, ventilator manipulations as well as the technical specifications of the transport ventilator may preclude the patient from being transported by the HEMS team. It is imperative that the patient's current ventilator setting be evaluated before the launch of the aircraft to prevent any possible delays in patient care.
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Affiliation(s)
- Garrett A Cavaliere
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St 6th floor, Ste 200, Baltimore, MD 21201.
| | - Gregory N Jasani
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St 6th floor, Ste 200, Baltimore, MD 21201
| | - David Gordon
- Department of Internal Medicine, University of Maryland Medical Center, Baltimore, MD 21201
| | - Benjamin J Lawner
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca St 6th floor, Ste 200, Baltimore, MD 21201; Maryland ExpressCare Critical Care Transport Program, Baltimore, MD
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31
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Zhong X, Wu Q, Yang H, Dong W, Wang B, Zhang Z, Liang G. Airway pressure release ventilation versus low tidal volume ventilation for patients with acute respiratory distress syndrome/acute lung injury: a meta-analysis of randomized clinical trials. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1641. [PMID: 33490153 PMCID: PMC7812231 DOI: 10.21037/atm-20-6917] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background It is uncertain whether airway pressure release ventilation (APRV) is better than low tidal volume ventilation (LTVV) for patients with acute respiratory distress syndrome (ARDS). The purpose of this meta-analysis was to compare APRV and LTVV on patients with ARDS. Methods Randomized controlled trials (RCTs) comparing outcomes in ARDS ventilator therapy with APRV or LTVV were identified using Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, the Cochrane Library, and The Chinese Biomedicine Literature Database (SinoMed) from inception to March 2019. Results A total of 7 RCTs with a 405 patients were eligible for our meta-analysis. The results revealed that APRV was associated with lower hospital mortality [405 patients; odds ratio (OR), 0.57; 95% confidence interval (CI), 0.37-0.88; P=0.01], a shorter time of ventilator therapy [373 patients; mean difference (MD), 5.36; 95% CI, 1.99-8.73; P=0.002], and intensive care unit (ICU) stay (315 patients; MD, -4.50; 95% CI, -6.56 to -2.44; P<0.0001), better respiratory system compliance on day 3 (202 patients; MD, 8.19; 95% CI, 0.84-15.54; P=0.03), arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) on day 3 (294 patients; MD, 44.40; 95% CI, 16.05-72.76; P=0.002), and higher mean arterial pressure (MAP) on day 3 (285 patients; MD, 4.18; 95% CI, 3.10-5.25; P<0.00001). There was no statistical difference in the incidence of pneumothorax (170 patients; OR, 0.40; 95% CI, 0.12-1.34; P=0.14). Conclusions The meta-analysis showed that APRV could reduce hospital mortality, duration of ventilation and ICU stay, improve lung compliance, oxygenation index, and MAP compared with LTVV for patients with ARDS. We found APRV to be a safe and effective ventilation mode for patients with ARDS.
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Affiliation(s)
- Xi Zhong
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Hao Yang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Wei Dong
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Guopeng Liang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
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Sine ventilation in lung injury models: a new perspective for lung protective ventilation. Sci Rep 2020; 10:11690. [PMID: 32678177 PMCID: PMC7366701 DOI: 10.1038/s41598-020-68614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022] Open
Abstract
Mechanical ventilation is associated with the risk of ventilator induced lung injury. For reducing lung injury in mechanically ventilated patients, the application of small tidal volumes and positive end-expiratory pressures has become clinical standard. Recently, an approach based on linear airway pressure decline and decelerated expiratory flow during expiration implied lung protective capacities. We assumed that ventilation with a smoothed, i.e. sinusoidal airway pressure profile may further improve ventilation efficiency and lung protection. We compared the effects of mechanical ventilation with sinusoidal airway pressure profile (SINE) regarding gas exchange, respiratory system compliance and histology to conventional volume and pressure controlled ventilation (VCV and PCV) and to VCV with flow-controlled expiration (FLEX) in two rat models of lung injury, tween induced surfactant depletion and high tidal volume mechanical ventilation. In both lung injury models ventilation with SINE showed more efficient CO2 elimination and blood oxygenation, improved respiratory system compliance and resulted in lower alveolar wall thickness, compared to VCV, PCV and FLEX. Optimization of the airway pressure profile may provide a novel means of lung protective mechanical ventilation.
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Nieman GF, Al-Khalisy H, Kollisch-Singule M, Satalin J, Blair S, Trikha G, Andrews P, Madden M, Gatto LA, Habashi NM. A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung. Front Physiol 2020; 11:227. [PMID: 32265734 PMCID: PMC7096584 DOI: 10.3389/fphys.2020.00227] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/27/2020] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) causes a heterogeneous lung injury and remains a serious medical problem, with one of the only treatments being supportive care in the form of mechanical ventilation. It is very difficult, however, to mechanically ventilate the heterogeneously damaged lung without causing secondary ventilator-induced lung injury (VILI). The acutely injured lung becomes time and pressure dependent, meaning that it takes more time and pressure to open the lung, and it recollapses more quickly and at higher pressure. Current protective ventilation strategies, ARDSnet low tidal volume (LVt) and the open lung approach (OLA), have been unsuccessful at further reducing ARDS mortality. We postulate that this is because the LVt strategy is constrained to ventilating a lung with a heterogeneous mix of normal and focalized injured tissue, and the OLA, although designed to fully open and stabilize the lung, is often unsuccessful at doing so. In this review we analyzed the pathophysiology of ARDS that renders the lung susceptible to VILI. We also analyzed the alterations in alveolar and alveolar duct mechanics that occur in the acutely injured lung and discussed how these alterations are a key mechanism driving VILI. Our analysis suggests that the time component of each mechanical breath, at both inspiration and expiration, is critical to normalize alveolar mechanics and protect the lung from VILI. Animal studies and a meta-analysis have suggested that the time-controlled adaptive ventilation (TCAV) method, using the airway pressure release ventilation mode, eliminates the constraints of ventilating a lung with heterogeneous injury, since it is highly effective at opening and stabilizing the time- and pressure-dependent lung. In animal studies it has been shown that by “casting open” the acutely injured lung with TCAV we can (1) reestablish normal expiratory lung volume as assessed by direct observation of subpleural alveoli; (2) return normal parenchymal microanatomical structural support, known as alveolar interdependence and parenchymal tethering, as assessed by morphometric analysis of lung histology; (3) facilitate regeneration of normal surfactant function measured as increases in surfactant proteins A and B; and (4) significantly increase lung compliance, which reduces the pathologic impact of driving pressure and mechanical power at any given tidal volume.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Hassan Al-Khalisy
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, United States
| | | | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Sarah Blair
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Girish Trikha
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Penny Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Maria Madden
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Louis A Gatto
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Biological Sciences, SUNY Cortland, Cortland, NY, United States
| | - Nader M Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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Fredericks AS, Bunker MP, Gliga LA, Ebeling CG, Ringqvist JR, Heravi H, Manley J, Valladares J, Romito BT. Airway Pressure Release Ventilation: A Review of the Evidence, Theoretical Benefits, and Alternative Titration Strategies. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2020; 14:1179548420903297. [PMID: 32076372 PMCID: PMC7003159 DOI: 10.1177/1179548420903297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 01/08/2020] [Indexed: 11/15/2022]
Abstract
Objective: To review the theoretical benefits of airway pressure release ventilation (APRV), summarize the evidence for its use in clinical practice, and discuss different titration strategies. Data Source: Published randomized controlled trials in humans, observational human studies, animal studies, review articles, ventilator textbooks, and editorials. Data Summary: Airway pressure release ventilation optimizes alveolar recruitment, reduces airway pressures, allows for spontaneous breathing, and offers many hemodynamic benefits. Despite these physiologic advantages, there are inconsistent data to support the use of APRV over other modes of ventilation. There is considerable heterogeneity in the application of APRV among providers and a shortage of information describing initiation and titration strategies. To date, no direct comparison studies of APRV strategies have been performed. This review describes 2 common management approaches that bedside providers can use to optimally tailor APRV to their patients. Conclusion: Airway pressure release ventilation remains a form of mechanical ventilation primarily used for refractory hypoxemia. It offers unique physiological advantages over other ventilatory modes, and providers must be familiar with different titration methods. Given its inconsistent outcome data and heterogeneous use in practice, future trials should directly compare APRV strategies to determine the optimal management approach.
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Affiliation(s)
- Andrew S Fredericks
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew P Bunker
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Louise A Gliga
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Callie G Ebeling
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jenny Rb Ringqvist
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hooman Heravi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Manley
- Department of Respiratory Care, Parkland Memorial Hospital, Dallas, TX, USA.,The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jason Valladares
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bryan T Romito
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abstract
PURPOSE OF REVIEW In patients with acute respiratory distress syndrome (ARDS), airway pressure release ventilation (APRV) has been purported to have several physiological benefits. This review synthesizes recent research evaluating APRV mode and provides perspectives on the utility of this mode in children with ARDS. RECENT FINDINGS Two single-center clinical trials on APRV, one adult and one pediatric, have been published this year. These two trials have not only elicited editorials and letters that highlight some of their strengths and weaknesses but also rekindled debate on several aspects of APRV. Despite their contradicting results, both trials provide significant insights into APRV strategies that work and those that may not. This review places the newer evidence in the context of existing literature and provides a comprehensive analysis of APRV use in children. SUMMARY There have been significant recent advancements in our understanding of the clinical utility of APRV in children with ARDS. The recent trial highlights the urgent need to evolve a consensus on definition of APRV and identify strategies that work. Pending further research, clinicians should avoid the use of a zero-PLOW Personalized-APRV strategy as a primary ventilation modality in children with moderate-severe ARDS.
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Nieman GF, Gatto LA, Andrews P, Satalin J, Camporota L, Daxon B, Blair SJ, Al-Khalisy H, Madden M, Kollisch-Singule M, Aiash H, Habashi NM. Prevention and treatment of acute lung injury with time-controlled adaptive ventilation: physiologically informed modification of airway pressure release ventilation. Ann Intensive Care 2020; 10:3. [PMID: 31907704 PMCID: PMC6944723 DOI: 10.1186/s13613-019-0619-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/23/2019] [Indexed: 12/16/2022] Open
Abstract
Mortality in acute respiratory distress syndrome (ARDS) remains unacceptably high at approximately 39%. One of the only treatments is supportive: mechanical ventilation. However, improperly set mechanical ventilation can further increase the risk of death in patients with ARDS. Recent studies suggest that ventilation-induced lung injury (VILI) is caused by exaggerated regional lung strain, particularly in areas of alveolar instability subject to tidal recruitment/derecruitment and stress-multiplication. Thus, it is reasonable to expect that if a ventilation strategy can maintain stable lung inflation and homogeneity, regional dynamic strain would be reduced and VILI attenuated. A time-controlled adaptive ventilation (TCAV) method was developed to minimize dynamic alveolar strain by adjusting the delivered breath according to the mechanical characteristics of the lung. The goal of this review is to describe how the TCAV method impacts pathophysiology and protects lungs with, or at high risk of, acute lung injury. We present work from our group and others that identifies novel mechanisms of VILI in the alveolar microenvironment and demonstrates that the TCAV method can reduce VILI in translational animal ARDS models and mortality in surgical/trauma patients. Our TCAV method utilizes the airway pressure release ventilation (APRV) mode and is based on opening and collapsing time constants, which reflect the viscoelastic properties of the terminal airspaces. Time-controlled adaptive ventilation uses inspiratory and expiratory time to (1) gradually “nudge” alveoli and alveolar ducts open with an extended inspiratory duration and (2) prevent alveolar collapse using a brief (sub-second) expiratory duration that does not allow time for alveolar collapse. The new paradigm in TCAV is configuring each breath guided by the previous one, which achieves real-time titration of ventilator settings and minimizes instability induced tissue damage. This novel methodology changes the current approach to mechanical ventilation, from arbitrary to personalized and adaptive. The outcome of this approach is an open and stable lung with reduced regional strain and greater lung protection.
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Affiliation(s)
- Gary F Nieman
- Dept of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Louis A Gatto
- Dept of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Penny Andrews
- Multi-trauma Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, USA
| | - Joshua Satalin
- Dept of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA.
| | - Luigi Camporota
- Department of Critical Care, Guy's and St, Thomas' NHS Foundation Trust, Westminster Bridge Rd, London, SE1 7EH, UK
| | - Benjamin Daxon
- Dept of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Sarah J Blair
- Dept of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Hassan Al-Khalisy
- Dept of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Maria Madden
- Multi-trauma Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, USA
| | | | - Hani Aiash
- Dept of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA.,Department of Clinical Perfusion, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Nader M Habashi
- Multi-trauma Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, USA
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Mallory P, Cheifetz I. A comprehensive review of the use and understanding of airway pressure release ventilation. Expert Rev Respir Med 2020; 14:307-315. [PMID: 31869259 DOI: 10.1080/17476348.2020.1708719] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Airway pressure release ventilation (APRV) is a mode of ventilation typically utilized as a rescue or alternative mode for patients with acute respiratory distress syndrome (ARDS) and hypoxemia that is refractory to conventional mechanical ventilation. APRV's indication and efficacy continue to remain unclear given lack of consensus amongst practitioners, inconsistent methodology for its use, and scarcity of convincing evidence.Areas covered: This review discusses the history of APRV, how APRV works, rationales for its use, and its theoretical advantages and disadvantages. This is followed by a review of current available literature examining APRV's use in the intensive care unit, with further focus on its use in the pediatric intensive care unit.Expert opinion: APRV is a ventilation mode with theoretical risks and benefits. Appropriate study of APRV's clinical efficacy is difficult given a heterogeneous patient population and widely variable use of APRV between centers. Despite a paucity of definitive evidence in support of either mode, it is possible that the use of APRV will begin to outpace the use of high-frequency oscillatory ventilation (HFOV) for the management of refractory hypoxemia as more attention is paid to benefits of spontaneous breathing and minimizing sedation. Furthermore, APRV's role during ECMO deserves further investigation.
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Affiliation(s)
- Palen Mallory
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ira Cheifetz
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
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Sun X, Liu Y, Li N, You D, Zhao Y. The safety and efficacy of airway pressure release ventilation in acute respiratory distress syndrome patients: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e18586. [PMID: 31895807 PMCID: PMC6946469 DOI: 10.1097/md.0000000000018586] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) is a critical illness with high mortality and a worse prognosis. Mechanical ventilation (MV) is currently considered to be one of the most effective methods of treating ARDS. In this meta-analysis, we discussed the efficacy of airway pressure release ventilation (APRV) in treating ARDS. METHODS Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA), Ovid Medline, Embase, and PubMed were systematically searched with the keywords of "ARDS" and "APRV". The studies containing the treatment of APRV in ARDS were included. According to the MV protocol used in the studies, the comparison was undertaken between the APRV group vs low tidal volume (LTV) group and synchronized intermittent mandatory ventilation (SIMV) group. The relative risk (RR) and the standard mean difference with 95% confidence intervals (CI) were used for the comparison between groups. RESULTS Fourteen studies with 2096 patients were included in the meta-analysis. The average increasing rate of PaO2/FiO2 was 75.4% in the APRV group vs 44.1% in the non-APRV group. No significant differences were found in mortality and duration of ICU stay between APRV vs LTV (P = .073 and P = .404) and APRV vs SIMV (P = .370 and P = .894). CONCLUSION The APRV protocol would have a higher increase in the PaO2/FiO2 ratio, which was a safe protocol with a compatible effect comparing to LTV and SIMV.
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Affiliation(s)
- Xuri Sun
- Department of Critical Care Medicine, The Second Affiliated Hospital, Fujian Medical University, Quanzhou
| | - Yuqi Liu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Fujian Medical University, Quanzhou
| | - Neng Li
- Department of Pathogenic Biology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, Fujian Province
| | - Deyuan You
- Department of Critical Care Medicine, The Second Affiliated Hospital, Fujian Medical University, Quanzhou
| | - Yanping Zhao
- Department of Critical Care Medicine, Chinese Medicine Hospital Changji Autonomous Prefecture, Changji, Xinjiang Uygur Autonomous Region, PR China
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Randomized Feasibility Trial of a Low Tidal Volume-Airway Pressure Release Ventilation Protocol Compared With Traditional Airway Pressure Release Ventilation and Volume Control Ventilation Protocols. Crit Care Med 2019; 46:1943-1952. [PMID: 30277890 PMCID: PMC6250244 DOI: 10.1097/ccm.0000000000003437] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: Low tidal volume (= tidal volume ≤ 6 mL/kg, predicted body weight) ventilation using volume control benefits patients with acute respiratory distress syndrome. Airway pressure release ventilation is an alternative to low tidal volume-volume control ventilation, but the release breaths generated are variable and can exceed tidal volume breaths of low tidal volume-volume control. We evaluate the application of a low tidal volume-compatible airway pressure release ventilation protocol that manages release volumes on both clinical and feasibility endpoints. Design: We designed a prospective randomized trial in patients with acute hypoxemic respiratory failure. We randomized patients to low tidal volume-volume control, low tidal volume-airway pressure release ventilation, and traditional airway pressure release ventilation with a planned enrollment of 246 patients. The study was stopped early because of low enrollment and inability to consistently achieve tidal volumes less than 6.5 mL/kg in the low tidal volume-airway pressure release ventilation arm. Although the primary clinical study endpoint was Pao2/Fio2 on study day 3, we highlight the feasibility outcomes related to tidal volumes in both arms. Setting: Four Intermountain Healthcare tertiary ICUs. Patients: Adult ICU patients with hypoxemic respiratory failure anticipated to require prolonged mechanical ventilation. Interventions: Low tidal volume-volume control, airway pressure release ventilation, and low tidal volume-airway pressure release ventilation. Measurements and Main Results: We observed wide variability and higher tidal (release for airway pressure release ventilation) volumes in both airway pressure release ventilation (8.6 mL/kg; 95% CI, 7.8–9.6) and low tidal volume-airway pressure release ventilation (8.0; 95% CI, 7.3–8.9) than volume control (6.8; 95% CI, 6.2–7.5; p = 0.005) with no difference between airway pressure release ventilation and low tidal volume-airway pressure release ventilation (p = 0.58). Recognizing the limitations of small sample size, we observed no difference in 52 patients in day 3 Pao2/ Fio2 (p = 0.92). We also observed no significant difference between arms in sedation, vasoactive medications, or occurrence of pneumothorax. Conclusions: Airway pressure release ventilation resulted in release volumes often exceeding 12 mL/kg despite a protocol designed to target low tidal volume ventilation. Current airway pressure release ventilation protocols are unable to achieve consistent and reproducible delivery of low tidal volume ventilation goals. A large-scale efficacy trial of low tidal volume-airway pressure release ventilation is not feasible at this time in the absence of an explicit, generalizable, and reproducible low tidal volume-airway pressure release ventilation protocol.
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Lalgudi Ganesan S, Jayashree M, Chandra Singhi S, Bansal A. Airway Pressure Release Ventilation in Pediatric Acute Respiratory Distress Syndrome. A Randomized Controlled Trial. Am J Respir Crit Care Med 2019; 198:1199-1207. [PMID: 29641221 DOI: 10.1164/rccm.201705-0989oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Although case series describe benefits of airway pressure release ventilation (APRV), this mode of ventilation has not been evaluated against the conventional low-tidal volume ventilation (LoTV) in children with acute respiratory distress syndrome (ARDS). OBJECTIVES To compare the effect of APRV and conventional LoTV on ventilator-free days in children with ARDS. METHODS This open-label, parallel-design randomized controlled trial was conducted in a 15-bed ICU. Children aged 1 month to 12 years satisfying the modified Berlin definition were included. We excluded children with air leaks, increased intracranial pressure, poor spontaneous breathing efforts, chronic lung disease, and beyond 24 hours of ARDS diagnosis or 72 hours of ventilation. Children were randomized using unstratified, variable-sized block technique. A priori interim analysis was planned at 50% enrollment. All enrolled children were followed up until 180 days after enrollment or death, whichever was earlier. MEASUREMENTS AND MAIN RESULTS The trial was terminated after 50% enrollment (52 children) when analysis revealed higher mortality in the intervention arm. Ventilator-free days were statistically similar in both arms (P = 0.23). The 28-day all-cause mortality was 53.8% in APRV as compared with 26.9% among control subjects (risk ratio, 2.0; 95% confidence interval, 0.97-4.1; Fisher exact P = 0.089). The multivariate-adjusted risk ratio of death for APRV compared with LoTV was 2.02 (95% confidence interval, 0.99-4.12; P = 0.05). Higher mean airway pressures, greater spontaneous breathing, and early improvement in oxygenation were seen in the intervention arm. CONCLUSIONS APRV, as a primary ventilation strategy in children with ARDS, was associated with a trend toward higher mortality compared with the conventional LoTV. Limitations should be considered while interpreting these results. Clinical trial registered with www.clinicaltrials.gov (NCT02167698) and Clinical Trials Registry of India (CTRI/2014/06/004677).
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Affiliation(s)
- Saptharishi Lalgudi Ganesan
- 1 Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and
| | - Muralidharan Jayashree
- 1 Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and
| | - Sunit Chandra Singhi
- 1 Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and.,2 Division of Pediatrics, Medanta, The Medicity, Gurugram, National Capital Region, India
| | - Arun Bansal
- 1 Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and
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Biological Response to Time-Controlled Adaptive Ventilation Depends on Acute Respiratory Distress Syndrome Etiology. Crit Care Med 2019; 46:e609-e617. [PMID: 29485489 DOI: 10.1097/ccm.0000000000003078] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To compare a time-controlled adaptive ventilation strategy, set in airway pressure release ventilation mode, versus a protective mechanical ventilation strategy in pulmonary and extrapulmonary acute respiratory distress syndrome with similar mechanical impairment. DESIGN Animal study. SETTING Laboratory investigation. SUBJECTS Forty-two Wistar rats. INTERVENTIONS Pulmonary acute respiratory distress syndrome and extrapulmonary acute respiratory distress syndrome were induced by instillation of Escherichia coli lipopolysaccharide intratracheally or intraperitoneally, respectively. After 24 hours, animals were randomly assigned to receive 1 hour of volume-controlled ventilation (n = 7/etiology) or time-controlled adaptive ventilation (n = 7/etiology) (tidal volume = 8 mL/kg). Time-controlled adaptive ventilation consisted of the application of continuous positive airway pressure 2 cm H2O higher than baseline respiratory system peak pressure for a time (Thigh) of 0.75-0.85 seconds. The release pressure (Plow = 0 cm H2O) was applied for a time (Tlow) of 0.11-0.18 seconds. Tlow was set to target an end-expiratory flow to peak expiratory flow ratio of 75%. Nonventilated animals (n = 7/etiology) were used for Diffuse Alveolar Damage and molecular biology markers analyses. MEASUREMENT AND MAIN RESULTS Time-controlled adaptive ventilation increased mean respiratory system pressure regardless of acute respiratory distress syndrome etiology. The Diffuse Alveolar Damage score was lower in time-controlled adaptive ventilation compared with volume-controlled ventilation in pulmonary acute respiratory distress syndrome and lower in time-controlled adaptive ventilation than nonventilated in extrapulmonary acute respiratory distress syndrome. In pulmonary acute respiratory distress syndrome, volume-controlled ventilation, but not time-controlled adaptive ventilation, increased the expression of amphiregulin, vascular cell adhesion molecule-1, and metalloproteinase-9. Collagen density was higher, whereas expression of decorin was lower in time-controlled adaptive ventilation than nonventilated, independent of acute respiratory distress syndrome etiology. In pulmonary acute respiratory distress syndrome, but not in extrapulmonary acute respiratory distress syndrome, time-controlled adaptive ventilation increased syndecan expression. CONCLUSION In pulmonary acute respiratory distress syndrome, time-controlled adaptive ventilation led to more pronounced beneficial effects on expression of biomarkers related to overdistension and extracellular matrix homeostasis.
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Venkataraman S, Kinsella JP. Airway Pressure Release Ventilation: A Therapy in Search of a Disease? Am J Respir Crit Care Med 2019; 198:1118-1119. [PMID: 29757660 DOI: 10.1164/rccm.201804-0778ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shekhar Venkataraman
- 1 Department of Critical Care University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania and
| | - John P Kinsella
- 2 Department of Pediatrics University of Colorado School of Medicine and Children's Hospital Colorado Aurora, Colorado
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Ayala C, Baiu I, Owyang C, Forrester JD, Spain D. Rhinovirus-associated severe acute respiratory distress syndrome (ARDS) managed with airway pressure release ventilation (APRV). Trauma Surg Acute Care Open 2019; 4:e000322. [PMID: 31392279 PMCID: PMC6660799 DOI: 10.1136/tsaco-2019-000322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Carlos Ayala
- Department of General Surgery, Stanford University, Stanford, California, USA
| | - Ioana Baiu
- Department of General Surgery, Stanford University, Stanford, California, USA
| | - Clark Owyang
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Joseph D Forrester
- Department of General Surgery, Stanford University, Stanford, California, USA
| | - David Spain
- Department of General Surgery, Stanford University, Stanford, California, USA
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Lovisari F, Fodor GH, Peták F, Habre W, Bayat S. Effect of PEEP and I:E ratio on cerebral oxygenation in ARDS: an experimental study in anesthetized rabbit. BMC Anesthesiol 2019; 19:110. [PMID: 31216981 PMCID: PMC6582519 DOI: 10.1186/s12871-019-0782-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 06/09/2019] [Indexed: 12/03/2022] Open
Abstract
Background Although PEEP and inversed I:E ratio have been shown to improve gas exchange in ARDS, both can adversely affect systemic hemodynamics and cerebral perfusion. The goal of this study was to assess how changes in PEEP and I:E ratio affect systemic and cerebral oxygenation and perfusion in normal and injured lung. Methods Eight anesthetized Chinchilla-Bastard rabbits were ventilated at baseline with pressure-regulated volume control mode, VT = 6 ml/kg, PEEP = 6 cmH2O, FIO2 = 0.4; respiratory rate set for ETCO2 = 5.5%, and I:E = 1:2, 1:1 or 2:1 in random order. Ultrasonic carotid artery flow (CF), arterial (PaO2), jugular venous blood gases and near infrared spectroscopic cerebral oxygenation (∆HBO2) were recorded for each experimental condition. After induced lung injury, the animals were ventilated with PEEP = 9 followed by 6 cmH2O. Results At baseline, inverse-ratio ventilation (IRV) significantly reduced cerebral oxygenation (∆O2HB; − 27 at 1:2; − 15 at 1:1 vs. 0.27 μmol/L at 2:1; p < 0.05), due to a significant reduction in mean arterial pressure and CF without modifying gas exchange. In injured lung, IRV improved gas exchange but decreased cerebral perfusion without affecting brain oxygenation. The higher PEEP level, however, improved PaO2 (67.5 ± 19.3 vs. 42.2 ± 8.4, p < 0.05), resulting in an improved ∆HBO2 (− 13.8 ± 14.7 vs. –43.5 ± 21.3, p < 0.05), despite a drop in CF. Conclusions Our data suggest that unlike moderate PEEP, IRV is not effective in improving brain oxygenation in ARDS. In normal lung, IRV had a deleterious effect on brain oxygenation, which is relevant in anesthetized patients. Electronic supplementary material The online version of this article (10.1186/s12871-019-0782-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Federica Lovisari
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland.,University of Milano-Bicocca, Milan, Italy
| | - Gergely H Fodor
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Walid Habre
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland.,Pediatric Anesthesia Unit, Geneva Children's Hospital, Geneva, Switzerland
| | - Sam Bayat
- Unit for Anesthesiological Investigations Department of Anesthesiology Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland. .,Inserm UA7 STROBE Laboratory, University of Grenoble, Grenoble, France. .,Department of Clinical Physiology, Sleep and Exercise, Grenoble University Hospital, Grenoble, France.
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Ramin S, Charbit J, Jaber S, Capdevila X. Acute respiratory distress syndrome after chest trauma: Epidemiology, specific physiopathology and ventilation strategies. Anaesth Crit Care Pain Med 2019; 38:265-276. [DOI: 10.1016/j.accpm.2018.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 01/07/2023]
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Mahajan M, DiStefano D, Satalin J, Andrews P, Al-Khalisy H, Baker S, Gatto LA, Nieman GF, Habashi NM. Time-controlled adaptive ventilation (TCAV) accelerates simulated mucus clearance via increased expiratory flow rate. Intensive Care Med Exp 2019; 7:27. [PMID: 31098761 PMCID: PMC6522588 DOI: 10.1186/s40635-019-0250-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/29/2019] [Indexed: 01/31/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units. Distal airway mucus clearance has been shown to reduce VAP incidence. Studies suggest that mucus clearance is enhanced when the rate of expiratory flow is greater than inspiratory flow. The time-controlled adaptive ventilation (TCAV) protocol using the airway pressure release ventilation (APRV) mode has a significantly increased expiratory relative to inspiratory flow rate, as compared with the Acute Respiratory Distress Syndrome Network (ARDSnet) protocol using the conventional ventilation mode of volume assist control (VAC). We hypothesized the TCAV protocol would be superior to the ARDSnet protocol at clearing mucus by a mechanism of net flow in the expiratory direction. Methods Preserved pig lungs fitted with an endotracheal tube (ETT) were used as a model to study the effect of multiple combinations of peak inspiratory (IPF) and peak expiratory flow rate (EPF) on simulated mucus movement within the ETT. Mechanical ventilation was randomized into 6 groups (n = 10 runs/group): group 1—TCAV protocol settings with an end-expiratory pressure (PLow) of 0 cmH2O and PHigh 25 cmH2O, group 2—modified TCAV protocol with increased PLow 5 cmH2O and PHigh 25 cmH2O, group 3—modified TCAV with PLow 10 cmH2O and PHigh 25 cmH2O, group 4—ARDSnet protocol using low tidal volume (LTV) and PEEP 0 cmH2O, group 5—ARDSnet protocol using LTV and PEEP 10 cmH2O, and group 6—ARDSnet protocol using LTV and PEEP 20 cmH2O. PEEP of ARDSnet is analogous to PLow of TCAV. Proximal (towards the ventilator) mucus movement distance was recorded after 1 min of ventilation in each group. Results The TCAV protocol groups 1, 2, and 3 generated significantly greater peak expiratory flow (EPF 51.3 L/min, 46.8 L/min, 36.8 L/min, respectively) as compared to the ARDSnet protocol groups 4, 5, and 6 (32.9 L/min, 23.5 L/min, and 23.2 L/min, respectively) (p < 0.001). The TCAV groups also demonstrated the greatest proximal mucus movement (7.95 cm/min, 5.8 cm/min, 1.9 cm/min) (p < 0.01). All ARDSnet protocol groups (4–6) had zero proximal mucus movement (0 cm/min). Conclusions The TCAV protocol groups promoted the greatest proximal movement of simulated mucus as compared to the ARDSnet protocol groups in this excised lung model. The TCAV protocol settings resulted in the highest EPF and the greatest proximal movement of mucus. Increasing PLow reduced proximal mucus movement. We speculate that proximal mucus movement is driven by EPF when EPF is greater than IPF, creating a net force in the proximal direction.
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Affiliation(s)
- Melissa Mahajan
- Department of Surgery, SUNY Upstate Medical University, 750 East Adams St., 766 Irving Avenue, Syracuse, NY, 13210, USA
| | - David DiStefano
- Department of Surgery, SUNY Upstate Medical University, 750 East Adams St., 766 Irving Avenue, Syracuse, NY, 13210, USA
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, 750 East Adams St., 766 Irving Avenue, Syracuse, NY, 13210, USA.
| | - Penny Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Hassan Al-Khalisy
- Department of Surgery, SUNY Upstate Medical University, 750 East Adams St., 766 Irving Avenue, Syracuse, NY, 13210, USA
| | - Sarah Baker
- Department of Surgery, SUNY Upstate Medical University, 750 East Adams St., 766 Irving Avenue, Syracuse, NY, 13210, USA
| | - Louis A Gatto
- Department of Biological Sciences, SUNY Cortland, 22 Graham Avenue, Cortland, NY, 13045, USA
| | - Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, 750 East Adams St., 766 Irving Avenue, Syracuse, NY, 13210, USA
| | - Nader M Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
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Sagar AES, Casal RF. Mechanical ventilation during lobectomy: is this lung behaving as a "baby"? J Thorac Dis 2019; 11:376-378. [PMID: 30962978 DOI: 10.21037/jtd.2018.12.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ala-Eddin S Sagar
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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