1
|
Morrison S, Van Oostende C, Aerts S, Saldien V. The Tritube: Facilitating Upper Airway Surgery With an Ultrathin Cuffed Airway Device. A A Pract 2023; 17:e01697. [PMID: 37433059 DOI: 10.1213/xaa.0000000000001697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
The Tritube is a narrow-bore cuffed tracheal tube (outer diameter 4.4 mm and inner diameter ~2.4 mm) that permits effective alveolar gas exchange using flow-controlled ventilation. Constant gas flow delivers physiological minute volumes, within preset pressure limits, and applies suction to the airway during expiration. The technique has attracted interest for laryngotracheal microsurgery as it provides superior surgical exposure and avoids many of the complications associated with high-frequency jet ventilation. Cuff inflation protects the lower airway and produces a motionless operating field. We describe the structure of the device, discuss its benefits, and suggest how it should be used clinically.
Collapse
Affiliation(s)
- Stuart Morrison
- From the Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
| | | | | | | |
Collapse
|
2
|
Grassetto A, Pettenuzzo T, Badii F, Carlon R, Sella N, Navalesi P. Flow-controlled ventilation may reduce mechanical power and increase ventilatory efficiency in severe coronavirus disease-19 acute respiratory distress syndrome. Pulmonology 2023; 29:154-156. [PMID: 35864057 PMCID: PMC9186429 DOI: 10.1016/j.pulmoe.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/15/2022] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- A Grassetto
- Anesthesia and Intensive Care, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029 Vittorio Veneto, Italy.
| | - T Pettenuzzo
- Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Via V. Gallucci 13, 35121 Padua, Italy
| | - F Badii
- Anesthesia and Intensive Care, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029 Vittorio Veneto, Italy
| | - R Carlon
- Anesthesia and Intensive Care, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029 Vittorio Veneto, Italy
| | - N Sella
- Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Via V. Gallucci 13, 35121 Padua, Italy
| | - P Navalesi
- Institute of Anesthesiology and Intensive Care, Padua University Hospital, Padua, Via V. Gallucci 13, 35121 Padua, Italy; Department of Medicine, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
| |
Collapse
|
3
|
SAYİN KART J, DALKİLİNC HOKENEK U. Comparison of TritubeTM Tube and Evone® ventilator use with traditional narrow-lumen tube use in microlaryngeal surgery cases. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1220801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Comparison of TritubeTM Tube and Evone® Ventilator Use with Traditional Narrow-Lumen Tube Use in Microlaryngeal Surgery Cases
ABSTRACT
Introduction: Upper airway surgery involves certain difficulties, such as tumors located in the endotracheal area, narrowing of the tracheal lumen by the tumor, the use of a narrow lumen tube constantly increasing pressure. In the literature, difficult airway management has been successfully performed in patients intubated with Tritube™ and ventilated with Evone® (Ventinova Medical, Eindhoven, The Netherlands), and the benefits of these tools during laryngeal surgery have been reported.
Objectives: To evaluate the feasibility and safety of the Tritube™ tube and Evone® ventilator and compare patients intubated using Tritube™ and ventilated with flow-controlled ventilation (FCV) using Evone® (TT–FCV group) to those intubated using a traditional microlaryngeal intubation tube and ventilated with volume-controlled ventilation (MLT-VCV group) in terms of perioperative parameters and outcomes during microlaryngeal surgery (MLS).
Materials and Methods: After receiving their informed consent, 18 patients were randomly assigned to two groups. Patients older than 18 years, who were scheduled for elective MLS were included in the study. The patients’ demographic parameters, American Society of Anesthesiology physical status (ASA), Mallampati and Cormack-Lehane scores, duration of ventilation, duration of surgery, hemodynamic parameters, ventilation parameters, and complications were recorded.
Results: When the intraoperative respiratory and hemodynamic parameters of the patients were compared between the two groups, the intraoperative cerebral oxygen saturation (SpO₂) (p=0.020), tidal volume (p=0.005), compliance of the respiratory system (p=0.001), and post-extubation SpO₂ (p=0.001) values were statistically significantly higher in the TT-FVC group compared to the MLT-VCV group. Right SpO₂ (p=0.038), left SpO₂ (p=0.047), and time to extubation (p=0.021) were statistically significantly lower in the TT-FVC group compared to the MLT-VCV group.
Discussion: Low airway peak pressure and stable hemodynamics were achieved with Tritube™, and no complications were encountered in the perioperative period. At the end of the surgery, the cuff was lowered, high-frequency jet ventilation was applied, and extubation was safe performed (3). Although the literature on TritubeTM and Evone® is still limited, the use of these tools in MLS appears to be advantageous to achieve safe airway management.
Keywords: Microlaryngeal surgery, Ventilation, Hemodynamics
Collapse
Affiliation(s)
- Jülide SAYİN KART
- UNİVERSİTY OF HEALTH SCİENCES, KARTAL DR. LÜTFİ KIRDAR CİTY HOSPİTAL
| | | |
Collapse
|
4
|
Brandly JE, Midon M, Douglas HF, Hopster K. Flow-controlled expiration reduces positive end-expiratory pressure requirement in dorsally recumbent, anesthetized horses. Front Vet Sci 2023; 10:1135452. [PMID: 37124564 PMCID: PMC10140341 DOI: 10.3389/fvets.2023.1135452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Equine peri-anesthetic mortality is higher than that for other commonly anesthetized veterinary species. Unique equine pulmonary pathophysiologic aspects are believed to contribute to this mortality due to impairment of gas exchange and subsequent hypoxemia. No consistently reliable solution for the treatment of peri-anesthetic gas exchange impairment is available. Flow-controlled expiration (FLEX) is a ventilatory mode that linearizes gas flow throughout the expiratory phase, reducing the rate of lung emptying and alveolar collapse. FLEX has been shown to improve gas exchange and pulmonary mechanics in anesthetized horses. This study further evaluated FLEX ventilation in anesthetized horses positioned in dorsal recumbency, hypothesizing that after alveolar recruitment, horses ventilated using FLEX would require a lower positive end-expiratory pressure (PEEP) to prevent alveolar closure than horses conventionally ventilated. Methods Twelve adult horses were used in this prospective, randomized study. Horses were assigned either to conventional volume-controlled ventilation (VCV) or to FLEX. Following induction of general anesthesia, horses were placed in dorsal recumbency mechanically ventilated for a total of approximately 6.5 hours. Thirty-minutes after starting ventilation with VCV or FLEX, a PEEP-titration alveolar recruitment maneuver was performed at the end of which the PEEP was reduced in decrements of 3 cmH2O until the alveolar closure pressure was determined. The PEEP was then increased to the previous level and maintained for additional three hours. During this time, the mean arterial blood pressure, pulmonary arterial pressure, central venous blood pressure, cardiac output (CO), dynamic respiratory system compliance and arterial blood gas values were measured. Results The alveolar closure pressure was significantly lower (6.5 ± 1.2 vs 11.0 ± 1.5 cmH2O) and significantly less PEEP was required to prevent alveolar closure (9.5 ± 1.2 vs 14.0 ± 1.5 cmH2O) for horses ventilated using FLEX compared with VCV. The CO was significantly higher in the horses ventilated with FLEX (37.5 ± 4 vs 30 ± 6 l/min). Discussion We concluded that FLEX ventilation was associated with a lower PEEP requirement due to a more homogenous distribution of ventilation in the lungs during expiration. This lower PEEP requirement led to more stable and improved cardiovascular conditions in horses ventilated with FLEX.
Collapse
|
5
|
Accuracy of calculating mechanical power of ventilation by one commonly used equation. J Clin Monit Comput 2022; 36:1753-1759. [PMID: 35426575 PMCID: PMC9637605 DOI: 10.1007/s10877-022-00823-3] [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: 10/04/2021] [Accepted: 01/29/2022] [Indexed: 11/21/2022]
Abstract
Gattinoni's equation, [Formula: see text], now commonly used to calculate the mechanical power (MP) of ventilation. However, it calculates only inspiratory MP. In addition, the inclusion of PEEP in Gattinoni's equation raises debate because PEEP does not produce net displacement or contribute to MP. Measuring the area within the pressure-volume loop accurately reflects the MP received in a whole ventilation cycle and the MP thus obtained is not influenced by PEEP. The MP of 25 invasively ventilated patients were calculated by Gattinoni's equation and measured by integration of the areas within the pressure-volume loops of the ventilation cycles. The MP obtained from both methods were compared. The effects of PEEPs on MP were also evaluated. We found that the MP obtained from both methods were correlated by R2 = 0.75 and 0.66 at PEEP 5 and 10 cmH2O, respectively. The biases of the two methods were 3.13 (2.03 to 4.23) J/min (P < 0.0001) and - 1.23 (- 2.22 to - 0.24) J/min (P = 0.02) at PEEP 5 and 10 cmH2O, respectively. These P values suggested that both methods were significantly incongruent. When the tidal volume used was 6 ml/Kg, the MP by Gattinoni's equation at PEEP 5 and 10 cmH2O were significantly different (4.51 vs 7.21 J/min, P < 0.001), but the MP by PV loop area was not influenced by PEEPs (6.46 vs 6.47 J/min, P = 0.331). Similar results were observed across all tidal volumes. We conclude that the Gattinoni's equation is not accurate in calculating the MP of a whole ventilatory cycle and is significantly influenced by PEEP, which theoretically does not contribute to MP.
Collapse
|
6
|
Van Dessel ED, De Meyer GR, Morrison SG, Jorens PG, Schepens T. Flow-controlled ventilation in moderate acute respiratory distress syndrome due to COVID-19: an open-label repeated-measures controlled trial. Intensive Care Med Exp 2022; 10:19. [PMID: 35608696 PMCID: PMC9127816 DOI: 10.1186/s40635-022-00449-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/09/2022] [Indexed: 01/07/2023] Open
Abstract
Background Flow-controlled ventilation (FCV), a novel mode of mechanical ventilation characterised by constant flow during active expiration, may result in more efficient alveolar gas exchange, better lung recruitment and might be useful in limiting ventilator-induced lung injury. However, data regarding FCV in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome (ARDS) are scarce. Objectives We hypothesised that the use of FCV is feasible and would improve oxygenation in moderate COVID-19 ARDS compared to conventional ventilation. Design Open-label repeated-measures controlled trial. Setting From February to April 2021, patients with moderate COVID-19 ARDS were recruited in a tertiary referral intensive care unit. Patients Patients with moderate ARDS (PaO2/FIO2 ratio 100–200 mmHg, SpO2 88–94% and PaO2 60–80 mmHg) were considered eligible. Exclusion criteria were: extremes of age (< 18 years, > 80 years), obesity (body mass index > 40 kg/m2), prone positioning at the time of intervention, mechanical ventilation for more than 10 days and extracorporeal membrane oxygenation. Eleven patients were recruited. Intervention Participants were ventilated in FCV mode for 30 min, and subsequently in volume-control mode (VCV) for 30 min. Main outcome measures Feasibility of FCV to maintain oxygenation was assessed by the PaO2/FiO2 ratio (mmHg) as a primary outcome parameter. Secondary outcomes included ventilator parameters, PaCO2 and haemodynamic data. All adverse events were recorded. Results FCV was feasible in all patients and no adverse events were observed. There was no difference in the PaO2/FIO2 ratio after 30 min of ventilation in FCV mode (169 mmHg) compared to 30 min of ventilation in VCV mode subsequently (168 mmHg, 95% CI of pseudo-medians (− 10.5, 3.6), p = 0.56). The tidal volumes (p < 0.01) and minute ventilation were lower during FCV (p = 0.01) while PaCO2 was similar at the end of the 30-min ventilation periods (p = 0.31). Mean arterial pressure during FCV was comparable to baseline. Conclusions Thirty minutes of FCV in patients with moderate COVID-19 ARDS receiving neuromuscular blocking agents resulted in similar oxygenation, compared to VCV. FCV was feasible and did not result in adverse events. Trial registration: Clinicaltrials.gov identifier: NCT04894214.
Collapse
Affiliation(s)
- Eleni D Van Dessel
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Gregory R De Meyer
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium.,Department of Anesthesiology, Antwerp University Hospital/University of Antwerp, Edegem, Belgium
| | - Stuart G Morrison
- Department of Anesthesiology, Antwerp University Hospital/University of Antwerp, Edegem, Belgium
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium.
| |
Collapse
|
7
|
Hopster K, Hurcombe SD, Simpson K, VanderBroek AR, Driessen B. Flow-controlled expiration improves respiratory mechanics, ventilation, and gas exchange in anesthetized horses. Am J Vet Res 2022; 83:393-398. [PMID: 35175934 DOI: 10.2460/ajvr.21.10.0158] [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: 11/20/2022]
Abstract
OBJECTIVE Mechanical ventilation is usually achieved by active lung inflation during inspiration and passive lung emptying during expiration. By contrast, flow-controlled expiration (FLEX) ventilation actively reduces the rate of lung emptying by causing linear gas flow throughout the expiratory phase. Our aim was to evaluate the effects of FLEX on lung compliance and gas exchange in anesthetized horses in dorsal recumbency. ANIMALS 8 healthy horses. PROCEDURES All animals were anesthetized twice and either ventilated beginning with FLEX or conventional volume-controlled ventilation in a randomized, crossover design. Total anesthesia time was 3 hours, with the ventilatory mode being changed after 1.5 hours. During anesthesia, cardiac output (thermodilution), mean arterial blood pressures, central venous pressure, and pulmonary arterial pressure were recorded. Further, peak, plateau, and mean airway pressures and dynamic lung compliance (Cdyn) were measured. Arterial blood gases were analyzed every 15 minutes. Data were analyzed using ANOVA (P < 0.05). RESULTS FLEX ventilation resulted in significantly higher arterial oxygen partial pressures (521 vs 227 mm Hg) and Cdyn (564 vs 431 mL/cm H2O) values compared to volume-controlled ventilation. The peak and plateau airway pressure were lower, but mean airway pressure was significantly higher (4.8 vs 9.2 cm H2O) in FLEX ventilated horses. No difference for cardiovascular parameters were detected. CLINICAL RELEVANCE The results of this study showed a significant improvement of the Pao2 and Cdyn without compromising the cardiovascular system when horses were ventilated by use of FLEX compared to conventional ventilation.
Collapse
|
8
|
Schmidt J, Martin A, Wenzel C, Weber J, Wirth S, Schumann S. Control of the expiratory flow in a lung model and in healthy volunteers with an adjustable flow regulator: a combined bench and randomized crossover study. Respir Res 2021; 22:292. [PMID: 34775965 PMCID: PMC8590868 DOI: 10.1186/s12931-021-01886-7] [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: 02/08/2021] [Accepted: 11/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Pursed-lips breathing (PLB) is a technique to attenuate small airway collapse by regulating the expiratory flow. During mandatory ventilation, flow-controlled expiration (FLEX), which mimics the expiratory flow course of PLB utilizing a digital system for measurement and control, was shown to exert lung protective effects. However, PLB requires a patient’s participation and coordinated muscular effort and FLEX requires a complex technical setup. Here, we present an adjustable flow regulator to mimic PLB and FLEX, respectively, without the need of a patient’s participation, or a complex technical device. Methods Our study consisted of two parts: First, in a lung model which was ventilated with standard settings (tidal volume 500 ml, respiratory rate 12 min−1, positive end-expiratory pressure (PEEP) 5 cmH2O), the possible reduction of the maximal expiratory flow by utilizing the flow regulator was assessed. Second, with spontaneously breathing healthy volunteers, the short-term effects of medium and strong expiratory flow reduction on airway pressure, the change of end-expiratory lung volume (EELV), and breathing discomfort was investigated. Results In the lung model experiments, expiratory flow could be reduced from − 899 ± 9 ml·s−1 down to − 328 ± 25 ml·s−1. Thereby, inspiratory variables and PEEP were unaffected. In the volunteers, the maximal expiratory flow of − 574 ± 131 ml·s−1 under baseline conditions was reduced to − 395 ± 71 ml·s−1 for medium flow regulation and to − 266 ± 58 ml·s−1 for strong flow regulation, respectively (p < 0.001). Accordingly, mean airway pressure increased from 0.6 ± 0.1 cmH2O to 2.9 ± 0.4 cmH2O with medium flow regulation and to 5.4 ± 2.4 cmH2O with strong flow regulation, respectively (p < 0.001). The EELV increased from baseline by 31 ± 458 ml for medium flow regulation and 320 ± 681 ml for strong flow regulation (p = 0.033). The participants rated breathing with the flow regulator as moderately uncomfortable, but none rated breathing with the flow regulator as intolerable. Conclusions The flow regulator represents an adjustable device for application of a self-regulated expiratory resistive load, representing an alternative for PLB and FLEX. Future applications in spontaneously breathing patients and patients with mandatory ventilation alike may reveal potential benefits. Trial registration: DRKS00015296, registered on 20th August, 2018; URL: https://www.drks.de/drks_web/setLocale_EN.do. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01886-7.
Collapse
Affiliation(s)
- Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Anna Martin
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Christin Wenzel
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesia, Intensive Care and Pain Medicine, Medical Center of the German Accident Insurance Institution, Murnau, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| |
Collapse
|
9
|
Höhne T, Wenzel C, Schumann S. Flow-controlled expiration (FLEX) homogenizes pressure distribution in a four compartment physical model of the respiratory system with chest wall compliance. Physiol Meas 2021; 42. [PMID: 34192675 DOI: 10.1088/1361-6579/ac0ff8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022]
Abstract
Objective.Flow-controlled expiration (FLEX) has been shown to attenuate ventilator-induced lung injury in animal models. It has also shown to homogenize compartmental pressure distribution in a physical model of the inhomogeneous respiratory system having independent compartments. We hypothesized that the homogenizing effects of FLEX are also effective in this regard when the independence of compartments is suspended by simulated chest wall compliance.Approach.A four compartment physical model of the respiratory system having chest wall compliance (137 ml/cmH2O) was developed. Two of the four compartments had high compliance (18 ml/cmH2O) and two had low compliance (10 ml/cmH2O). These compartments were each combined with either high (6.8 cmH2O·s/l) or low resistance (3.5 cmH2O·s/l). The model was ventilated in the volume-controlled ventilation mode with either passive expiration or with FLEX. The maximal pressure differences (ΔPmax) and the maximal differences of mean pressure (ΔPmean) between the compartments during expiration were determined.Main results.With passive expiration ΔPmaxreached up to 3.4 ± 0.03 cmH2O but only 0.9 ± 0.01 cmH2O with FLEX (p < 0.001). Maximal differences of ΔPmeanwere significantly lower with FLEX as compared to passive expiration (extending up to 0.4 ± 0.04 cmH2O versus 2.0 ± 0.15 cmH2O,p < 0.001).Significance.The homogenizing effects of FLEX on compartmental pressure distribution could be reproduced in a more complex physical model of the inhomogeneous respiratory system having chest wall compliance and might be a mechanism underlying the lung protective effects of ventilation with FLEX.
Collapse
Affiliation(s)
- Tobias Höhne
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Christin Wenzel
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| |
Collapse
|
10
|
Ordies S, Orlitova M, Heigl T, Sacreas A, Van Herck A, Kaes J, Saez B, Vanstapel A, Ceulemans L, Vanaudenaerde BM, Vos R, Verschakelen J, Verleden GM, Verleden SE, Van Raemdonck DE, Neyrinck AP. Flow-controlled ventilation during EVLP improves oxygenation and preserves alveolar recruitment. Intensive Care Med Exp 2020; 8:70. [PMID: 33237343 PMCID: PMC7686942 DOI: 10.1186/s40635-020-00360-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 11/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a widespread accepted platform for preservation and evaluation of donor lungs prior to lung transplantation (LTx). Standard lungs are ventilated using volume-controlled ventilation (VCV). We investigated the effects of flow-controlled ventilation (FCV) in a large animal EVLP model. Fourteen porcine lungs were mounted on EVLP after a warm ischemic interval of 2 h and randomized in two groups (n = 7/group). In VCV, 7 grafts were conventionally ventilated and in FCV, 7 grafts were ventilated by flow-controlled ventilation. EVLP physiologic parameters (compliance, pulmonary vascular resistance and oxygenation) were recorded hourly. After 6 h of EVLP, broncho-alveolar lavage (BAL) was performed and biopsies for wet-to-dry weight (W/D) ratio and histology were taken. The left lung was inflated, frozen in liquid nitrogen vapors and scanned with computed tomography (CT) to assess regional distribution of Hounsfield units (HU). RESULTS All lungs endured 6 h of EVLP. Oxygenation was better in FCV compared to VCV (p = 0.01) and the decrease in lung compliance was less in FCV (p = 0.03). W/D ratio, pathology and BAL samples did not differ between both groups (p = 0.16, p = 0.55 and p = 0.62). Overall, CT densities tended to be less pronounced in FCV (p = 0.05). Distribution of CT densities revealed a higher proportion of well-aerated lung parts in FCV compared to VCV (p = 0.01). CONCLUSIONS FCV in pulmonary grafts mounted on EVLP is feasible and leads to improved oxygenation and alveolar recruitment. This ventilation strategy might prolong EVLP over time, with less risk for volutrauma and atelectrauma.
Collapse
Affiliation(s)
- Sofie Ordies
- Unit of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michaela Orlitova
- Unit of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tobias Heigl
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Annelore Sacreas
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Anke Van Herck
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Janne Kaes
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Berta Saez
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Arno Vanstapel
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Laurens Ceulemans
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Robin Vos
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | | | - Geert M Verleden
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Dirk E Van Raemdonck
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Arne P Neyrinck
- Unit of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium. .,Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.
| |
Collapse
|
11
|
Abstract
Tracheobronchial pathology can be related to trauma, infection, tumor, or a combination of these. Per definition, planning for tracheobronchial surgery can be complicated by the overlap of anesthesiological interests in airway management and the primary surgical field. Therefore, following a detailed description of the stenosis, management of tracheobronchial surgery requires an interdisciplinary discussion and individualized planning of the procedure. There are several options for intraoperative ventilation depending on the exact localization of the defect. Hence, different tubes and ventilation techniques from cross-field ventilation, to jet ventilation, or even spontaneous breathing under regional anesthesia, have to be discussed. Moreover, an innovative ventilation mode called flow-controlled ventilation (FVC) has been developed, which allows to apply standard tidal volumes through a narrow-bore endotracheal tube. In addition, the Ventrain has been developed as an emergency device following the same technique of an active expiration based on the Venturi principle and a controlled gas flow. In critical situations, it allows even ventilation through the working channel of a bronchoscope. Overall, tracheobronchial surgery is performed under total intravenous anesthesia and the aim of an early extubation at the end of surgery. Airway management has to be discussed and planned between surgeon and anesthesiologist. All of the steps of the procedure need constant and clear communication.
Collapse
Affiliation(s)
- Anna Schleicher
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Kliniken Essen-Mitte, Essen, Germany
| | - Harald Groeben
- Department of Anesthesiology, Critical Care Medicine and Pain Therapy, Kliniken Essen-Mitte, Essen, Germany
| |
Collapse
|
12
|
Glottic visibility for laryngeal surgery: Tritube vs. microlaryngeal tube: A randomised controlled trial. Eur J Anaesthesiol 2020; 36:963-971. [PMID: 31644514 PMCID: PMC6855316 DOI: 10.1097/eja.0000000000001110] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Good visibility is essential for successful laryngeal surgery. A Tritube with outer diameter 4.4 mm, combined with flow-controlled ventilation (FCV), enables ventilation by active expiration with a sealed trachea and may improve laryngeal visibility. OBJECTIVES We hypothesised that a Tritube with FCV would provide better laryngeal visibility and surgical conditions for laryngeal surgery than a conventional microlaryngeal tube (MLT) with volume-controlled ventilation (VCV). DESIGN Randomised, controlled trial. SETTING University Medical Centre. PATIENTS A total of 55 consecutive patients (>18 years) undergoing elective laryngeal surgery were assessed for participation, providing 40 evaluable data sets with 20 per group. INTERVENTIONS Random allocation to intubation with Tritube and ventilation with FCV (Tritube-FCV group) or intubation with MLT 6.0 and ventilation with VCV (MLT-VCV) as control. Tidal volumes of 7 ml kg predicted body weight, and positive end-expiratory pressure of 7 cmH2O were standardised between groups. MAIN OUTCOME MEASURES Primary endpoint was the tube-related concealment of laryngeal structures, measured on videolaryngoscopic photographs by appropriate software. Secondary endpoints were surgical conditions (categorical four-point rating scale), respiratory variables and change of end-expiratory lung volume from atmospheric airway pressure to ventilation with positive end-expiratory pressure. Data are presented as median [IQR]. RESULTS There was less concealment of laryngeal structures with the Tritube than with the MLT; 7 [6 to 9] vs. 22 [18 to 27] %, (P < 0.001). Surgical conditions were rated comparably (P = 0.06). A subgroup of residents in training perceived surgical conditions to be better with the Tritube compared with the MLT (P = 0.006). Respiratory system compliance with the Tritube was higher at 61 [52 to 71] vs. 46 [41 to 51] ml cmH2O (P < 0.001), plateau pressure was lower at 14 [13 to 15] vs. 17 [16 to 18] cmH2O (P < 0.001), and change of end-expiratory lung volume was higher at 681 [463 to 849] vs. 414 [194 to 604] ml, (P = 0.023) for Tritube-FCV compared with MLT-VCV. CONCLUSION During laryngeal surgery a Tritube improves visibility of the surgical site but not surgical conditions when compared with a MLT 6.0. FCV improves lung aeration and respiratory system compliance compared with VCV. TRIAL REGISTRY NUMBER DRKS00013097.
Collapse
|
13
|
Wenzel C, Frey C, Schmidt J, Lozano-Zahonero S, Urban G, Schumann S. A linearized expiration flow homogenizes the compartmental pressure distribution in a physical model of the inhomogeneous respiratory system. Physiol Meas 2020; 41:045005. [DOI: 10.1088/1361-6579/ab83e6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
14
|
Weber J, Schmidt J, Straka L, Wirth S, Schumann S. Flow-controlled ventilation improves gas exchange in lung-healthy patients- a randomized interventional cross-over study. Acta Anaesthesiol Scand 2020; 64:481-488. [PMID: 31828755 DOI: 10.1111/aas.13526] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/04/2019] [Accepted: 11/27/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Flow-controlled ventilation (FCV) is a new ventilation mode that provides constant inspiratory and expiratory flow. FCV was shown to improve gas exchange and lung recruitment in porcine models of healthy and injured ventilated lungs. The primary aim of our study was to verify the influences of FCV on gas exchange, respiratory mechanics and haemodynamic variables in mechanically ventilated lung-healthy patients. METHODS After obtaining ethical approval and informed consent, we measured arterial blood gases, respiratory and haemodynamic variables during volume-controlled ventilation (VCV) and FCV in 20 consecutive patients before they underwent abdominal surgery. After baseline (BL) ventilation, patients were randomly assigned to either BL-VCV-FCV or BL-FCV-VCV. Thereby, BL ventilation settings were kept, except for the ventilation mode-related differences (FCV is supposed to be used with an I:E ratio of 1:1). RESULTS Compared to BL and VCV, PaO2 was higher [PaO2 : FCV: 38.2 (7.1), BL ventilation: 35.0 (5.8), VCV: 35.2 (7.0) kPa, P < .001] and PaCO2 lower [PaCO2 : FCV: 4.8 (0.5), BL ventilation: 5.1 (0.5), VCV: 5.1 (0.5) kPa, P < .001] during FCV. With comparable plateau pressure [BL: 14.9 (1.9), VCV: 15.3 (1.6), FCV: 15.2 (1.5) cm H2 O), P = .185], tracheal mean pressure was higher during FCV [BL: 10.2 (1.1), VCV: 10.4 (0.7), FCV: 11.5 (1.0) cm H2 O, P < .001]. Haemodynamic variables did not differ between ventilation phases. CONCLUSION Flow-controlled ventilation improves oxygenation and carbon dioxide elimination within a short time, compared to VCV with identical tidal volume, inspiratory plateau pressure and end-expiratory pressure.
Collapse
Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care Medical Center – University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care Medical Center – University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Leonie Straka
- Department of Anesthesiology and Critical Care Medical Center – University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care Medical Center – University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care Medical Center – University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| |
Collapse
|
15
|
Schmidt J, Wenzel C, Spassov S, Borgmann S, Lin Z, Wollborn J, Weber J, Haberstroh J, Meckel S, Eiden S, Wirth S, Schumann S. Flow-Controlled Ventilation Attenuates Lung Injury in a Porcine Model of Acute Respiratory Distress Syndrome: A Preclinical Randomized Controlled Study. Crit Care Med 2020; 48:e241-e248. [PMID: 31856000 PMCID: PMC7017946 DOI: 10.1097/ccm.0000000000004209] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Lung-protective ventilation for acute respiratory distress syndrome aims for providing sufficient oxygenation and carbon dioxide clearance, while limiting the harmful effects of mechanical ventilation. "Flow-controlled ventilation", providing a constant expiratory flow, has been suggested as a new lung-protective ventilation strategy. The aim of this study was to test whether flow-controlled ventilation attenuates lung injury in an animal model of acute respiratory distress syndrome. DESIGN Preclinical, randomized controlled animal study. SETTING Animal research facility. SUBJECTS Nineteen German landrace hybrid pigs. INTERVENTION Flow-controlled ventilation (intervention group) or volume-controlled ventilation (control group) with identical tidal volume (7 mL/kg) and positive end-expiratory pressure (9 cm H2O) after inducing acute respiratory distress syndrome with oleic acid. MEASUREMENTS AND MAIN RESULTS PaO2 and PaCO2, minute volume, tracheal pressure, lung aeration measured via CT, alveolar wall thickness, cell infiltration, and surfactant protein A concentration in bronchoalveolar lavage fluid. Five pigs were excluded leaving n equals to 7 for each group. Compared with control, flow-controlled ventilation elevated PaO2 (154 ± 21 vs 105 ± 9 torr; 20.5 ± 2.8 vs 14.0 ± 1.2 kPa; p = 0.035) and achieved comparable PaCO2 (57 ± 3 vs 54 ± 1 torr; 7.6 ± 0.4 vs 7.1 ± 0.1 kPa; p = 0.37) with a lower minute volume (6.4 ± 0.5 vs 8.7 ± 0.4 L/min; p < 0.001). Inspiratory plateau pressure was comparable in both groups (31 ± 2 vs 34 ± 2 cm H2O; p = 0.16). Flow-controlled ventilation increased normally aerated (24% ± 4% vs 10% ± 2%; p = 0.004) and decreased nonaerated lung volume (23% ± 6% vs 38% ± 5%; p = 0.033) in the dependent lung region. Alveolar walls were thinner (5.5 ± 0.1 vs 7.8 ± 0.2 µm; p < 0.0001), cell infiltration was lower (20 ± 2 vs 32 ± 2 n/field; p < 0.0001), and normalized surfactant protein A concentration was higher with flow-controlled ventilation (1.1 ± 0.04 vs 1.0 ± 0.03; p = 0.039). CONCLUSIONS Flow-controlled ventilation enhances lung aeration in the dependent lung region and consequently improves gas exchange and attenuates lung injury. Control of the expiratory flow may provide a novel option for lung-protective ventilation.
Collapse
Affiliation(s)
- Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christin Wenzel
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sashko Spassov
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Silke Borgmann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ziwei Lin
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jakob Wollborn
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jörg Haberstroh
- Experimental Surgery, Center for Experimental Models and Transgenic Service, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Eiden
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
16
|
Meulemans J, Jans A, Vermeulen K, Vandommele J, Delaere P, Vander Poorten V. Evone® Flow-Controlled Ventilation During Upper Airway Surgery: A Clinical Feasibility Study and Safety Assessment. Front Surg 2020; 7:6. [PMID: 32185179 PMCID: PMC7058692 DOI: 10.3389/fsurg.2020.00006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/13/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction: During upper airway surgery in a narrowed airway due to tumor or stenosis, safe ventilation, good laryngotracheal exposure, and preservation of an adequate surgical working space are of paramount importance. This can be achieved by small-lumen ventilation such as High Frequency Jet Ventilation (HFJV). However, this technique has major drawbacks, such as air-trapping and desaturation in patients with poor pulmonary reserve. Recently, an innovative ventilating system with flow-controlled ventilation (FCV) and a small-lumen endotracheal tube, the Evone® (Ventinova, Eindhoven, The Netherlands), was introduced, claiming to counter the drawbacks of HFJV. Objectives: To evaluate feasibility and safety of the Evone® FCV system in difficult upper airway surgery and to critically appraise this novel ventilation method. Patients and methods: Evone® is a FCV-device using a small-bore cuffed tube (Tritube®). This ventilator actively sucks air out of the lungs, rather than relying on the passive backflow of air like in HFJV. Data related to the medical history, surgery, and anesthesia of all consecutive patients undergoing upper airway surgery with Evone® FCV ventilation were included in a tertiary center retrospective observational study. Results: Fifteen Patients, with a median age of 54 years, were included. Surgical procedures and indications included laser-assisted endoscopic treatment of idiopathic subglottic stenosis (n = 3), tracheal stenosis (n = 1), and posterior glottic stenosis (n = 2), biopsy and/or Transoral Laser Microsurgery for laryngeal (pre)malignancy (n = 7) and resection of benign lesions with posterior (supra)glottic location (n = 2). Mean ventilation duration was 52.0 min (range 30-115 min, SD 19.6 min), mean surgery duration was 31.7 min (range 15-65 min, SD 13.2 min), mean minimal SaO2 was 96.3% (range 89-100%, SD 4.0%) and mean peak pCO2 was 41.4 mmHg (range 31-50 mmHg, SD = 5.5 mmHg). No anesthesia- or surgery-related complications, adverse events or intra-operative difficulties were reported during or after any of the 15 procedures. In all cases, compared to HFJV, Evone® FCV ventilation allowed a superior visualization and working space during the surgical procedure. Conclusion: The Evone® FCV ventilation system provides excellent conditions in patients undergoing upper airway surgery, as it combines excellent accessibility and visibility of the operation site with safe and stable ventilation.
Collapse
Affiliation(s)
- Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Alexander Jans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Pierre Delaere
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| |
Collapse
|
17
|
Lozano-Zahonero S, Schneider M, Spassov S, Schumann S. A novel mechanical ventilator providing flow-controlled expiration for small animals. Lab Anim 2020; 54:568-575. [PMID: 32075500 DOI: 10.1177/0023677220906857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
For investigating the effects of mechanical ventilation on the respiratory system, experiments in small mammal models are used. However, conventional ventilators for small animals are usually limited to a specific ventilation mode, and in particular to passive expiration. Here, we present a computer-controlled research ventilator for small animals which provides conventional mechanical ventilation as well as new type ventilation profiles. Typical profiles of conventional mechanical ventilation, as well as flow-controlled expiration and sinusoidal ventilation profiles can be generated with our new ventilator. Flow control during expiration reduced the expiratory peak flow rate by 73% and increased the mean airway pressure by up to 1 mbar compared with conventional ventilation without increasing peak pressure and end-expiratory pressure. Our new ventilator for small animals allows for the application of various ventilation profiles. We could analyse the effects of applying conventional ventilation profiles, pressure-controlled ventilation and volume-controlled ventilation, as well as the novel flow-controlled ventilation profile. This new approach enables studying the mechanical properties of the respiratory system with an increased freedom for choosing independent ventilation parameters.
Collapse
Affiliation(s)
- Sara Lozano-Zahonero
- Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Schneider
- Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sashko Spassov
- Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
18
|
Weber J, Straka L, Borgmann S, Schmidt J, Wirth S, Schumann S. Flow-controlled ventilation (FCV) improves regional ventilation in obese patients - a randomized controlled crossover trial. BMC Anesthesiol 2020; 20:24. [PMID: 31992213 PMCID: PMC6986135 DOI: 10.1186/s12871-020-0944-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 01/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background In obese patients, high closing capacity and low functional residual capacity increase the risk for expiratory alveolar collapse. Constant expiratory flow, as provided by the new flow-controlled ventilation (FCV) mode, was shown to improve lung recruitment. We hypothesized that lung aeration and respiratory mechanics improve in obese patients during FCV. Methods We compared FCV and volume-controlled (VCV) ventilation in 23 obese patients in a randomized crossover setting. Starting with baseline measurements, ventilation settings were kept identical except for the ventilation mode related differences (VCV: inspiration to expiration ratio 1:2 with passive expiration, FCV: inspiration to expiration ratio 1:1 with active, linearized expiration). Primary endpoint of the study was the change of end-expiratory lung volume compared to baseline ventilation. Secondary endpoints were the change of mean lung volume, respiratory mechanics and hemodynamic variables. Results The loss of end-expiratory lung volume and mean lung volume compared to baseline was lower during FCV compared to VCV (end-expiratory lung volume: FCV, − 126 ± 207 ml; VCV, − 316 ± 254 ml; p < 0.001, mean lung volume: FCV, − 108.2 ± 198.6 ml; VCV, − 315.8 ± 252.1 ml; p < 0.001) and at comparable plateau pressure (baseline, 19.6 ± 3.7; VCV, 20.2 ± 3.4; FCV, 20.2 ± 3.8 cmH2O; p = 0.441), mean tracheal pressure was higher (baseline, 13.1 ± 1.1; VCV, 12.9 ± 1.2; FCV, 14.8 ± 2.2 cmH2O; p < 0.001). All other respiratory and hemodynamic variables were comparable between the ventilation modes. Conclusions This study demonstrates that, compared to VCV, FCV improves regional ventilation distribution of the lung at comparable PEEP, tidal volume, PPlat and ventilation frequency. The increase in end-expiratory lung volume during FCV was probably caused by the increased mean tracheal pressure which can be attributed to the linearized expiratory pressure decline. Trial registration German Clinical Trials Register: DRKS00014925. Registered 12 July 2018.
Collapse
Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Leonie Straka
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Silke Borgmann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
19
|
Schumann S, Berger N, Lozano-Zahonero S, Wirth S. Flow controlled expiration does not impair pedal power during physical exercise on a bicycle ergometer. Respir Physiol Neurobiol 2020; 271:103303. [DOI: 10.1016/j.resp.2019.103303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/06/2019] [Accepted: 09/20/2019] [Indexed: 10/26/2022]
|
20
|
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Anesthesia is increasingly common in elderly and overweight patients and prompted the current study to explore mechanisms of age- and weight-dependent worsening of arterial oxygen tension (Pao2).
Methods
This is a primary analysis of pooled data in patients with (1) American Society of Anesthesiologists (ASA) classification of 1; (2) normal forced vital capacity; (3) preoxygenation with an inspired oxygen fraction (Fio2) more than 0.8 and ventilated with Fio2 0.3 to 0.4; (4) measurements done during anesthesia before surgery. Eighty patients (21 women and 59 men, aged 19 to 69 yr, body mass index up to 30 kg/m2) were studied with multiple inert gas elimination technique to assess shunt and perfusion of poorly ventilated regions (low ventilation/perfusion ratio []) and computed tomography to assess atelectasis.
Results
Pao2/Fio2 was lower during anesthesia than awake (368; 291 to 470 [median; quartiles] vs. 441; 397 to 462 mm Hg; P = 0.003) and fell with increasing age and body mass index. Log shunt was best related to a quadratic function of age with largest shunt at 45 yr (r2 =0.17, P = 0.001). Log shunt was linearly related to body mass index (r2 = 0.15, P < 0.001). A multiple regression analysis including age, age2, and body mass index strengthened the association further (r2 = 0.27). Shunt was highly associated to atelectasis (r2 = 0.58, P < 0.001). Log low showed a linear relation to age (r2 = 0.14, P = 0.001).
Conclusions
Pao2/Fio2 ratio was impaired during anesthesia, and the impairment increased with age and body mass index. Shunt was related to atelectasis and was a more important cause of oxygenation impairment in middle-aged patients, whereas low, likely caused by airway closure, was more important in elderly patients. Shunt but not low increased with increasing body mass index. Thus, increasing age and body mass index impaired gas exchange by different mechanisms during anesthesia.
Collapse
|
21
|
Ventilation-Like Mechanical Strain Modulates the Inflammatory Response of BEAS2B Epithelial Cells. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:2769761. [PMID: 31320981 PMCID: PMC6607724 DOI: 10.1155/2019/2769761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/29/2019] [Accepted: 05/28/2019] [Indexed: 01/16/2023]
Abstract
Protective mechanical ventilation is aimed at preventing ventilator-induced lung injury while ensuring sufficient gas exchange. A new approach focuses on the temporal profile of the mechanical ventilation. We hypothesized that the temporal mechanical strain profile modulates inflammatory signalling. We applied cyclic strain with various temporal profiles to human bronchial epithelial cells (BEAS2B) and assessed proinflammatory response. The cells were subjected to sinusoidal, rectangular, or triangular strain profile and rectangular strain profile with prestrain set to 0, 25, 50, or 75% of the maximum stain, static strain, and strain resembling a mechanical ventilation-like profile with or without flow-controlled expiration. The BEAS2B response to mechanical load included altered mitochondrial activity, increased superoxide radical levels, NF-kappaB translocation, and release of interleukin-8. The response to strain was substantially modulated by the dynamics of the stimulation pattern. The rate of dynamic changes of the strain profile correlates with the degree of mechanical stress-induced cell response.
Collapse
|
22
|
|
23
|
Barnes T, Enk D. Ventilation for low dissipated energy achieved using flow control during both inspiration and expiration. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
24
|
Schmidt J, Wenzel C, Mahn M, Spassov S, Cristina Schmitz H, Borgmann S, Lin Z, Haberstroh J, Meckel S, Eiden S, Wirth S, Buerkle H, Schumann S. Improved lung recruitment and oxygenation during mandatory ventilation with a new expiratory ventilation assistance device: A controlled interventional trial in healthy pigs. Eur J Anaesthesiol 2018; 35:736-744. [PMID: 29734208 PMCID: PMC6133202 DOI: 10.1097/eja.0000000000000819] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND In contrast to conventional mandatory ventilation, a new ventilation mode, expiratory ventilation assistance (EVA), linearises the expiratory tracheal pressure decline. OBJECTIVE We hypothesised that due to a recruiting effect, linearised expiration oxygenates better than volume controlled ventilation (VCV). We compared the EVA with VCV mode with regard to gas exchange, ventilation volumes and pressures and lung aeration in a model of peri-operative mandatory ventilation in healthy pigs. DESIGN Controlled interventional trial. SETTING Animal operating facility at a university medical centre. ANIMALS A total of 16 German Landrace hybrid pigs. INTERVENTION The lungs of anaesthetised pigs were ventilated with the EVA mode (n=9) or VCV (control, n=7) for 5 h with positive end-expiratory pressure of 5 cmH2O and tidal volume of 8 ml kg. The respiratory rate was adjusted for a target end-tidal CO2 of 4.7 to 6 kPa. MAIN OUTCOME MEASURES Tracheal pressure, minute volume and arterial blood gases were recorded repeatedly. Computed thoracic tomography was performed to quantify the percentages of normally and poorly aerated lung tissue. RESULTS Two animals in the EVA group were excluded due to unstable ventilation (n=1) or unstable FiO2 delivery (n=1). Mean tracheal pressure and PaO2 were higher in the EVA group compared with control (mean tracheal pressure: 11.6 ± 0.4 versus 9.0 ± 0.3 cmH2O, P < 0.001 and PaO2: 19.2 ± 0.7 versus 17.5 ± 0.4 kPa, P = 0.002) with comparable peak inspiratory tracheal pressure (18.3 ± 0.9 versus 18.0 ± 1.2 cmH2O, P > 0.99). Minute volume was lower in the EVA group compared with control (5.5 ± 0.2 versus 7.0 ± 1.0 l min, P = 0.02) with normoventilation in both groups (PaCO2 5.4 ± 0.3 versus 5.5 ± 0.3 kPa, P > 0.99). In the EVA group, the percentage of normally aerated lung tissue was higher (81.0 ± 3.6 versus 75.8 ± 3.0%, P = 0.017) and of poorly aerated lung tissue lower (9.5 ± 3.3 versus 15.7 ± 3.5%, P = 0.002) compared with control. CONCLUSION EVA ventilation improves lung aeration via elevated mean tracheal pressure and consequently improves arterial oxygenation at unaltered positive end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP). These findings suggest the EVA mode is a new approach for protective lung ventilation.
Collapse
Affiliation(s)
- Johannes Schmidt
- From the Department of Anesthesiology and Critical Care (JS, CW, MM, SS, HCS, SB, ZL, SW, HB, SS), Experimental Surgery, Centre for Experimental Models and Transgenic Service (JH) and Department of Neuroradiology (SM, SE), Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Borgmann S, Schmidt J, Goebel U, Haberstroh J, Guttmann J, Schumann S. Dorsal recruitment with flow-controlled expiration (FLEX): an experimental study in mechanically ventilated lung-healthy and lung-injured pigs. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:245. [PMID: 30268138 PMCID: PMC6162883 DOI: 10.1186/s13054-018-2168-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 08/26/2018] [Indexed: 12/22/2022]
Abstract
Background Concepts for optimizing mechanical ventilation focus mainly on modifying the inspiratory phase. We propose flow-controlled expiration (FLEX) as an additional means for lung protective ventilation and hypothesize that it is capable of recruiting dependent areas of the lungs. This study investigates potential recruiting effects of FLEX using models of mechanically ventilated pigs before and after induction of lung injury with oleic acid. Methods Seven pigs in the supine position were ventilated with tidal volume 8 ml·kg− 1 and positive end-expiratory pressure (PEEP) set to maintain partial pressure of oxygen in arterial blood (paO2) at ≥ 60 mmHg and monitored with electrical impedance tomography (EIT). Two ventilation sequences were recorded - one before and one after induction of lung injury. Each sequence comprised 2 min of conventional volume-controlled ventilation (VCV), 2 min of VCV with FLEX and 1 min again of conventional VCV. Analysis of the EIT recordings comprised global and ventral and dorsal baseline levels of impedance curves, end-expiratory no-flow periods, tidal variation in ventral and dorsal areas, and regional ventilation delay index. Results With FLEX, the duration of the end-expiratory zero flow intervals was significantly shortened (VCV 1.4 ± 0.3 s; FLEX 0.7 ± 0.1 s, p < 0.001), functional residual capacity was significantly elevated in both conditions of the lungs (global: healthy, increase of 87 ± 12 ml, p < 0.001; injured, increase of 115 ± 44 ml, p < 0.001; ventral: healthy, increase of 64 ± 11 ml, p < 0.001; injured, increase of 83 ± 22 ml, p < 0.001; dorsal: healthy, increase of 23 ± 5 ml, p < 0.001; injured, increase of 32 ± 26 ml, p = 0.02), and ventilation was shifted from ventral to dorsal areas (dorsal increase: healthy, 1 ± 0.5%, p < 0.01; dorsal increase: injured, 6 ± 2%, p < 0.01), compared to conventional VCV. Recruiting effects of FLEX persisted during conventional VCV following FLEX ventilation mostly in the injured but also in the healthy lungs. Conclusions FLEX shifts regional ventilation towards dependent lung areas in healthy and in injured pig lungs. The recruiting capabilities of FLEX may be mainly responsible for lung-protective effects observed in an earlier study.
Collapse
Affiliation(s)
- Silke Borgmann
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany. .,Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joerg Haberstroh
- Experimental Surgery, Center for Experimental Models and Transgenic Service, Medical Center, University of Freiburg, Breisacher Str. 66, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Josef Guttmann
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
26
|
Hedenstierna G. Unstable Inflation Is Harmful and More Common Supine Than Prone. Am J Respir Crit Care Med 2018; 198:146-147. [DOI: 10.1164/rccm.201802-0313ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|