1
|
Liu Y, Cai X, Fang R, Peng S, Luo W, Du X. Future directions in ventilator-induced lung injury associated cognitive impairment: a new sight. Front Physiol 2023; 14:1308252. [PMID: 38164198 PMCID: PMC10757930 DOI: 10.3389/fphys.2023.1308252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024] Open
Abstract
Mechanical ventilation is a widely used short-term life support technique, but an accompanying adverse consequence can be pulmonary damage which is called ventilator-induced lung injury (VILI). Mechanical ventilation can potentially affect the central nervous system and lead to long-term cognitive impairment. In recent years, many studies revealed that VILI, as a common lung injury, may be involved in the central pathogenesis of cognitive impairment by inducing hypoxia, inflammation, and changes in neural pathways. In addition, VILI has received attention in affecting the treatment of cognitive impairment and provides new insights into individualized therapy. The combination of lung protective ventilation and drug therapy can overcome the inevitable problems of poor prognosis from a new perspective. In this review, we summarized VILI and non-VILI factors as risk factors for cognitive impairment and concluded the latest mechanisms. Moreover, we retrospectively explored the role of improving VILI in cognitive impairment treatment. This work contributes to a better understanding of the pathogenesis of VILI-induced cognitive impairment and may provide future direction for the treatment and prognosis of cognitive impairment.
Collapse
Affiliation(s)
- Yinuo Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Xintong Cai
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Ruiying Fang
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Shengliang Peng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wei Luo
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Du
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| |
Collapse
|
2
|
Dilday J, Leon D, Kuza CM. A review of the utility of high-frequency oscillatory ventilation in burn and trauma ICU patients. Curr Opin Anaesthesiol 2023; 36:126-131. [PMID: 36729001 DOI: 10.1097/aco.0000000000001228] [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: 02/03/2023]
Abstract
PURPOSE OF REVIEW The purpose was to examine the utility of high-frequency oscillatory ventilation (HFOV) in trauma and burn ICU patients who require mechanical ventilation, and provide recommendations on its use. RECENT FINDINGS HFOV may be beneficial in burn patients with smoke inhalation injury with or without acute lung injury/acute respiratory distress syndrome (ARDS), as it improves oxygenation and minimizes ventilator-induced lung injury. It also may have a role in improving oxygenation in trauma patients with blast lung injury, pulmonary contusions, pneumothorax with massive air leak, and ARDS; however, the mortality benefit is unknown. SUMMARY Although some studies have shown promise and improved outcomes associated with HFOV, we recommend its use as a rescue modality for patients who have failed conventional ventilation.
Collapse
Affiliation(s)
- Joshua Dilday
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - David Leon
- Department of Emergency Medicine, Department of Anesthesia & Critical Care Medicine
| | | |
Collapse
|
3
|
Miller AG, Tan HL, Smith BJ, Rotta AT, Lee JH. The Physiological Basis of High-Frequency Oscillatory Ventilation and Current Evidence in Adults and Children: A Narrative Review. Front Physiol 2022; 13:813478. [PMID: 35557962 PMCID: PMC9087180 DOI: 10.3389/fphys.2022.813478] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/08/2022] [Indexed: 12/12/2022] Open
Abstract
High-frequency oscillatory ventilation (HFOV) is a type of invasive mechanical ventilation that employs supra-physiologic respiratory rates and low tidal volumes (VT) that approximate the anatomic deadspace. During HFOV, mean airway pressure is set and gas is then displaced towards and away from the patient through a piston. Carbon dioxide (CO2) is cleared based on the power (amplitude) setting and frequency, with lower frequencies resulting in higher VT and CO2 clearance. Airway pressure amplitude is significantly attenuated throughout the respiratory system and mechanical strain and stress on the alveoli are theoretically minimized. HFOV has been purported as a form of lung protective ventilation that minimizes volutrauma, atelectrauma, and biotrauma. Following two large randomized controlled trials showing no benefit and harm, respectively, HFOV has largely been abandoned in adults with ARDS. A multi-center clinical trial in children is ongoing. This article aims to review the physiologic rationale for the use of HFOV in patients with acute respiratory failure, summarize relevant bench and animal models, and discuss the potential use of HFOV as a primary and rescue mode in adults and children with severe respiratory failure.
Collapse
Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Respiratory Care Services, Durham, NC, United States
| | - Herng Lee Tan
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore
| | - Brian J Smith
- University of California, Davis, Respiratory Care Services, Sacramento, CA, United States
| | - Alexandre T Rotta
- Duke University Medical Center, Division of Pediatric Critical Care Medicine, Durham, NC, United States
| | - Jan Hau Lee
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| |
Collapse
|
4
|
Terzi N, Guérin C. Optimizing Mechanical Ventilation in Refractory ARDS. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8740657 DOI: 10.1016/b978-0-12-801238-3.11480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation in patients with refractory acute respiratory distress syndrome (ARDS) must provide lung protection. This is achieved by limiting tidal volume (VT) and plateau pressure (Pplat). With the current evidence available VT should be initially set around 6 mL per kg predicted body weight and PPlat maintained below 30 cmH2O and monitored. Positive end-expiratory pressure (PEEP), which also contributes to lung protection, should be set > 12 cmH2O, provided oxygenation gets improved, with same Pplat target. Recruitment maneuvers should be used with caution avoiding higher PEEP. Neuromuscular blockade should be started and prone position performed for sessions longer than 16 h. High frequency oscillation ventilation should be used in expert centers only if previous management failed to improve oxygenation.
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Junqueira FMD, Nadal JAH, Brandão MB, Nogueira RJN, de Souza TH. High-frequency oscillatory ventilation in children: A systematic review and meta-analysis. Pediatr Pulmonol 2021; 56:1872-1888. [PMID: 33902159 DOI: 10.1002/ppul.25428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/01/2021] [Accepted: 04/11/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND High-frequency oscillatory ventilation (HFOV) is an alternative mechanical ventilation mode proposed to reduce ventilator-induced lung injuries and improve clinical outcomes. The aim of this study was to determine the effects of HFOV compared to conventional mechanical ventilation (CMV) when used in children with hypoxemic respiratory failure. METHODS The literature search was conducted to identify all studies published before December 2020. Eligible studies included a population aged between 28 days and 18 years old, presented original data from randomized controlled trials (RCTs) or observational studies, compared the use of HFOV with CMV. Meta-analyses of the pooled data were performed by using random-effects models with inverse-variance weighting. RESULTS A total of 11 studies (2605 cases) were included, most of them evaluating patients with acute respiratory distress syndrome. The mean age of participants was 8.2 months and the mean oxygenation index of those included in the RCTs was 24.4. The effect of HFOV on mortality was not significant, and clinically significant harm or benefit could not be excluded (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.72 to 1.20). No significant difference between groups was found in duration of mechanical ventilation (-2.23; 95% CI, -5.07 to 0.61), treatment failure (RR, 0.28; 95% CI, 0.08 to 1.02), and occurrence of barotrauma (RR, 0.88; 95% CI, 0.39 to 1.99). CONCLUSION The scarce evidence currently available does not allow us to conclude that HFOV has advantages over CMV and further studies are needed to clarify its role in the treatment of acute hypoxemic respiratory failure in children.
Collapse
Affiliation(s)
- Fernanda M D Junqueira
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - José A H Nadal
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Marcelo B Brandão
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Roberto J N Nogueira
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil.,Department of Pediatrics, School of Medicine São Leopoldo Mandic, Campinas, São Paulo, Brazil
| | - Tiago H de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| |
Collapse
|
7
|
Gattinoni L, Quintel M, Marini JJ. "Less is More" in mechanical ventilation. Intensive Care Med 2020; 46:780-782. [PMID: 32162029 PMCID: PMC7103002 DOI: 10.1007/s00134-020-05981-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/20/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Luciano Gattinoni
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany.
| | - Michael Quintel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - John J Marini
- University of Minnesota and Regions Hospital, Minneapolis/St. Paul, MN, USA
| |
Collapse
|
8
|
Liu S, Zhao Z, Tan L, Wang L, Möller K, Frerichs I, Yu T, Huang Y, Pan C, Yang Y, Qiu H. Optimal mean airway pressure during high-frequency oscillatory ventilation in an experimental model of acute respiratory distress syndrome: EIT-based method. Ann Intensive Care 2020; 10:31. [PMID: 32144514 PMCID: PMC7060304 DOI: 10.1186/s13613-020-0647-z] [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: 01/28/2019] [Accepted: 02/26/2020] [Indexed: 12/26/2022] Open
Abstract
Background High-frequency oscillatory ventilation (HFOV) may theoretically provide lung protective ventilation. The negative clinical results may be due to inadequate mean airway pressure (mPaw) settings in HFOV. Our objective was to evaluate the air distribution, ventilatory and hemodynamic effects of individual mPaw titration during HFOV in ARDS animal based on oxygenation and electrical impedance tomography (EIT). Methods ARDS was introduced with repeated bronchoalveolar lavage followed by injurious mechanical ventilation in ten healthy male pigs (51.2 ± 1.9 kg). Settings of HFOV were 9 Hz (respiratory frequency), 33% (inspiratory time) and 70 cmH2O (∆pressure). After lung recruitment, the mPaw was reduced in steps of 3 cmH2O every 6 min. Hemodynamics and blood gases were obtained in each step. Regional ventilation distribution was determined with EIT. Results PaO2/FiO2 decreased significantly during the mPaw decremental phase (p < 0.001). Lung overdistended regions decreased, while recruitable regions increased as mPaw decreased. The optimal mPaw with respect to PaO2/FiO2 was 21 (18.0–21.0) cmH2O, that is comparable to EIT-based center of ventilation (EIT-CoV) and EIT-collapse/over, 19.5 (15.0–21.0) and 19.5 (18.0–21.8), respectively (p = 0.07). EIT-CoV decreasing along with mPaw decrease revealed redistribution toward non-dependent regions. The individual mPaw titrated by EIT-based indices improved regional ventilation distribution with respect to overdistension and collapse (p = 0.035). Conclusion Our data suggested personalized optimal mPaw titration by EIT-based indices improves regional ventilation distribution and lung homogeneity during high-frequency oscillatory ventilation.
Collapse
Affiliation(s)
- Songqiao Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China
| | - Zhanqi Zhao
- Institute of Technical Medicine, Furtwangen University, Jakob-Kienzle Strasse 17, 78054, VS-Schwenningen, Germany.,Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Li Tan
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China.,Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Bejing, 100730, China
| | - Lihui Wang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Jakob-Kienzle Strasse 17, 78054, VS-Schwenningen, Germany
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein Campus Kiel, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Tao Yu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China
| | - Yingzi Huang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China
| | - Chun Pan
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Jiangsu Province, Nanjing, 210009, China.
| |
Collapse
|
9
|
Acute Respiratory Distress Syndrome in Cancer Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7123590 DOI: 10.1007/978-3-319-74588-6_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a heterogeneous form of acute, diffuse lung injury that is characterized by dysregulated inflammation, increased alveolar-capillary interface permeability, and non-cardiogenic pulmonary edema. In the general population, the incidence and mortality associated with ARDS over the last two decades have steadily declined in parallel with optimized approaches to pneumonia and other underlying causes of ARDS as well as increased utilization of multimodal treatment strategies that include lung-protective ventilation. In the cancer settings, significant declines in the incidence and mortality of ARDS over the past two decades have also been reported, although these rates remain significantly higher than those in the general population. Epidemiologic studies identify infection, including disseminated fungal pneumonias, as a major underlying cause of ARDS in the cancer setting. More than half of cancer patients who develop ARDS will not survive to hospital discharge. Those who do survive often face a protracted and often incomplete recovery, resulting in significant long-term physical, psychological, and cognitive sequelae. The residual organ dysfunction and poor functional status after ARDS may delay or preclude subsequent cancer treatments. As such, close collaboration between the critical care physicians and oncology team is essential in identifying and reversing the underlying causes and optimizing treatments for cancer patients with ARDS. This chapter reviews the diagnosis and common causes of ARDS in cancer and gives an update on the general management principles for cancer patients with ARDS in the ICU.
Collapse
|
10
|
Abstract
Acute respiratory distress syndrome continues to have high morbidity and mortality despite more than 50 years of research. The Berlin definition in 2012 established risk stratification based on degree of hypoxemia and the use of positive end-expiratory pressure. The use of prone positioning as a treatment modality has been studied for more than 40 years, with recent studies showing an improvement in oxygenation and decreased mortality. The studies also provide evidence to support the methodology and length of treatment time. Recent guidelines include several ventilator strategies for acute respiratory distress syndrome, including prone positioning. Protocols and procedures discussed in this article ensure successful prone repositioning and prevention of complications related to the procedure itself.
Collapse
Affiliation(s)
- Dannette A Mitchell
- Dannette A. Mitchell is Critical Care Clinical Nurse Specialist, Christiana Care Health Service, Wilmington Hospital, 501 W 14th Street, Intensive Care and Transitional Care Unit - 6S45, Wilmington, DE 19801 . Maureen A. Seckel is Lead Critical Care Clinical Nurse Specialist and Sepsis Leader, Christiana Care Health Service, Christiana Hospital, Newark, Delaware
| | - Maureen A Seckel
- Dannette A. Mitchell is Critical Care Clinical Nurse Specialist, Christiana Care Health Service, Wilmington Hospital, 501 W 14th Street, Intensive Care and Transitional Care Unit - 6S45, Wilmington, DE 19801 . Maureen A. Seckel is Lead Critical Care Clinical Nurse Specialist and Sepsis Leader, Christiana Care Health Service, Christiana Hospital, Newark, Delaware
| |
Collapse
|
11
|
Fioretto JR, Pires RB, Klefens SO, Kurokawa CS, Carpi MF, Bonatto RC, Moraes MA, Ronchi CF. Inflammatory lung injury in rabbits: effects of high-frequency oscillatory ventilation in the prone position. J Bras Pneumol 2019; 45:e20180067. [PMID: 30916116 PMCID: PMC6715165 DOI: 10.1590/1806-3713/e20180067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/12/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To compare the effects that prone and supine positioning during high-frequency oscillatory ventilation (HFOV) have on oxygenation and lung inflammation, histological injury, and oxidative stress in a rabbit model of acute lung injury (ALI). METHODS Thirty male Norfolk white rabbits were induced to ALI by tracheal saline lavage (30 mL/kg, 38°C). The injury was induced during conventional mechanical ventilation, and ALI was considered confirmed when a PaO2/FiO2 ratio < 100 mmHg was reached. Rabbits were randomly divided into two groups: HFOV in the supine position (SP group, n = 15); and HFOV with prone positioning (PP group, n = 15). For HFOV, the mean airway pressure was initially set at 16 cmH2O. At 30, 60, and 90 min after the start of the HFOV protocol, the mean airway pressure was reduced to 14, 12, and 10 cmH2O, respectively. At 120 min, the animals were returned to or remained in the supine position for an extra 30 min. We evaluated oxygenation indices and histological lung injury scores, as well as TNF-α levels in BAL fluid and lung tissue. RESULTS After ALI induction, all of the animals showed significant hypoxemia, decreased respiratory system compliance, decreased oxygenation, and increased mean airway pressure in comparison with the baseline values. There were no statistically significant differences between the two groups, at any of the time points evaluated, in terms of the PaO2 or oxygenation index. However, TNF-α levels in BAL fluid were significantly lower in the PP group than in the SP group, as were histological lung injury scores. CONCLUSIONS Prone positioning appears to attenuate inflammatory and histological lung injury during HFOV in rabbits with ALI.
Collapse
Affiliation(s)
- Jose Roberto Fioretto
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | | | - Susiane Oliveira Klefens
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Cilmery Suemi Kurokawa
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Mario Ferreira Carpi
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Rossano César Bonatto
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Marcos Aurélio Moraes
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
| | - Carlos Fernando Ronchi
- . Disciplina de Pediatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista - UNESP - Botucatu (SP) Brasil
- . Departamento de Fisioterapia, Universidade Federal de Uberlândia, Uberlândia (MG) Brasil
| |
Collapse
|
12
|
Moralesa D, Tapia P, Mercado P, Ortiz C. ¿QUÉ HEMOS APRENDIDO DE FALLA RESPIRATORIA CATASTRÓFICA? REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
13
|
Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Med 2018; 46:1820-1831. [PMID: 30247273 PMCID: PMC6277052 DOI: 10.1097/ccm.0000000000003406] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Despite decades of research, the acute respiratory distress syndrome remains associated with significant morbidity and mortality. This Concise Definitive Review provides a practical and evidence-based summary of treatments in addition to low tidal volume ventilation and their role in the management of severe respiratory failure in acute respiratory distress syndrome. DATA SOURCES We searched the PubMed database for clinical trials, observational studies, and review articles describing treatment adjuncts in acute respiratory distress syndrome patients, including high positive end-expiratory pressure strategies, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade, prone positioning, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, glucocorticoids, and renal replacement therapy. STUDY SELECTION AND DATA EXTRACTION Results were reviewed by the primary author in depth. Disputed findings and conclusions were then reviewed with the other authors until consensus was achieved. DATA SYNTHESIS Severe respiratory failure in acute respiratory distress syndrome may present with refractory hypoxemia, severe respiratory acidosis, or elevated plateau airway pressures despite lung-protective ventilation according to acute respiratory distress syndrome Network protocol. For severe hypoxemia, first-line treatment adjuncts include high positive end-expiratory pressure strategies, recruitment maneuvers, neuromuscular blockade, and prone positioning. For refractory acidosis, we recommend initial modest liberalization of tidal volumes, followed by neuromuscular blockade and prone positioning. For elevated plateau airway pressures, we suggest first decreasing tidal volumes, followed by neuromuscular blockade, modification of positive end-expiratory pressure, and prone positioning. Therapies such as inhaled pulmonary vasodilators, glucocorticoids, and renal replacement therapy have significantly less evidence in favor of their use and should be considered second line. Extracorporeal membrane oxygenation may be life-saving in selected patients with severe acute respiratory distress syndrome but should be used only when other alternatives have been applied. CONCLUSIONS Severe respiratory failure in acute respiratory distress syndrome often necessitates the use of treatment adjuncts. Evidence-based application of these therapies in acute respiratory distress syndrome remains a significant challenge. However, a rational stepwise approach with frequent monitoring for improvement or harm can be achieved.
Collapse
Affiliation(s)
- Vikram Fielding-Singh
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA
| | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Carolyn S. Calfee
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| |
Collapse
|
14
|
Abstract
IMPORTANCE Acute respiratory distress syndrome (ARDS) is a life-threatening form of respiratory failure that affects approximately 200 000 patients each year in the United States, resulting in nearly 75 000 deaths annually. Globally, ARDS accounts for 10% of intensive care unit admissions, representing more than 3 million patients with ARDS annually. OBJECTIVE To review advances in diagnosis and treatment of ARDS over the last 5 years. EVIDENCE REVIEW We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from 2012 to 2017 focusing on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines. Articles were identified for full text review with manual review of bibliographies generating additional references. FINDINGS After screening 1662 citations, 31 articles detailing major advances in the diagnosis or treatment of ARDS were selected. The Berlin definition proposed 3 categories of ARDS based on the severity of hypoxemia: mild (200 mm Hg<Pao2/Fio2≤300 mm Hg), moderate (100 mm Hg<Pao2/Fio2≤200 mm Hg), and severe (Pao2/Fio2 ≤100 mm Hg), along with explicit criteria related to timing of the syndrome's onset, origin of edema, and the chest radiograph findings. The Berlin definition has significantly greater predictive validity for mortality than the prior American-European Consensus Conference definition. Clinician interpretation of the origin of edema and chest radiograph criteria may be less reliable in making a diagnosis of ARDS. The cornerstone of management remains mechanical ventilation, with a goal to minimize ventilator-induced lung injury (VILI). Aspirin was not effective in preventing ARDS in patients at high-risk for the syndrome. Adjunctive interventions to further minimize VILI, such as prone positioning in patients with a Pao2/Fio2 ratio less than 150 mm Hg, were associated with a significant mortality benefit whereas others (eg, extracorporeal carbon dioxide removal) remain experimental. Pharmacologic therapies such as β2 agonists, statins, and keratinocyte growth factor, which targeted pathophysiologic alterations in ARDS, were not beneficial and demonstrated possible harm. Recent guidelines on mechanical ventilation in ARDS provide evidence-based recommendations related to 6 interventions, including low tidal volume and inspiratory pressure ventilation, prone positioning, high-frequency oscillatory ventilation, higher vs lower positive end-expiratory pressure, lung recruitment maneuvers, and extracorporeal membrane oxygenation. CONCLUSIONS AND RELEVANCE The Berlin definition of acute respiratory distress syndrome addressed limitations of the American-European Consensus Conference definition, but poor reliability of some criteria may contribute to underrecognition by clinicians. No pharmacologic treatments aimed at the underlying pathology have been shown to be effective, and management remains supportive with lung-protective mechanical ventilation. Guidelines on mechanical ventilation in patients with acute respiratory distress syndrome can assist clinicians in delivering evidence-based interventions that may lead to improved outcomes.
Collapse
Affiliation(s)
- Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| |
Collapse
|