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Schortgen F, Tabra Osorio C, Demiri S, Dzogang C, Jung C, Lavenu A, Lecarpentier E. Management of pregnant women in tertiary maternity hospitals in the Paris area referred to the intensive care unit for acute hypoxaemic respiratory failure related to SARS-CoV-2: which practices for which outcomes? Ann Intensive Care 2024; 14:94. [PMID: 38890164 DOI: 10.1186/s13613-024-01313-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Evidence for the management of pregnant women with acute hypoxaemic respiratory failure (AHRF) is currently lacking. The likelihood of avoiding intubation and the risks of continuing the pregnancy under invasive ventilation remain undetermined. We report the management and outcome of pregnant women with pneumonia related to SARS-CoV-2 admitted to the ICU of tertiary maternity hospitals of the Paris area. METHODS We studied a retrospective cohort of pregnant women admitted to 15 ICUs with AHRF related to SARS-CoV-2 defined by the need for O2 ≥ 6 L/min, high-flow nasal oxygen (HFNO), non-invasive or invasive ventilation. Trajectories were assessed to determine the need for intubation and the possibility of continuing the pregnancy on invasive ventilation. RESULTS One hundred and seven pregnant women, 34 (IQR: 30-38) years old, at a gestational age of 27 (IQR: 25-30) weeks were included. Obesity was present in 37/107. Intubation was required in 47/107 (44%). Intubation rate according to respiratory support was 14/19 (74%) for standard O2, 17/36 (47%) for non-invasive ventilation and 16/52 (31%) for HFNO. Factors significantly associated with intubation were pulmonary co-infection: adjusted OR: 3.38 (95% CI 1.31-9.21), HFNO: 0.11 (0.02-0.41) and non-invasive ventilation: 0.20 (0.04-0.80). Forty-six (43%) women were delivered during ICU stay, 39/46 (85%) for maternal pulmonary worsening, 41/46 (89%) at a preterm stage. Fourteen non-intubated women were delivered under regional anaesthesia; 9/14 ultimately required emergency intubation. Four different trajectories were identified: 19 women were delivered within 2 days after ICU admission while not intubated (12 required prolonged intubation), 23 women were delivered within 2 days after intubation, in 11 intubated women pregnancy was continued allowing delivery after ICU discharge in 8/11, 54 women were never intubated (53 were delivered after discharge). Timing of delivery after intubation was mainly dictated by gestational age. One maternal death and one foetal death were recorded. CONCLUSION In pregnant women with AHRF related to SARS-CoV-2, HFNO and non-invasive mechanical ventilation were associated with a reduced rate of intubation, while pulmonary co-infection was associated with an increased rate. Pregnancy was continued on invasive mechanical ventilation in one-third of intubated women. Study registration retrospectively registered in ClinicalTrials (NCT05193526).
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Affiliation(s)
- Frédérique Schortgen
- Department of Adult Intensive Care, Service de médecine intensive réanimation, Centre Hospitalier Intercommunal de Créteil, 40 avenue de Verdun, 94000, Créteil, France.
| | - Cecilia Tabra Osorio
- Department of Adult Intensive Care, Service de médecine intensive réanimation, Centre Hospitalier Intercommunal de Créteil, 40 avenue de Verdun, 94000, Créteil, France
| | - Suela Demiri
- Department of Adult Intensive Care, Service de médecine intensive réanimation, Centre Hospitalier Intercommunal de Créteil, 40 avenue de Verdun, 94000, Créteil, France
| | - Cléo Dzogang
- Department of Obstetrics and Gynaecology, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Camille Jung
- Research Centre, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- Université Paris Est Créteil (UPEC), Créteil, France
| | - Audrey Lavenu
- IRMAR, Mathematical Research Institute, University of Rennes, Rennes, France
- Clinical Investigation Centre, INSERM CIC 1414, University of Rennes, Rennes, France
| | - Edouard Lecarpentier
- Department of Obstetrics and Gynaecology, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- Université Paris Est Créteil (UPEC), Créteil, France
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Hassan A, Takacs S, Orde S, Alison JA, Huang S, Milross MA. Clinical application of intrapulmonary percussive ventilation: A scoping review. Hong Kong Physiother J 2024; 44:39-56. [PMID: 38577395 PMCID: PMC10988273 DOI: 10.1142/s1013702524500033] [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: 02/28/2023] [Accepted: 08/23/2023] [Indexed: 04/06/2024] Open
Abstract
Impaired respiratory function secondary to acute or chronic respiratory disease poses a significant clinical and healthcare burden. Intrapulmonary percussive ventilation (IPV) is used in various clinical settings to treat excessive airway secretions, pulmonary atelectasis, and impaired gas exchange. Despite IPV's wide use, there is a lack of clinical guidance on IPV application which may lead to inconsistency in clinical practice. This scoping review aimed to summarise the clinical application methods and dosage of IPV used by clinicians and researchers to provide guidance. A two-staged systematic search was conducted to retrieve studies that used IPV in inpatient and outpatient settings. MEDLINE, EMBASE, CINAHL, Scopus, and Google scholar were searched from January 1979 till 2022. Studies with patients aged ≥16 years and published in any language were included. Two reviewers independently screened the title and abstract, reviewed full text articles, and extracted data. Search yielded 514 studies. After removing duplicates and irrelevant studies, 25 studies with 905 participants met the inclusion criteria. This is the first scoping review to summarise IPV application methods and dosages from the available studies in intensive care unit (ICU), acute inpatient (non-ICU), and outpatient settings. Some variations in clinical applications and prescribed dosages of IPV were noted. Despite variations, common trends in clinical application and prescription of IPV dosages were observed and summarised to assist clinicians with IPV intervention. Although an evidence-based clinical guideline could not be provided, this review provides detailed information on IPV application and dosages in order to provide clinical guidance and lays a foundation towards developing a clinical practice guideline in the future.
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Affiliation(s)
- Anwar Hassan
- Physiotherapy Department, Nepean Hospital, Nepean Blue Mountains Local Health District Kingswood, NSW, Australia
- Intensive Care Unit, Nepean Hospital, Nepean Blue Mountains Local Health District Kingswood, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Sidney Takacs
- Physiotherapy Department, Nepean Hospital, Nepean Blue Mountains Local Health District Kingswood, NSW, Australia
| | - Sam Orde
- Intensive Care Unit, Nepean Hospital, Nepean Blue Mountains Local Health District Kingswood, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Jennifer A Alison
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Allied Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Stephen Huang
- Intensive Care Unit, Nepean Hospital, Nepean Blue Mountains Local Health District Kingswood, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Maree A Milross
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
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Kim EJ, Kim H, Park Y. Enhancing Safety in Tumescent Liposuction: Managing Sedation-Related Respiratory Issues and Serious Complications Under Deep Sedation with the Propofol-Ketamine Protocol. Aesthetic Plast Surg 2024; 48:1964-1976. [PMID: 38536431 DOI: 10.1007/s00266-024-03963-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/16/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Over the past 4 years, aesthetic surgery, notably liposuction, has substantially increased. Tumescent liposuction, a popular technique, has two variants-true tumescent liposuction (TTL) and semi-tumescent liposuction. While TTL reduces risks, it has limitations. There is no literature reported on semi-tumescent liposuction under deep sedation using the propofol-ketamine protocol, which is proposed as a potentially safe alternative. METHODS The retrospective analysis covered 8 years and included 3094 patients performed for tumescent liposuction under deep sedation, utilizing the propofol-ketamine protocol. The evaluation of patient safety involved an examination of potential adverse events with a specific focus on respiratory issues related to sedation, including instances of mask ventilation. RESULTS Among the 3094 cases, no fatalities were recorded. Noteworthy events included 43 mask ventilation instances, primarily occurring in the initial 10 min. Twelve cases experienced surgery cancellation due to various factors, including respiratory issues. Three patients were transferred to upper-level hospitals, while another three required blood transfusions. Vigilant management prevented significant complications, and other adverse events like venous thromboembolism (VTE), fat embolism, severe lidocaine toxicity, and so on were not observed. CONCLUSIONS The analysis of 3094 tumescent liposuction cases highlighted the overall safety profile of the propofol-ketamine protocol under deep sedation. The scarcity of severe complications underscores its viability. The study emphasizes the significance of thorough preoperative assessments, careful patient selection, and awareness of potential complications. Prompt interventions, particularly in addressing sedation-related respiratory issues, further contribute to positive outcomes for patients. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Eun Ju Kim
- Department of Chemistry Education, Daegu University, Gyeongsan-si, Gyeongbuk, 38453, South Korea
| | - Hyunju Kim
- Liposuction Center, 365mc Hospital, Busanjin-gu, Busan, 47286, South Korea.
| | - Younchan Park
- Liposuction Center, 365mc Hospital, Busanjin-gu, Busan, 47286, South Korea
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Rodrigues PSM, Shimano MM, de Oliveira E, Kawamura FM, Silveira AF, José Luvizutto G, de Souza LAPS. Adaptation and clinical application of assistive device chair for bedside sitting in acute stroke phase: two case reports. Disabil Rehabil Assist Technol 2024; 19:1272-1278. [PMID: 36630593 DOI: 10.1080/17483107.2023.2166600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/16/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
PURPOSE This report presents the adaptation of an assistive device chair for bedside sitting and its application in two patients with trunk control impairment in the acute stroke phase. MATERIALS AND METHODS The device was built with polyvinylchloride (PVC) pipes and designed by a team of mechanical engineers and physiotherapists to maintain a prolonged sitting position with less demand from therapists. To test the device, two patients were followed up during the acute phase of stroke. Both patients underwent an early mobilization program (30 min, twice a day, for three days) with an assistive device chair for bedside sitting. Patients were evaluated using the National Institutes of Health Stroke Scale (NIHSS), Trunk Impairment Scale (TIS), and International Classification of Functioning, Disability, and Health (ICF) checklist (b: body function; d: activity and participation). RESULTS The adaptations generated the following equipment: 1) foldable, 2) three levels of backrest inclination, and 3) a safety anterior support or an activity table. Both patients showed clinical improvement after the intervention period, with NIHSS score reduction, TIS improvement, and greater functionality and independence on the ICF framework. CONCLUSION The equipment with adaptations seems to be functional, easy to handle, and can potentially contribute to clinical and functional improvements in patients with trunk control deficits after stroke.
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Affiliation(s)
| | - Marcos Massao Shimano
- Department of Mechanical Engineering, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Edimar de Oliveira
- Student of the Mechanical Engineering, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Fábio Masao Kawamura
- Student of the Mechanical Engineering, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Ana Flávia Silveira
- Doctorate Student in Physiotherapy, Federal University of São Carlos, São Carlos, Brazil
| | - Gustavo José Luvizutto
- Department of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Brazil
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Vaidy A, O'Corragain O, Vaidya A. Diagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit. Crit Care Clin 2024; 40:121-135. [PMID: 37973349 DOI: 10.1016/j.ccc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.
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Affiliation(s)
- Anika Vaidy
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | | | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Division of Cardiology, Temple University Hospital, 9th floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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Zhao DF, Xue L, Zhou XS, Jin WY, Zhou YJ, Tong SM, Wang PF, Li YX, Piro R, Qiao HM, Yu GX, Su CY, Li BH. Importance of timing and training to implement awake prone positioning in patients with COVID-19: a single-center prospective observational study. J Thorac Dis 2023; 15:6858-6867. [PMID: 38249881 PMCID: PMC10797349 DOI: 10.21037/jtd-23-1441] [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: 09/13/2023] [Accepted: 11/10/2023] [Indexed: 01/23/2024]
Abstract
Background Awake prone positioning (APP) is broadly implemented in patients with severe acute respiratory syndrome coronavirus 2 related disease [coronavirus disease 2019 (COVID-19)] admitted to hospital with severe respiratory distress syndrome. This prospective observational study aimed to explore the factors influencing the implementation of APP in patients with acute respiratory failure due to COVID-19. Methods Patients with COVID-19, all hospitalized with positive X-ray findings and oxygen supplementation requirement, in the Respiratory Step-Down Unit of the Peking University Third Hospital between January 6th, 2023, and January 20th, 2023, were included in this study. Data regarding basic information, activities of daily living (ADLs) scores, oxygen therapy, vital signs, and duration of APP were collected to investigate the factors influencing prone positioning. Results Among the 134 patients included, 55.2% showed an improvement in oxygen saturation 1 hour after APP. Logistic regression revealed that the pre-APP heart rate (HR) [odds ratio (OR) =1.032; P=0.046] and peripheral oxygen saturation (SpO2) (OR =0.720; P<0.001) were the associated factors of the improvement in SpO2 after treatment. Multiple linear regression revealed that the ADL scores and pre-APP respiratory rate (RR) were the associated factors of the duration of prone positioning (P<0.01). The APP technical steering group effectively improved duration of APP. Conclusions Patients with low SpO2 and increased HR before treatment showed greater improvement in oxygen saturation. Patients with lower tolerance to ADL but lower RRs were those to demonstrate a longer duration of prone positioning. This is pointing towards establishing the most favorable time window for APP during the course of COVID-19: after the ADLs have already decreased, but before significant tachypnea has appeared.
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Affiliation(s)
- Dong-Fang Zhao
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Lei Xue
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Xiao-Shu Zhou
- Department of Nursing, Peking University Third Hospital, Beijing, China
| | - Wei-Yi Jin
- Department of Nursing, Peking University Third Hospital, Beijing, China
| | - Yu-Jie Zhou
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Su-Mei Tong
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Pan-Feng Wang
- Department of Tumor Radiotherapy, Peking University Third Hospital, Beijing, China
| | - Yu-Xuan Li
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Roberto Piro
- Pulmonology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Hong-Mei Qiao
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Gui-Xiang Yu
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Chun-Yan Su
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Bao-Hua Li
- Department of Nursing, Peking University Third Hospital, Beijing, China
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7
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Noe C, Rottmann FA, Bemtgen X, Supady A, Wengenmayer T, Staudacher DL. Dual lumen cannulation and mobilization of patients with venovenous extracorporeal membrane oxygenation. Artif Organs 2023; 47:1654-1662. [PMID: 37358935 DOI: 10.1111/aor.14604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Mobilization is important in longer courses in intensive care unit (ICU), typical for patients requiring venovenous extracorporeal membrane oxygenation (V-V ECMO). For patients supported with ECMO, especially out-of-bed mobilizations improve outcome. We hypothesized that utilization of a dual lumen cannula (DLC) for V-V ECMO would facilitate out-of-bed mobilization compared to single lumen cannulas (SLC). METHODS Retrospective single center registry study including all V-V ECMO patients cannulated between 10/2010 and 05/2021 for respiratory failure. RESULTS The registry included 355 V-V ECMO patients (median age 55.6 years, 31.8% female, 27.3% with preexisting pulmonary disease), 289/355 (81.4%) primary cannulated with DLC, and 66/355 (18.6%) using SLC. Both groups had similar pre-ECMO characteristics. The runtime of the first ECMO cannula was significantly longer in DLC compared to SLC (169 vs. 115 h, p = 0.015). The frequency of prone positioning during V-V ECMO was similar in both groups (38.4 vs. 34.8%, p = 0.673). There was no difference in in-bed mobilization (41.2 vs. 36.4%, for DLC and SLC, respectively, p = 0.491). Patients with DLC were more often mobilized out-of-bed (25.6 vs. 12.1%, OR 2.495 [95% CI 1.150 to 5.268], for DLC and SLC, respectively, p = 0.023). Hospital survival was similar in both groups (46.4 vs. 39.4%, for DLC and SLC, respectively, p = 0.339). CONCLUSION Patients cannulated with a dual lumen cannula for V-V ECMO support were significantly more often mobilized out-of-bed. Since mobilization is important in prolonged ICU courses typical for ECMO patients, this might be an important benefit. Other benefits of DLC were the longer runtime of the initial cannula set and fewer suction events.
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Affiliation(s)
- Christian Noe
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University of Freiburg Medical Center, University of Freiburg, Freiburg, Germany
| | - Felix A Rottmann
- Department of Medicine IV - Nephrology and Primary Care, Faculty of Medicine, University of Freiburg Medical Center, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg Medical Center, University of Freiburg, Freiburg, Germany
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University of Freiburg Medical Center, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University of Freiburg Medical Center, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University of Freiburg Medical Center, University of Freiburg, Freiburg, Germany
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Morais CCA, Alcala G, De Santis Santiago RR, Valsecchi C, Diaz E, Wanderley H, Fakhr BS, Di Fenza R, Gianni S, Foote S, Chang MG, Bittner EA, Carroll RW, Costa ELV, Amato MBP, Berra L. Pronation Reveals a Heterogeneous Response of Global and Regional Respiratory Mechanics in Patients With Acute Hypoxemic Respiratory Failure. Crit Care Explor 2023; 5:e0983. [PMID: 37795456 PMCID: PMC10547249 DOI: 10.1097/cce.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Experimental models suggest that prone position and positive end-expiratory pressure (PEEP) homogenize ventral-dorsal ventilation distribution and regional respiratory compliance. However, this response still needs confirmation on humans. Therefore, this study aimed to assess the changes in global and regional respiratory mechanics in supine and prone positions over a range of PEEP levels in acute respiratory distress syndrome (ARDS) patients. DESIGN A prospective cohort study. PATIENTS Twenty-two intubated patients with ARDS caused by COVID-19 pneumonia. INTERVENTIONS Electrical impedance tomography and esophageal manometry were applied during PEEP titrations from 20 cm H2O to 6 cm H2O in supine and prone positions. MEASUREMENTS Global respiratory system compliance (Crs), chest wall compliance, regional lung compliance, ventilation distribution in supine and prone positions. MAIN RESULTS Compared with supine position, the maximum level of Crs changed after prone position in 59% of ARDS patients (n = 13), of which the Crs decreased in 32% (n = 7) and increased in 27% (n = 6). To reach maximum Crs after pronation, PEEP was changed in 45% of the patients by at least 4 cm H2O. After pronation, the ventilation and compliance of the dorsal region did not consistently change in the entire sample of patients, increasing specifically in a subgroup of patients who showed a positive change in Crs when transitioning from supine to prone position. These combined changes in ventilation and compliance suggest dorsal recruitment postpronation. In addition, the subgroup with increased Crs postpronation demonstrated the most pronounced difference between dorsal and ventral ventilation distribution from supine to prone position (p = 0.01), indicating heterogeneous ventilation distribution in prone position. CONCLUSIONS Prone position modifies global respiratory compliance in most patients with ARDS. Only a subgroup of patients with a positive change in Crs postpronation presented a consistent improvement in dorsal ventilation and compliance. These data suggest that the response to pronation on global and regional mechanics can vary among ARDS patients, with some patients presenting more dorsal lung recruitment than others.
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Affiliation(s)
- Caio C A Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Roberta R De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Eduardo Diaz
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Hatus Wanderley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Sara Foote
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ryan W Carroll
- Division of Pediatric Critical Care, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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9
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Schellenberg CM, Lindholz M, Grunow JJ, Boie S, Bald A, Warner LO, Ulm B, Milnik A, Zickler D, Angermair S, Reißhauer A, Witzenrath M, Menk M, Balzer F, Ocker T, Weber-Carstens S, Schaller SJ. Mobilisation practices during the SARS-CoV-2 pandemic: A retrospective analysis (MobiCOVID). Anaesth Crit Care Pain Med 2023; 42:101255. [PMID: 37257753 PMCID: PMC10226277 DOI: 10.1016/j.accpm.2023.101255] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Corona Virus Disease 2019 (COVID-19) patients display risk factors for intensive care unit acquired weakness (ICUAW). The pandemic increased existing barriers to mobilisation. This study aimed to compare mobilisation practices in COVID-19 and non-COVID-19 patients. METHODS This retrospective cohort study was conducted at Charité-Universitätsmedizin Berlin, Germany, including adult patients admitted to one of 16 ICUs between March 2018, and November 2021. The effect of COVID-19 on mobilisation level and frequency, early mobilisation (EM) and time to active sitting position (ASP) was analysed. Subgroup analysis on COVID-19 patients and the ICU type influencing mobilisation practices was performed. Mobilisation entries were converted into the ICU mobility scale (IMS) using supervised machine learning. The groups were matched using 1:1 propensity score matching. RESULTS A total of 12,462 patients were included, receiving 59,415 mobilisations. After matching 611 COVID-19 and non-COVID-19 patients were analysed. They displayed no significant difference in mobilisation frequency (0.4 vs. 0.3, p = 0.7), maximum IMS (3 vs. 3; p = 0.17), EM (43.2% vs. 37.8%; p = 0.06) or time to ASP (HR 0.95; 95% CI: 0.82, 1.09; p = 0.44). Subgroup analysis showed that patients in surge ICUs, i.e., temporarily created ICUs for COVID-19 patients during the pandemic, more commonly received EM (53.9% vs. 39.8%; p = 0.03) and reached higher maximum IMS (4 vs. 3; p = 0.03) without difference in mobilisation frequency (0.5 vs. 0.3; p = 0.32) or time to ASP (HR 1.15; 95% CI: 0.85, 1.56; p = 0.36). CONCLUSION COVID-19 did not hinder mobilisation. Those treated in surge ICUs were more likely to receive EM and reached higher mobilisation levels.
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Affiliation(s)
- Clara M Schellenberg
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany
| | - Maximilian Lindholz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany
| | - Julius J Grunow
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany
| | - Sebastian Boie
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Annika Bald
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany
| | - Linus O Warner
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany
| | - Bernhard Ulm
- Technical University of Munich, School of Medicine, Department of Anesthesiology and Intensive Care, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University Hospital Ulm, Ulm, Germany
| | - Annette Milnik
- Research Platform Molecular and Cognitive Neurosciences (MCN), Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Daniel Zickler
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - Stefan Angermair
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine (CBF), Berlin, Germany
| | - Anett Reißhauer
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Rehabilitation Medicine, Berlin, Germany
| | - Martin Witzenrath
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Infectious Diseases, Pulmonary Medicine and Critical Care, Berlin, Germany; German Center for Lung Research (DZL), Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Felix Balzer
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Thomas Ocker
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany; Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Steffen Weber-Carstens
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine | CCM | CVK, Berlin, Germany; Technical University of Munich, School of Medicine, Department of Anesthesiology and Intensive Care, Munich, Germany.
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Meitner C, Feuerstein RA, Steele AM. Nursing strategies for the mechanically ventilated patient. Front Vet Sci 2023; 10:1145758. [PMID: 37576838 PMCID: PMC10421733 DOI: 10.3389/fvets.2023.1145758] [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: 01/16/2023] [Accepted: 06/19/2023] [Indexed: 08/15/2023] Open
Abstract
The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.
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Affiliation(s)
- Cassandra Meitner
- Department of Small Animal Clinical Medicine, Small Animal Emergency and Critical Care, University of Tennessee College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
| | - Rachel A. Feuerstein
- Department of Small Animal Clinical Medicine, Small Animal Emergency and Critical Care, University of Tennessee College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
| | - Andrea M. Steele
- Ontario Veterinary College, Health Sciences Centre, University of Guelph, Guelph, ON, Canada
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11
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Almazroea AH, Alharbi AH, Alawfi BA, Alsaedi BQ, Samman RS, Almohalwas MA. Does Good Nebulization Therapy in the Emergency Room Reduce the Need for Hospitalization in Asthmatic Children? Cureus 2023; 15:e41270. [PMID: 37533610 PMCID: PMC10391584 DOI: 10.7759/cureus.41270] [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] [Accepted: 06/30/2023] [Indexed: 08/04/2023] Open
Abstract
INTRODUCTION Asthma is a chronic inflammatory disorder characterized by obstruction, hyperresponsiveness, and inflammatory changes in the airways. The overall prevalence of asthma in Saudi Arabian children ranges from 8% to 25%. Studies have shown that children who did not respond adequately to treatment in the emergency room (ER) were admitted to hospital for additional treatment which increased the cost and risk of hospital-acquired infections. The quality of nebulization therapy is influenced by several factors such as the position, dose, oxygen flow rate, and duration of treatment. Objectives: In this study, we aimed to explore factors that affect nebulization therapy in ER and to assess the relation between nebulization technique in ER and hospital admission for asthmatic children, and these aims were achieved over the period from December 2021 to May 2023. METHODOLOGY An observational cross-sectional study was conducted in Maternity and Children Hospital (MCH) in Medina at the ER over the period from December 2021 to May 2023 for all children admitted to ER with asthma exacerbation. The sample size used to include patients in the study is 289 calculated using the Openepi website. Data were collected by observation and using medical records of the patients and analyzed using Statistical Package for Social Sciences (SPSS) version 26.0 (IBM Corp., Armonk, NY, USA). RESULTS The total number of the sample was 289 children ages between two to 14 years. Sixty-four percent (n=185) reported as their gender as male while 36% (n = 104) as female. The median age of the children was four years old (interquartile range [IQR] = 4), and their median weight was 15 kg (IQR = 8.15). Also, more than 83% of the patients has mild asthma, while 16.3% of the sample were diagnosed with moderate to severe asthma. Besides, 92.4% of the sample was discharged from a hospital, and 76.5% received an appropriate dose of nebulization. DISCUSSION After reviewing the results of the statistical analysis, the main findings were that the severity of asthma exacerbation was the most important factor influencing the outcome. It was found that 0.4% of patients with mild asthma were admitted to the hospital, compared to 44.7% of patients with moderate to severe asthma. CONCLUSION Our study assessed whether effective nebulization therapy in the ER will reduce the need for hospitalization in asthmatic children and the results indicate that the severity of asthma exacerbation was the most significant factor impacting hospital admission in asthmatic patients and influenced other factors of nebulization therapy. However, the other factors, such as the patient position, oxygen flow rate, and the dose of medications did not show any clinically significant impact on hospitalization rates.
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Affiliation(s)
| | - Ahmad H Alharbi
- Pediatric Emergency Medicine, Maternity and Children Hospital in Madinah, Al-Madinah Al-Munawwarah, SAU
| | - Bushra A Alawfi
- Pediatrics, Taibah University, Al-Madinah Al-Munawwarah, SAU
| | | | - Razan S Samman
- Pediatrics, Taibah University, Al-Madinah Al-Munawwarah, SAU
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Rampon GL, Simpson SQ, Agrawal R. Prone Positioning for Acute Hypoxemic Respiratory Failure and ARDS: A Review. Chest 2023; 163:332-340. [PMID: 36162482 DOI: 10.1016/j.chest.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 01/14/2023] Open
Abstract
Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years ago. Initially implemented clinically as an empiric therapy for refractory hypoxemia, multiple clinical trials were performed on the use of prone positioning in various respiratory conditions, cumulating in the landmark Proning Severe ARDS Patients trial, which demonstrated mortality benefit in patients with severe ARDS. After this trial and the corresponding meta-analysis, expert consensus and societal guidelines recommended the use of prone positioning for the management of severe ARDS. The ongoing COVID-19 pandemic has brought prone positioning to the forefront of medicine, including widespread implementation of prone positioning in awake, spontaneously breathing, nonintubated patients with acute hypoxemic respiratory failure. Multiple clinical trials now have been performed to investigate the safety and effectiveness of prone positioning in these patients and have enhanced our understanding of the effects of the prone position in respiratory failure. In this review, we discuss the physiologic features, clinical outcome data, practical considerations, and lingering questions of prone positioning.
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Affiliation(s)
- Garrett L Rampon
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Steven Q Simpson
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS.
| | - Ritwick Agrawal
- Pulmonary Critical Care and Sleep Medicine Section, Medical Care Line, Michael E. DeBakey Veteran Affairs Medical Center, Houston, TX; Pulmonary Critical Care and Sleep Medicine Section, Department of Medicine, Baylor College of Medicine, Houston, TX
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13
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Martinsson A, Houltz E, Wallinder A, Magnusson J, Lindgren S, Stenqvist O, Thorén A. Inspiratory and end-expiratory effects of lung recruitment in the prone position on dorsal lung aeration - new physiological insights in a secondary analysis of a randomised controlled study in post-cardiac surgery patients. BJA OPEN 2022; 4:100105. [PMID: 37588783 PMCID: PMC10430825 DOI: 10.1016/j.bjao.2022.100105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/20/2022] [Indexed: 08/18/2023]
Abstract
Background Cardiac surgery produces dorso-basal atelectasis and ventilation/perfusion mismatch, associated with infection and prolonged intensive care. A postoperative lung volume recruitment manoeuvre to decrease the degree of atelectasis is routine. In patients with severe respiratory failure, prone positioning and recruitment manoeuvres may increase survival, oxygenation, or both. We compared the effects of lung recruitment in prone vs supine positions on dorsal inspiratory and end-expiratory lung aeration. Methods In a prospective RCT, 30 post-cardiac surgery patients were randomly allocated to recruitment manoeuvres in the prone (n=15) or supine position (n=15). The primary endpoints were late dorsal inspiratory volume (arbitrary units [a.u.]) and left/right dorsal end-expiratory lung volume change (a.u.), prone vs supine after extubation, measured using electrical impedance tomography. Secondary outcomes included left/right dorsal inspiratory volumes (a.u.) and left/right dorsal end-expiratory lung volume change (a.u.) after prone recruitment and extubation. Results The last part of dorsal end-inspiratory volume after extubation was higher after prone (49.1 a.u.; 95% confidence interval [CI], 37.4-60.6) vs supine recruitment (24.2 a.u.; 95% CI, 18.4-29.6; P=0.024). Improvement in left dorsal end-expiratory lung volume after extubation was higher after prone (382 a.u.; 95% CI, 261-502) vs supine recruitment (-71 a.u., 95% CI, -140 to -2; n=15; P<0.001). After prone recruitment, left vs right predominant end-expiratory dorsal lung volume change disappeared after extubation. However, both left and right end-expiratory volumes were higher in the prone group, after extubation. Conclusions Recruitment in the prone position improves dorsal inspiratory and end-expiratory lung volumes after cardiac surgery. Clinical trial registration NCT03009331.
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Affiliation(s)
- Andreas Martinsson
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Erik Houltz
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Andreas Wallinder
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jesper Magnusson
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sophie Lindgren
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ola Stenqvist
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Anders Thorén
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Papi D, Montigiani G, Bucciardini L. How the work of respiratory physiotherapists changes the tracheostomy management and decannulation in a NICU department: an Italian experience. Monaldi Arch Chest Dis 2022; 93. [PMID: 36426898 DOI: 10.4081/monaldi.2022.2451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/25/2022] Open
Abstract
Tracheotomy is a clinical procedure that is often necessary though not without complications, hence the need for appropriate and timely decannulation. The inclusion of trained respiratory physiotherapists (RPT) in the staff and the use of shared protocols could help the team to manage the patient with tracheotomy cannula. The objective of this study was to describe the difference in the rate of decannulation and clinical outcomes of tracheostomized patients admitted to a NeuroIntensive Care Unit (NICU) team after the inclusion of a group of physiotherapists specialized in respiratory physiotherapy and a new phoniatric protocol. It is a 6-year retrospective study, in which two periods of 3 years each were compared: in the first period (P1: September 2013-August 2016) physiotherapists were called to treat NICU patients on a consultative basis (2 hours/day for 5 days a week); in the second period (P2: September 2016-August 2019) two full-time respiratory physiotherapists were present on the ward (7 hours/day, 6/7 days/week). In P2 period, a decannulation protocol was used. Patients who had undergone a tracheotomy procedure and who were alive at the time of discharge were retrospectively evaluated. We described the number of decannulations, the length of stay in NICU and decannulation time; the diagnosis of decannulated patients and the number of deaths. 928 total patients were analysed: 468 in P1, 460 in P2. Total length of stay or number of deaths did not change significantly between the two periods, while the number of decannulated patients before the discharge was higher in P2 143 (64%), compared with P1 79 (36%) p<0.001. More patients with neurological pathologies involving possible swallowing disorders, such as cerebral haemorrhage, head trauma and stroke, have been successfully decannulated in P2 than in P1 (120 patients in P2 vs 54 in P1). A multidisciplinary approach, including respiratory physiotherapist, dedicated to tracheostomy management, decannulation and early mobilization in NICU is safe, feasible and seems to improve the number of severe patients decannulated, even if no change was observed in NICU length of stay or deaths. Further studies must confirm our results in other ICU settings.
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Affiliation(s)
- Davide Papi
- NeuroIntensive Care Unit, Careggi University Hospital, Florence.
| | | | - Luca Bucciardini
- NeuroIntensive Care Unit, Careggi University Hospital, Florence.
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15
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Esophageal Pressure Measurement in Acute Hypercapnic Respiratory Failure Due to Severe COPD Exacerbation Requiring NIV-A Pilot Safety Study. J Clin Med 2022; 11:jcm11226810. [PMID: 36431287 PMCID: PMC9699291 DOI: 10.3390/jcm11226810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/06/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Esophageal pressure (Pes) measurements could optimise ventilator parameters in acute respiratory failure (ARF) patients requiring noninvasive ventilation (NIV). Consequently, the objectives of our study were to evaluate the safety and accuracy of applying a Pes measuring protocol in ARF patients with AECOPD under NIV in our respiratory intermediate care unit (RICU). An observational cohort study was undertaken. The negative inspiratory swing of Pes (ΔPes) was measured: in an upright/supine position in the presence/absence of NIV at D1 (day of admission), D3 (3rd day of NIV), and DoD (day of discharge). A digital filter for artefact removal was developed. We included 15 patients. The maximum values for ∆Pes were recorded at admission (mean ∆Pes 23.2 cm H2O) in the supine position. ∆Pes decreased from D1 to D3 (p < 0.05), the change being BMI-dependent (p < 0.01). The addition of NIV decreased ∆Pes at D1 and D3 (p < 0.01). The reduction of ∆Pes was more significant in the supine position at D1 (8.8 cm H2O, p < 0.01). Under NIV, ∆Pes values remained higher in the supine versus upright position. Therefore, the measurement of Pes in AECOPD patients requiring NIV can be safely done in an RICU. Under NIV, ∆Pes reduction is most significant within the first 24 h of admission.
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Selickman J, Marini JJ. Chest wall loading in the ICU: pushes, weights, and positions. Ann Intensive Care 2022; 12:103. [PMID: 36346532 PMCID: PMC9640797 DOI: 10.1186/s13613-022-01076-8] [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: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Clinicians monitor mechanical ventilatory support using airway pressures—primarily the plateau and driving pressure, which are considered by many to determine the safety of the applied tidal volume. These airway pressures are influenced not only by the ventilator prescription, but also by the mechanical properties of the respiratory system, which consists of the series-coupled lung and chest wall. Actively limiting chest wall expansion through external compression of the rib cage or abdomen is seldom performed in the ICU. Recent literature describing the respiratory mechanics of patients with late-stage, unresolving, ARDS, however, has raised awareness of the potential diagnostic (and perhaps therapeutic) value of this unfamiliar and somewhat counterintuitive practice. In these patients, interventions that reduce resting lung volume, such as loading the chest wall through application of external weights or manual pressure, or placing the torso in a more horizontal position, have unexpectedly improved tidal compliance of the lung and integrated respiratory system by reducing previously undetected end-tidal hyperinflation. In this interpretive review, we first describe underappreciated lung and chest wall interactions that are clinically relevant to both normal individuals and to the acutely ill who receive ventilatory support. We then apply these physiologic principles, in addition to published clinical observation, to illustrate the utility of chest wall modification for the purposes of detecting end-tidal hyperinflation in everyday practice.
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Affiliation(s)
- John Selickman
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| | - John J. Marini
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
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Stieglitz S, Mandal M, Bhakta P, Esquinas AM. Balancing the risks and benefits is essential for reaping the success of adding in-circuit bacterial filters. Eur Respir J 2022; 59:59/5/2200562. [PMID: 35589116 DOI: 10.1183/13993003.00562-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Sven Stieglitz
- Dept of Pneumology, Allergy, Sleep, and Intensive Care Medicine, Petrus Hospital Wuppertal, University of Witten-Herdecke, Wuppertal, Germany
| | - Mohanchandra Mandal
- Dept of Anaesthesiology, Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Pradipta Bhakta
- Dept of Anaesthesiology and Intensive Care, University Hospital Waterford, Waterford, Ireland
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Lippi L, de Sire A, D’Abrosca F, Polla B, Marotta N, Castello LM, Ammendolia A, Molinari C, Invernizzi M. Efficacy of Physiotherapy Interventions on Weaning in Mechanically Ventilated Critically Ill Patients: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:889218. [PMID: 35615094 PMCID: PMC9124783 DOI: 10.3389/fmed.2022.889218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/07/2022] [Indexed: 01/23/2023] Open
Abstract
Mechanical ventilation (MV) is currently considered a life-saving intervention. However, growing evidence highlighted that prolonged MV significantly affects functional outcomes and length of stay. In this scenario, controversies are still open about the optimal rehabilitation strategies for improving MV duration in ICU patients. In addition, the efficacy of physiotherapy interventions in critical ill patients without positive history of chronic respiratory conditions is still debated. Therefore, this systematic review of randomized controlled trials (RCTs) with meta-analysis aimed at characterizing the efficacy of a comprehensive physiotherapy intervention in critically ill patients. PubMed, Scopus, and Web of Science databases were systematically searched up to October 22, 2021 to identify RCTs assessing acute patients mechanical ventilated in ICU setting undergoing a rehabilitative intervention. The primary outcomes were MV duration, extubation, and weaning time. The secondary outcomes were weaning successful rate, respiratory function, ICU discharge rate and length of stay. Out of 2503 records, 12 studies were included in the present work. The meta-analysis performed in 6 RCTs showed a significant improvement in terms of MV duration (overall effect size: −3.23 days; 95% CI = −5.79, −0.67, p = 0.01; Z = 2.47) in patients treated with a comprehensive physiotherapy intervention including early mobilization, positioning, airway clearance techniques, lung expansion and respiratory muscle training. The quality assessment underlined 9 studies (75%) of good quality and 3 studies of fair quality according to the PEDro scale. In conclusion, our results provided previously unavailable data about the role of comprehensive physiotherapy intervention in improving MV duration in critical ill patients without chronic respiratory conditions. Further studies are needed to better characterize the optimal combination of rehabilitation strategies enhancing the improvements in critical ill patients without chronic respiratory disorders.
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Affiliation(s)
- Lorenzo Lippi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, Novara, Italy
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Alessandro de Sire
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro Magna Graecia, Catanzaro, Italy
| | - Francesco D’Abrosca
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, Novara, Italy
| | - Biagio Polla
- Cardiopulmonary Rehabilitation Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Nicola Marotta
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro Magna Graecia, Catanzaro, Italy
| | - Luigi Mario Castello
- Department of Translational Medicine, University of Eastern Piedmont “A. Avogadro”, Novara, Italy
- Unit of Internal Medicine, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Antonio Ammendolia
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro Magna Graecia, Catanzaro, Italy
| | - Claudio Molinari
- Laboratory of Physiology, Department for Sustainable Development and Ecological Transition, University of Eastern Piedmont “A. Avogadro”, Novara, Italy
| | - Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, Novara, Italy
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
- *Correspondence: Marco Invernizzi,
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Ray A, Nyogi SG, Mahajan V, Puri GD, Singla K. Effect of head-end of bed elevation on respiratory mechanics in mechanically ventilated patients with moderate-to-severe COVID-19 ARDS - A cohort study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022; 43:11-16. [PMID: 38620982 PMCID: PMC8913433 DOI: 10.1016/j.tacc.2022.02.005] [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: 11/30/2021] [Revised: 01/22/2022] [Accepted: 02/28/2022] [Indexed: 11/16/2022]
Abstract
Background Head-end elevation (HEE) is known to improve oxygenation and respiratory mechanics. In ARDS, poor lung compliance limits positive pressure ventilation causing delivery of inadequate minute ventilation (MVe). We observed that, in moderate-to-severe COVID-19 ARDS, the respiratory system compliance (Crs) reduces upon elevating the head-end of the bed, and vice-versa, which can be utilized to improve ventilation and avoid respiratory acidosis.We hypothesized that increasing the degree of HEE reduces Crs. Methods We included 20 consecutive mechanically ventilated, moderate-to-severe COVID-19 ARDS patients in this pilot study (CTRI/2021/06/034,182). The Crs, Mve and Rinsp were recorded at 0°, 10°, 20° and 30° HEE. Repeated measures ANOVA was used to determine significant differences in measurements with increasing degrees and repeated measures correlation (rmcorr) for correlation. Results Repeated measures ANOVA showed a significant difference (p < 0.0001) between values of Crs, MVe and Rinsp. Rmcorr showed a strong negative correlation between increasing degrees and Crs and Mve (r-0.87 [95% CI -0.79 to -0.92, p < 0.0001 and r-0.77 [95% CI -0.64 to -0.85, p < 0.0001]) and a moderate negative correlation for Rinsp (r-0.67; 95% CI -0.79 to -0.50; p < 0.0001). Conclusions Increasing degree of HEE reduces compliance in moderate-to-severe COVID-19 ARDS. Reducing HEE may optimize ventilation and mitigate ventilator induced lung injury.
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Affiliation(s)
- Ananya Ray
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhrashis Guha Nyogi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Mahajan
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Karan Singla
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Liang M, Chen X. Differential Prognostic Analysis of Higher and Lower PEEP in ARDS Patients: Systematic Review and Meta-Analysis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:5399416. [PMID: 35356616 PMCID: PMC8959975 DOI: 10.1155/2022/5399416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 12/30/2022]
Abstract
Background Positive end-expiratory pressure (PEEP) refers to the positive pressure in the respiratory tract at the end of the exhalation when we use a ventilator. The differences of higher PEEP and lower PEEP on clinical outcomes in acute respiratory distress syndrome (ARDS) patients are less well known. Methods A comprehensive literature search of all randomized control trials (RCTs) was conducted using PubMed, Embase, World Health Organization (WHO) Global Index Medicus, WHO clinical trial registry, and Clinicaltrials.gov. Inclusion criteria included RCTs comparing the clinical outcomes of higher and lower PEEP in ARDS patients. Results Eleven studies were included in the final analysis. In the higher PEEP group, the hospital mortality, 28-day mortality, and ICU mortality showed no significantly lower risk compared to the lower PEEP group (RR = 0.92, 95% CI 0.80-1.05, p = 0.22; RR = 0.88, 95% CI 0.73-1.05, p = 0.15; RR = 0.84, 95% CI 0.67-1.05, p = 0.12; respectively). High certainty could be obtained that there is no significant difference between the clinical outcomes of higher PEEP and lower PEEP in ARDS patients. Conclusions There is no significant difference of the hospital mortality, 28-day mortality, and ICU mortality between higher and lower PEEP in ARDS patients.
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Affiliation(s)
- Min Liang
- Department of Intensive Care Unit, Sir Run Run Shaw Hospital, Affiliated to School of Medicine, Zhejiang University, Hangzhou, China
| | - Xin Chen
- Department of Intensive Care Unit, Hangzhou Tumor Hospital, Affiliated to School of Medicine, Zhejiang University, Hangzhou, China
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21
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Cajanding RJM. Silent Hypoxia in COVID-19 Pneumonia: State of Knowledge, Pathophysiology, Mechanisms, and Management. AACN Adv Crit Care 2022; 33:143-153. [PMID: 35113990 DOI: 10.4037/aacnacc2022448] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Patients with COVID-19 often present with life-threatening hypoxemia without dyspnea or signs of respiratory distress. Termed silent or happy hypoxia, it has puzzled clinicians and challenged and defied our understanding of normal respiratory physiology. A range of host- and pathogen-related factors appears to contribute to its development, including SARS-CoV-2's ability to produce different COVID-19 phenotypes; induce endothelial damage and elicit a vascular distress response; invade cells of the central nervous system and disrupt normal interoception and response; and modulate transcription factors involved in hypoxic responses. Because hypoxemia in COVID-19 is associated with increased mortality risk and poorer survival, early detection and prompt treatment is essential to prevent potential complications. Interventions to prevent hypoxemia and improve oxygen delivery to the blood and the tissues include home pulse-oximetry monitoring, optimization of patient positioning, judicious use of supplemental oxygen, breathing control exercises, and timely and appropriate use of ventilatory modalities and adjuncts.
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Affiliation(s)
- Ruff Joseph Macale Cajanding
- Ruff Joseph Macale Cajanding is Senior Charge Nurse, Adult Critical Care Unit, 6th Floor, King George V Building, St Bartholomew's Hospital, Barts Health NHS Trust, 2 King Edward Street, London EC1A 1HQ, United Kingdom
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22
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Nakahashi S, Imai H, Shimojo N, Magata Y, Einama T, Hayakawa M, Wada T, Morimoto Y, Gando S. Effects of the Prone Position on Regional Neutrophilic Lung Inflammation According to 18F-FDG Pet in an Experimental Ventilator-Induced Lung Injury Model. Shock 2022; 57:298-308. [PMID: 34107528 DOI: 10.1097/shk.0000000000001818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Ventilator-induced lung injury (VILI) can be life-threatening and it is important to prevent the development of VILI. It remains unclear whether the prone position affects neutrophilic inflammation in the lung regions in vivo, which plays a crucial role in the pathogenesis of VILI. This study aimed to assess the relationship between the use of the prone position and the development of VILI-associated regional neutrophilic lung inflammation. Regional neutrophilic lung inflammation and lung aeration during low tidal volume mechanical ventilation were assessed using in vivo 2-deoxy-2-[(18)F] fluoro-D-glucose (18F-FDG) positron emission tomography and computed tomography in acutely experimentally injured rabbit lungs (lung injury induced by lung lavage and excessive ventilation). Direct comparisons were made among three groups: control, supine, and prone positions. After approximately 7 h, tissue-normalized 18F-FDG uptake differed significantly between the supine and prone positions (SUP: 0.038 ± 0.014 vs. PP: 0.029 ± 0.008, P = 0.038), especially in the ventral region (SUP: 0.052 ± 0.013 vs. PP: 0.026 ± 0.007, P = 0.003). The use of the prone position reduced lung inhomogeneities, which was demonstrated by the correction of the disproportionate rate of voxel gas over the given lung region. The progression of neutrophilic inflammation was affected by the interaction between the total strain (for aeration) and the inhomogeneity. The prone position is effective in slowing down the progression of VILI-associated neutrophilic inflammation. Under low-tidal-volume ventilation, the main drivers of its effect may be homogenization of lung tissue and that of mechanical forces.
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Affiliation(s)
- Susumu Nakahashi
- Department of Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Hiroshi Imai
- Department of Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuhiro Magata
- Department of Molecular Imaging, Institute for Medical Photonics Research, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Mineji Hayakawa
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yuji Morimoto
- Division of Anesthesia and Perioperative Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Ubolnuar N, Tantisuwat A, Mathiyakom W, Thaveeratitham P, Kruapanich C. Effect of pursed-lip breathing and forward trunk lean positions on regional chest wall volume and ventilatory pattern in older adults: An observational study. Medicine (Baltimore) 2022; 101:e28727. [PMID: 35089245 PMCID: PMC8797477 DOI: 10.1097/md.0000000000028727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 01/12/2022] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT Pursed-lip breathing (PLB) and forward trunk lean posture (FTLP) are commonly used to relieve dyspnea and improve ventilation in a rehabilitation program. However, their effect on chest wall volumes and movements in older adults without chronic obstructive pulmonary disease has never been investigated. This observational study aimed to identify the effect of combined PLB and FTLP on total and regional chest wall volumes, ventilatory pattern, and thoracoabdominal movement using in older adults. It was hypothesized that the combined PLB with FTLP would result in the highest chest wall volumes among the experimental tasks. Twenty older adults performed 2 breathing patterns of quiet breathing (QB) and PLB during a seated upright (UP) position and FTLP. An optoelectronic plethysmography system was used to capture the chest wall movements during the 4 experimental tasks. Tidal volume (VT) was separated into pulmonary ribcage, abdominal ribcage, and abdomen volume. The changes in anterior-posterior (AP) and medial-lateral (ML) chest wall diameters at 3 levels were measured and used to identify chest wall mechanics to improve chest wall volumes. The PLB significantly improved ventilation and chest wall volumes than the QB (P < .05). VT of pulmonary ribcage, VT of abdominal ribcage, and VT were significantly higher during the PLB + UP (P < .05) and during the PLB + FTLP (P < .01) as compared to those of QB performed in similar body positions. However, there was no significant in total and regional lung volumes between the PLB + UP and the PLB + FTLP. The AP diameter changes at the angle of Louis and xiphoid levels were greater during the PLB + UP than the QB + UP and the QB + FTLP (P < .01). The AP diameter changes at the umbilical level and the ML diameter changes at the xiphoid level were significantly larger during the PLB + FTLP than the QB + FTLP and the QB + UP (P < .05). The ML diameter changes at the umbilical level were significantly greater during the PLB + FTLP than the QB + UP (P < .05). However, no significant difference in the relative regional chest wall volumes and phase angle among the experimental tasks (P > .05). In conclusion, a combined PLB performed in an FTLP or UP sitting could be used as a strategy to improve chest wall volumes and ventilation in older adults.
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Affiliation(s)
- Nutsupa Ubolnuar
- Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
- Department of Physical Therapy, Faculty of Allied Health Sciences, Burapha University, Chonburi, Thailand
| | - Anong Tantisuwat
- Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Witaya Mathiyakom
- Department of Physical Therapy, California State University, Northridge, CA
| | - Premtip Thaveeratitham
- Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Chathipat Kruapanich
- Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
- Faculty of Physical Therapy, Saint Louis College, Bangkok, Thailand
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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Orthodeoxia and its implications on awake-proning in COVID-19 pneumonia. Crit Care 2021; 25:429. [PMID: 34915916 PMCID: PMC8674521 DOI: 10.1186/s13054-021-03859-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022] Open
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Yuan S, Chi Y, Long Y, He H, Zhao Z. Effect of Position Change From the Bed to a Wheelchair on the Regional Ventilation Distribution Assessed by Electrical Impedance Tomography in Patients With Respiratory Failure. Front Med (Lausanne) 2021; 8:744958. [PMID: 34805212 PMCID: PMC8600076 DOI: 10.3389/fmed.2021.744958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/28/2021] [Indexed: 11/19/2022] Open
Abstract
Background: There is limited knowledge about the effect of position change on regional lung ventilation in patients with respiratory failure. This study aimed to examine the physiological alteration of regional lung ventilation during the position change from lying in bed to sitting on a wheelchair. Methods: In this study, 41 patients with respiratory failure who were weaned from the ventilators were prospectively enrolled. The electrical impedance tomography (EIT) was used to assess the regional lung ventilation distribution at four time points (Tbase: baseline, supine position in the bed, T30min: sitting position in the wheelchair after 30 min, T60min: sitting position in the wheelchair after 60 min, Treturn: the same supine position in the bed after position changing). The EIT-based global inhomogeneity (GI) and center of ventilation (CoV) indices were calculated. The EIT images were equally divided into four ventral-to-dorsal horizontal regions of interest (ROIs 1–4). Depending on the improvement in ventilation distribution in the dependent regions at T60min (threshold set to 15%), the patients were divided into the dorsal ventilation improved (DVI) and not improved (non-DVI) groups. Results: When the patients moved from the bed to a wheelchair, there was a significant and continuous increase in ventilation in the dorsal regions (ROI 3 + 4: 45.9 ± 12.1, 48.7 ± 11.6, 49.9 ± 12.6, 48.8 ± 10.6 for Tbase, T30min, T60min, and Treturn, respectively; p = 0.015) and CoV (48.2 ± 10.1, 50.1 ± 9.2, 50.5 ± 9.6, and 49.5 ± 8.6, p = 0.047). In addition, there was a significant decrease in GI at T60min compared with Tbase. The DVI group (n = 18) had significantly higher oxygenation levels than the non-DVI group (n = 23) after position changing. ROI4Tbase was significantly negatively correlated with the ΔSpO2 (R = 0.72, p < 0.001). Using a cutoff value of 6.5%, ROI4Tbase had 79.2% specificity and 58.8% sensitivity in indicating the increase in the dorsal region related to the position change. The corresponding area under the curve (AUC) was 0.806 (95% CI, 0.677–0.936). Conclusions: Position change may improve the ventilation distribution in the study patients. The EIT can visualize real-time changes of the regional lung ventilation at the bedside to guide the body position change of the patients in the intensive care unit (ICU) and measure the effect of clinical practice. Trial Registration: Effect of Early Mobilization on Regional Lung Ventilation Assessed by EIT, NCT04081129. Registered 9 June 2019—Retrospectively registered. https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00096WT&selectaction=Edit&uid=U00020D9&ts=2&cx=v2cwij.
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Affiliation(s)
- Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China.,Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
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27
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Yuchi Y, Suzuki R, Teshima T, Matsumoto H, Koyama H. Investigation of the influence of manual ventilation-controlled respiration on right ventricular pressure-volume loops and echocardiographic variables in healthy anesthetized dogs. Am J Vet Res 2021; 82:865-871. [PMID: 34669489 DOI: 10.2460/ajvr.82.11.865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate the influence of manual ventilation-controlled respiration on right ventricular (RV) pressure-volume loop-derived and echocardiographic variables in dogs. ANIMALS 8 healthy, anesthetized Beagles. PROCEDURES In a prospective experimental study, pressure-volume catheters were percutaneously inserted into the right ventricle of each dog, and manual ventilation was performed; RV pressure-volume loop (hemodynamic) data and conventional echocardiographic variables were assessed. Two-dimensional speckle tracking echocardiography-derived RV strain (RVS) and RV systolic strain rate (RVSR) were obtained with RV free wall-only analysis (free wall) and RV global analysis (RVGA; interventricular septum). Variables were compared between end-inspiratory and end-expiratory phases of respiration by statistical methods. Multiple regression analysis was used to assess associations between selected hemodynamic and echocardiographic variables. RESULTS The RV pressure significantly increased, and RV volume, stroke volume, tricuspid annular plane systolic excursion, RV fractional area change, peak myocardial systolic velocity of the lateral tricuspid annulus, and RV free wall only-assessed RVS and RVSR significantly decreased in the inspiratory phase, compared with the expiratory phase. There were no significant differences in end-systolic elastance or RVGA-assessed RVS or RVSR between respiratory phases. The RVGA-assessed RVSR was significantly associated with stroke volume and end-systolic elastance. CONCLUSIONS AND CLINICAL RELEVANCE Specific RV echocardiographic variables were significantly affected by respiration. In contrast, RVS and RVSR determined with RVGA were not affected by respiration and were associated with hemodynamic indicators of RV contractility.
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Affiliation(s)
- Yunosuke Yuchi
- From the Laboratory of Veterinary Internal Medicine, School of Veterinary Medicine, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8602, Japan
| | - Ryohei Suzuki
- From the Laboratory of Veterinary Internal Medicine, School of Veterinary Medicine, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8602, Japan
| | - Takahiro Teshima
- From the Laboratory of Veterinary Internal Medicine, School of Veterinary Medicine, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8602, Japan
| | - Hirotaka Matsumoto
- From the Laboratory of Veterinary Internal Medicine, School of Veterinary Medicine, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8602, Japan
| | - Hidekazu Koyama
- From the Laboratory of Veterinary Internal Medicine, School of Veterinary Medicine, Faculty of Veterinary Science, Nippon Veterinary and Life Science University, 1-7-1 Kyonan-cho, Musashino-shi, Tokyo, 180-8602, Japan
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Kalidoss R, Umapathy S, Rani Thirunavukkarasu U. A breathalyzer for the assessment of chronic kidney disease patients’ breathprint: Breath flow dynamic simulation on the measurement chamber and experimental investigation. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.103060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Ghanem MA, El-Hefnawy AS. Cardiopulmonary effects of prolonged surgical abdominal retractors application during general anesthesia: a prospective observational comparative study. Braz J Anesthesiol 2021; 73:291-300. [PMID: 34298077 DOI: 10.1016/j.bjane.2021.06.019] [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] [Received: 06/02/2020] [Revised: 04/25/2021] [Accepted: 06/20/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Increasing abdominal pressures could affect pulmonary compliance and cardiac performance, a fact based on which the aim of the present study to detect the cardiopulmonary burden of multiple retractors application during supine versus lateral abdominal surgeries. We hypothesized that surgical ring multiple retractors application would affect the pulmonary and cardiac functions during both lateral and supine abdominal surgeries. METHODS Prospective observational comparative study on forty surgical patients subdivided into two groups twenty each, comparing pulmonary compliance and cardiac performance before, during and after retractors application, group (S) supine position cystectomy surgery, and group (L) lateral position nephrectomy surgery under general anesthesia, Composite 1ry outcome; dynamic compliance C-dyn and cardiac index CI and Other outcome variables ICON cardio-meter were also recorded. RESULTS C-dyn and C-stat were significantly decreased late during retractor application in lateral compared to supine surgery with significant decrease compared to basal values all over the surgical time. CI was significantly increased after retractor removal in both of the study groups compared to basal values. PAWP was significantly increased in -lateral compared to supine surgery -with significant increase compared to basal value all over the surgical time in both of the study groups. significant increase in DO2I compared to basal value during both supine and lateral positions. CONCLUSION Surgical retraction results in a short-lived significant decreases in lung compliance and cardiac output particularly during the lateral-kidney position than the supine position compliance.
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Affiliation(s)
- Mohamed A Ghanem
- Mansoura University, Faculty of Medicine, Anesthesia Department, Anesthesia and Surgical Intensive Care, Almançora, Egypt.
| | - Ahmed S El-Hefnawy
- Mansoura University, Faculty of Medicine, Urology Surgery, Urology and Nephrology Center, Almançora, Egypt
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30
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Sevdi MS, Demirgan S, Erkalp K, Akyol O, Ozcan FG, Guneyli HC, Tunali MC, Selcan A. Continuous Endotracheal Tube Cuff Pressure Control Decreases Incidence of Ventilator-Associated Pneumonia in Patients with Traumatic Brain Injury. J INVEST SURG 2021; 35:525-530. [PMID: 33583304 DOI: 10.1080/08941939.2021.1881190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common cause of morbidity and mortality in intensive care unit (ICU), and among the several preventative strategies described to reduce the incidence of VAP, the most important is the endotracheal tube cuff (ETC) pressure. The present study was conducted on 60 patients who required mechanical ventilation (MV) in the ICU with traumatic brain injury (TBI). METHODS The patients were randomized into two groups of 30, in which ETC pressure was regulated using a smart cuff manager (SCM) (Group II), or manual measurement approach (MMA) (Group I). Demographic data, MV duration, length of ICU stay and mortality rates were recorded. The clinical pulmonary infection scores (CPISs), C-reactive protein (CRP) values, and the fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) values of the groups were compared at baseline, and at hours 48, 72 and 96. RESULTS In Group I, CPIS values significantly higher than Group II in 48th, 72nd and 96th hours (p < 0.05). In Group I, PEEP values and deep tracheal aspirate (DTA) culture growth rates significantly higher than Group II in 72nd and 96th hours (p < 0.05). CONCLUSION The continuous maintenance of ETC pressure using SCM reduced the incidence of VAP.
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Affiliation(s)
- Mehmet Salih Sevdi
- Department of Anesthesiology and Reanimation, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Serdar Demirgan
- Department of Anesthesiology and Reanimation, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Kerem Erkalp
- Department of Anesthesiology and Reanimation, Istanbul University-Cerrahpasa, Institute of Cardiology, Istanbul, Turkey
| | - Onat Akyol
- Department of Anesthesiology and Reanimation, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Funda Gumus Ozcan
- Department of Anesthesiology and Reanimation, Istanbul Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Hasan Cem Guneyli
- Department of Anesthesiology and Reanimation, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Can Tunali
- Department of Anesthesiology and Reanimation, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Aysin Selcan
- Department of Anesthesiology and Reanimation, Istanbul Bagcilar Training and Research Hospital, Istanbul, Turkey
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Hassan EA, Baraka AAE. The effect of reverse Trendelenburg position versus semi-recumbent position on respiratory parameters of obese critically ill patients: A randomised controlled trial. J Clin Nurs 2021; 30:995-1002. [PMID: 33432600 DOI: 10.1111/jocn.15645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/12/2020] [Accepted: 12/31/2020] [Indexed: 01/21/2023]
Abstract
AIMS AND OBJECTIVES To investigate the effect of reverse Trendelenburg position versus semi-recumbent position on respiratory parameters of obese critically ill patients. BACKGROUND Reverse Trendelenburg position is recommended for obese patients; however, the effect among critically ill patients, especially those on mechanical ventilation, has limited study. DESIGN Randomised, controlled pretest, repeated post-test trial with two parallel groups. METHODS The study started from 13 January 2020-12 March 2020. Adult critically ill patients with a body mass index ≥30 were randomly assigned by computer-generated randomisation to either reverse Trendelenburg position group (intervention) or semi-recumbent position group (active comparator control). Outcome measures were ventilation parameters (dynamic compliance, partial pressure of arterial carbon dioxide and minute volume) and oxygenation parameters (hypoxaemic index and partial pressure of arterial oxygen). Measures were assessed immediately before positioning and after positioning in 10 minutes, 20 minutes and 30 minutes. CONSORT checklist was used to report the current study. SETTINGS Four general intensive care units. RESULTS One hundred and ten patients (55 patients in each group) completed the study. The reverse Trendelenburg position group had a higher improvement than the semi-recumbent position group as estimated by mean differences in their dynamic compliance, minute volume, partial pressure of carbon dioxide, partial pressure of oxygen and hypoxaemic index. CONCLUSION Reverse Trendelenburg position improves obese patients' respiratory parameters more than semi-recumbent position. RELEVANCE TO CLINICAL PRACTICE This study directs nurses to use the reverse Trendelenburg position, which is an important position for enhancing the parameters of ventilation and oxygenation of obese mechanically ventilated patients.
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Affiliation(s)
- Eman Arafa Hassan
- Lecturer of Critical Care and Emergency Nursing, Department of Critical Care and Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt
| | - Azza Abd Elrazek Baraka
- Lecturer of Critical Care and Emergency Nursing, Department of Critical Care and Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt
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32
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Clarke J, Geoghegan P, McEvoy N, Boylan M, Ní Choileáin O, Mulligan M, Hogan G, Keogh A, McElvaney OJ, McElvaney OF, Bourke J, McNicholas B, Laffey JG, McElvaney NG, Curley GF. Prone positioning improves oxygenation and lung recruitment in patients with SARS-CoV-2 acute respiratory distress syndrome; a single centre cohort study of 20 consecutive patients. BMC Res Notes 2021; 14:20. [PMID: 33422143 PMCID: PMC7796647 DOI: 10.1186/s13104-020-05426-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/18/2020] [Indexed: 01/04/2023] Open
Abstract
Objective We aimed to characterize the effects of prone positioning on respiratory mechanics and oxygenation in invasively ventilated patients with SARS-CoV-2 ARDS. Results This was a prospective cohort study in the Intensive Care Unit (ICU) of a tertiary referral centre. We included 20 consecutive, invasively ventilated patients with laboratory confirmed SARS-CoV-2 related ARDS who underwent prone positioning in ICU as part of their management. The main outcome was the effect of prone positioning on gas exchange and respiratory mechanics. There was a median improvement in the PaO2/FiO2 ratio of 132 in the prone position compared to the supine position (IQR 67–228). We observed lower PaO2/FiO2 ratios in those with low (< median) baseline respiratory system static compliance, compared to those with higher (> median) static compliance (P < 0.05). There was no significant difference in respiratory system static compliance with prone positioning. Prone positioning was effective in improving oxygenation in SARS-CoV-2 ARDS. Furthermore, poor respiratory system static compliance was common and was associated with disease severity. Improvements in oxygenation were partly due to lung recruitment. Prone positioning should be considered in patients with SARS-CoV-2 ARDS.
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Affiliation(s)
- Jennifer Clarke
- Department of Anaesthesia and Critical Care, Royal College of Surgeons Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, D09 YD60, Ireland.,Beaumont Hospital, Dublin 9, Ireland
| | - Pierce Geoghegan
- Department of Anaesthesia and Critical Care, Royal College of Surgeons Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, D09 YD60, Ireland.,Beaumont Hospital, Dublin 9, Ireland
| | - Natalie McEvoy
- Department of Anaesthesia and Critical Care, Royal College of Surgeons Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, D09 YD60, Ireland.,Beaumont Hospital, Dublin 9, Ireland
| | | | | | | | - Grace Hogan
- Department of Anaesthesia and Critical Care, Royal College of Surgeons Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, D09 YD60, Ireland
| | - Aoife Keogh
- Department of Anaesthesia and Critical Care, Royal College of Surgeons Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, D09 YD60, Ireland
| | | | | | - John Bourke
- Galway University Hospital, University Road, Galway, Ireland
| | | | - John G Laffey
- Galway University Hospital, University Road, Galway, Ireland
| | | | - Gerard F Curley
- Department of Anaesthesia and Critical Care, Royal College of Surgeons Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, D09 YD60, Ireland. .,Beaumont Hospital, Dublin 9, Ireland.
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Viola L, Russo E, Benni M, Gamberini E, Circelli A, Bissoni L, Santonastaso DP, Scognamiglio G, Bolondi G, Mezzatesta L, Agnoletti V. Lung mechanics in type L CoVID-19 pneumonia: a pseudo-normal ARDS. TRANSLATIONAL MEDICINE COMMUNICATIONS 2020; 5:27. [PMID: 33363256 PMCID: PMC7750393 DOI: 10.1186/s41231-020-00076-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND This study was conceived to provide systematic data about lung mechanics during early phases of CoVID-19 pneumonia, as long as to explore its variations during prone positioning. METHODS We enrolled four patients hospitalized in the Intensive Care Unit of "M. Bufalini" hospital, Cesena (Italy); after the positioning of an esophageal balloon, we measured mechanical power, respiratory system and transpulmonary parameters and arterial blood gases every 6 hours, just before decubitus change and 1 hour after prono-supination. RESULTS Both respiratory system and transpulmonary compliance and driving pressure confirmed the pseudo-normal respiratory mechanics of early CoVID-19 pneumonia (respectively, CRS 40.8 ml/cmH2O and DPRS 9.7 cmH2O; CL 53.1 ml/cmH2O and DPL 7.9 cmH2O). Interestingly, prone positioning involved a worsening in respiratory mechanical properties throughout time (CRS,SUP 56.3 ml/cmH2O and CRS,PR 41.5 ml/cmH2O - P 0.37; CL,SUP 80.8 ml/cmH2O and CL,PR 53.2 ml/cmH2O - P 0.23). CONCLUSIONS Despite the severe ARDS pattern, respiratory system and lung mechanical properties during CoVID-19 pneumonia are pseudo-normal and tend to worsen during pronation. TRIAL REGISTRATION Restrospectively registered.
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Affiliation(s)
- Lorenzo Viola
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Emanuele Russo
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Marco Benni
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Emiliano Gamberini
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Alessandro Circelli
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Luca Bissoni
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | | | - Giovanni Scognamiglio
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Giuliano Bolondi
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Luca Mezzatesta
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
- University of Messina, Messina, Italy
| | - Vanni Agnoletti
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
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Avsar P, Moore Z, Patton D, O'Connor T, Budri AMV, Nugent L. Repositioning for preventing pressure ulcers: a systematic review and meta-analysis. J Wound Care 2020; 29:496-508. [DOI: 10.12968/jowc.2020.29.9.496] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective:The aim of this systematic review was to assess the effects of different repositioning regimens on pressure ulcer (PU) incidence in at-risk adult individuals without existing PUs.Method:Using systematic review methodology, randomised controlled trials (RCTs), including cluster-RCTs, prospective non-RCTs, pre–post-studies and interrupted-time-series studies were considered. Specifically explored was the impact of the frequency of repositioning, use of repositioning systems and use of turning teams. The search was conducted in January 2019, using PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases. Data were extracted using a pre-designed extraction tool and analysis was undertaken using RevMan.Results:A total of 530 records were returned, of which 16 met the inclusion criteria. Half of studies were conducted in intensive care units (50%). The mean sample size was 629±604 participants. Frequency of repositioning was explored in nine studies. PU incidence was 8% (n=221/2834) for repositioning every 2–3 hours, versus 13% (n=398/3050) for repositioning every 4–6 hours. The odds ratio (OR) was 0.75 (95% confidence interval (CI): 0.61–0.90, p=0.03), suggesting that there is a 25% reduction in the odds of PU development in favour of more frequent repositioning. Use of a repositioning system was explored in three studies. PU incidence was 2% (17/865) for the repositioning system, versus 5.5% (51/926) for care without using the repositioning system. The OR was 0.26 (95% CI: 0.05–1.29, p=0.10); this finding was not statistically significant. Use of a turning team was explored in two studies. PU incidence was 11% (n=22/200) with use of a turning team versus 20% (n=40/200) for usual care. The OR was 0.49 (95% CI: 0.27–0.86, p=0.01) suggesting that there is a 51% reduction in the odds of PU development in favour of use of a turning team. Using GRADE appraisal, the certainty of the evidence was assessed as low.Conclusion:The results of this systematic review indicate that more frequent repositioning and use of a turning team reduce PU incidence. However, given the low certainty of evidence, results should be interpreted with caution.
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Affiliation(s)
- Pinar Avsar
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Science, Ireland
| | - Zena Moore
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Science, Ireland
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
- Lida Institute, Shanghai
- Monash University, Melbourne, Australia
- Faculty of Medicine and Health Sciences, Ghent University, Belgium
| | - Declan Patton
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Science, Ireland
- Lida Institute, Shanghai
- Monash University, Melbourne, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Australia
| | - Tom O'Connor
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Science, Ireland
- Monash University, Melbourne, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Australia
| | - Aglecia MV Budri
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Science, Ireland
| | - Linda Nugent
- School of Nursing and Midwifery and Skin Wounds and Trauma Research Centre, Royal College of Surgeons in Ireland University of Medicine and Science, Ireland
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
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Peng M, Ren D, Liu YF, Meng X, Wu M, Chen RL, Yu BJ, Tao LC, Chen L, Lai ZQ. Two mechanically ventilated cases of COVID-19 successfully managed with a sequential ventilation weaning protocol: Two case reports. World J Clin Cases 2020; 8:3305-3313. [PMID: 32874986 PMCID: PMC7441264 DOI: 10.12998/wjcc.v8.i15.3305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/15/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with critical coronavirus disease 2019 (COVID-19), characterized by respiratory failure requiring mechanical ventilation (MV), are at high risk of mortality. An effective and practical MV weaning protocol is needed for these fragile cases.
CASE SUMMARY Here, we present two critical COVID-19 patients who presented with fever, cough and fatigue. COVID-19 diagnosis was confirmed based on blood cell counts, chest computed tomography (CT) imaging, and nuclei acid test results. To address the patients’ respiratory failure, they first received noninvasive ventilation (NIV). When their condition did not improve after 2 h of NIV, each patient was advanced to MV [tidal volume (Vt), 6 mL/kg ideal body weight (IBW); 8-10 cmH2O of positive end-expiratory pressure; respiratory rate, 20 breaths/min; and 40%-80% FiO2] with prone positioning for 12 h/day for the first 5 d of MV. Extensive infection control measures were conducted to minimize morbidity, and pharmacotherapy consisting of an antiviral, immune-enhancer, and thrombosis prophylactic was administered in both cases. Upon resolution of lung changes evidenced by CT, the patients were sequentially weaned using a weaning screening test, spontaneous breathing test, and airbag leak test. After withdrawal of MV, the patients were transitioned through NIV and high-flow nasal cannula oxygen support. Both patients recovered well.
CONCLUSION A MV protocol attentive to intubation/extubation timing, prone positioning early in MV, infection control, and sequential withdrawal of respiratory support, may be an effective regimen for patients with critical COVID-19.
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Affiliation(s)
- Mian Peng
- Department of Intensive Care Unit, The Third Affiliated Hospital of Shenzhen University, Shenzhen 518001, Guangdong Province, China
| | - Di Ren
- Department of Intensive Care Unit, The Second People’s Hospital of Shenzhen, Shenzhen 518035, Guangdong Province, China
| | - Yong-Feng Liu
- Department of Intensive Care Unit, Shenzhen Longgang Central Hospital, Shenzhen 518116, Guangdong Province, China
| | - Xi Meng
- Department of Intensive Care Unit, The Third People’s Hospital of Shenzhen, Shenzhen 518112, Guangdong Province, China
| | - Ming Wu
- Department of Intensive Care Unit, The Second People’s Hospital of Shenzhen, Shenzhen 518035, Guangdong Province, China
| | - Rong-Lin Chen
- Department of Intensive Care Unit, Shenzhen Longgang Central Hospital, Shenzhen 518116, Guangdong Province, China
| | - Bao-Jun Yu
- Department of Intensive Care Unit, Shenzhen Baoan District People’s Hospital, Shenzhen 518101, Guangdong Province, China
| | - Long-Cheng Tao
- Department of Intensive Care Unit, The Third Affiliated Hospital of Shenzhen University, Shenzhen 518001, Guangdong Province, China
| | - Li Chen
- Department of Intensive Care Unit, The Third Affiliated Hospital of Shenzhen University, Shenzhen 518001, Guangdong Province, China
| | - Zeng-Qiao Lai
- Department of Intensive Care Unit, The Third Affiliated Hospital of Shenzhen University, Shenzhen 518001, Guangdong Province, China
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Chelly J, Mazerand S, Jochmans S, Weyer CM, Pourcine F, Ellrodt O, Thieulot-Rolin N, Serbource-Goguel J, Sy O, Vong LVP, Monchi M. Automated vs. conventional ventilation in the ICU: a randomized controlled crossover trial comparing blood oxygen saturation during daily nursing procedures (I-NURSING). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:453. [PMID: 32698860 PMCID: PMC7374079 DOI: 10.1186/s13054-020-03155-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/05/2020] [Indexed: 02/01/2023]
Abstract
Background Hypoxia is common during daily nursing procedures (DNPs) routinely performed on mechanically ventilated patients. The impact of automated ventilation on the incidence and severity of blood oxygen desaturation during DNPs remains unknown. Methods A prospective randomized controlled crossover trial was carried out in a French intensive care unit to compare blood oxygen pulse saturation (SpO2) during DNPs performed on patients mechanically ventilated in automated and conventional ventilation modes (AV and CV, respectively). All patients with FiO2 ≤ 60% and without prone positioning or neuromuscular blocking agents were included. Patients underwent two DNPs on the same day using AV (INTELLiVENT-ASV®) and CV (volume control, biphasic positive airway pressure, or pressure support ventilation) in a randomized order. The primary outcome was the percentage of time spent with SpO2 in the acceptable range of 90–95% during the DNP. Results Of the 265 included patients, 93% had been admitted for a medical pathology, the majority for acute respiratory failure (52%). There was no difference between the two periods in terms of DNP duration, sedation requirements, or ventilation parameters, but patients had more spontaneous breaths and lower peak airway pressures during the AV period (p < 0.001). The percentage of time spent with SpO2 in the acceptable range during DNPs was longer in the AV period than in the CV period (48 ± 37 vs. 43 ± 37, percentage of DNP period; p = 0.03). After adjustment, AV was associated with a higher number of DNPs carried out with SpO2 in the acceptable range (odds ratio, 1.82; 95% CI, 1.28 to 2.6; p = 0.001) and a lower incidence of blood oxygen desaturation ≤ 85% (adjusted odds ratio, 0.50; 95% CI, 0.30 to 0.85; p = 0.01). Conclusion AV appears to reduce the incidence and severity of blood oxygen desaturation during daily nursing procedures (DNPs) in comparison to CV. Trial registration This study was registered in clinical-trial.gov (NCT03176329) in June 2017. Graphical abstract ![]()
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Affiliation(s)
- Jonathan Chelly
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France. .,Clinical Research Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France.
| | - Sandie Mazerand
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Sebastien Jochmans
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France.,Clinical Research Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Claire-Marie Weyer
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Franck Pourcine
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Olivier Ellrodt
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Nathalie Thieulot-Rolin
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Jean Serbource-Goguel
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Oumar Sy
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Ly Van Phach Vong
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Mehran Monchi
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France.,Clinical Research Unit, Groupe Hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77000, Melun, France
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Lesny M, Conrad M, Latarche C, Sylvestre A, Gaujard E, Dubois V, Quignard C, Citro V, Thomas JC, Bridey C, Weber AM, Simon C, Klein S, Gibot S, Bollaert PE. Adverse events during nursing care procedure in intensive care unit: The PREVENIR study. Intensive Crit Care Nurs 2020; 60:102881. [PMID: 32499089 DOI: 10.1016/j.iccn.2020.102881] [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] [Received: 12/06/2019] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Intensive care unit patients undergo several nursing care procedures (NCP) every day. These procedures involve a risk for adverse events (AE). Yet, their prevalence, intensity, and predisposing risk factors remain poorly established. The main objective of the study was to measure the incidence and severity of NCP related AE. DESIGN This prospective observational multicentre study was conducted in 9 ICUs. All NCP were recorded for four consecutive weeks. For each NCP, the following were collected: patients' baseline characteristics, type of NCP, characteristics of the NCP, AE and therapeutic responses. RESULTS 5849 NCP occurred in 340 patients. Among the 340 patients included, 292 (85.9%) were affected by at least one AE, and 141 (41.5%) by an SAE during a NCP. Thirty % of NCP were associated with at least one AE: hemodynamic AE in 17.1%, respiratory AE in 13.6%, agitation and pain (3.7% and 3.3%). Eight invasive devices were accidentally removed. Severe Adverse Events (SAE) occurred in 5.5% of NCP. The main risk factor associated with SAE was pain/agitation at the beginning of the NCP. CONCLUSION AE are frequent during NCP in ICU. We identified several risk factors, some of them preventable, that could be considered for the development of recommendations for the nursing care of critically ill patients. TRIAL REGISTRATION ClinicalTrials.gov NCT02881645.
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Affiliation(s)
- M Lesny
- Réanimation médicale, Hôpital central, CHU Nancy, France
| | - M Conrad
- Réanimation médicale, Hôpital central, CHU Nancy, France.
| | - C Latarche
- Qualité Gestion des risques, CHU Nancy, France
| | | | - E Gaujard
- Réanimation médicale, Hôpital central, CHU Nancy, France
| | - V Dubois
- Réanimation neurochirurgicale, Hôpital central, CHU Nancy, France
| | - C Quignard
- Réanimation chirurgicale, Hôpital central, CHU Nancy, France
| | - V Citro
- Réanimation, CHR Metz, France
| | - J C Thomas
- Réanimation chirurgicale Cardiovasculaire, Hôpitaux de Brabois, CHU Nancy, France
| | - C Bridey
- Réanimation médicale, Hôpitaux de Brabois, CHU Nancy, France
| | - A M Weber
- Réanimation médicale, CHU Strasbourg, France
| | - C Simon
- Réanimation chirurgicale, Hôpitaux de Brabois, CHU Nancy, France
| | - S Klein
- CIC-EC INSERM, CHU Nancy, France
| | - S Gibot
- Réanimation médicale, Hôpital central, CHU Nancy, France
| | - P E Bollaert
- Réanimation médicale, Hôpital central, CHU Nancy, France
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Yilmaz C, Dane DM, Tustison NJ, Song G, Gee JC, Hsia CCW. In vivo imaging of canine lung deformation: effects of posture, pneumonectomy, and inhaled erythropoietin. J Appl Physiol (1985) 2020; 128:1093-1105. [PMID: 31944885 DOI: 10.1152/japplphysiol.00647.2019] [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: 12/21/2022] Open
Abstract
Mechanical stresses on the lung impose the major stimuli for developmental and compensatory lung growth and remodeling. We used computed tomography (CT) to noninvasively characterize the factors influencing lobar mechanical deformation in relation to posture, pneumonectomy (PNX), and exogenous proangiogenic factor supplementation. Post-PNX adult canines received weekly inhalations of nebulized nanoparticles loaded with recombinant human erythropoietin (EPO) or control (empty nanoparticles) for 16 wk. Supine and prone CT were performed at two transpulmonary pressures pre- and post-PNX following treatment. Lobar air and tissue volumes, fractional tissue volume (FTV), specific compliance (Cs), mechanical strains, and shear distortion were quantified. From supine to prone, lobar volume and Cs increased while strain and shear magnitudes generally decreased. From pre- to post-PNX, air volume increased less and FTV and Cs increased more in the left caudal (LCa) than in other lobes. FTV increased most in the dependent subpleural regions, and the portion of LCa lobe that expanded laterally wrapping around the mediastinum. Supine deformation was nonuniform pre- and post-PNX; strains and shear were most pronounced in LCa lobe and declined when prone. Despite nonuniform regional expansion and deformation, post-PNX lobar mechanics were well preserved compared with pre-PNX because of robust lung growth and remodeling establishing a new mechanical equilibrium. EPO treatment eliminated posture-dependent changes in FTV, accentuated the post-PNX increase in FTV, and reduced FTV heterogeneity without altering absolute air or tissue volumes, consistent with improved microvascular blood volume distribution and modestly enhanced post-PNX alveolar microvascular reserves.NEW & NOTEWORTHY Mechanical stresses on the lung impose the major stimuli for lung growth. We used computed tomography to image deformation of the lung in relation to posture, loss of lung units, and inhalational delivery of the growth promoter erythropoietin. Following loss of one lung in adult large animals, the remaining lung expanded and grew while retaining near-normal mechanical properties. Inhalation of erythropoietin promoted more uniform distribution of blood volume within the remaining lung.
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Affiliation(s)
- Cuneyt Yilmaz
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - D Merrill Dane
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas J Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
| | - Gang Song
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James C Gee
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Connie C W Hsia
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Clinical Evaluation of Stretchable and Wearable Inkjet-Printed Strain Gauge Sensor for Respiratory Rate Monitoring at Different Body Postures. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10020480] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Respiratory rate (RR) is a vital sign with continuous, convenient, and accurate measurement which is difficult and still under investigation. The present study investigates and evaluates a stretchable and wearable inkjet-printed strain gauge sensor (IJP) to estimate the RR continuously by detecting the respiratory volume change in the chest area. As the volume change could cause different strain changes at different body postures, this study aims to investigate the accuracy of the IJP RR sensor at selected postures. The evaluation was performed twice on 15 healthy male subjects (mean ± SD of age: 24 ± 1.22 years). The RR was simultaneously measured in breaths per minute (BPM) by the IJP RR sensor and a reference RR sensor (e-Health nasal thermal sensor) at each of the five body postures namely standing, sitting at 90°, Flower’s position at 45°, supine, and right lateral recumbent. There was no significant difference in measured RR between IJP and reference sensors, between two trials, or between different body postures (all p > 0.05). Body posture did not have any significant effect on the difference of RR measurements between IJP and the reference sensors (difference <0.01 BPM for each measurement in both trials). The IJP sensor could accurately measure the RR at different body postures, which makes it a promising, simple, and user-friendly option for clinical and daily uses.
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Jang MH, Shin MJ, Shin YB. Pulmonary and Physical Rehabilitation in Critically Ill Patients. Acute Crit Care 2019; 34:1-13. [PMID: 31723900 PMCID: PMC6849048 DOI: 10.4266/acc.2019.00444] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 02/19/2019] [Accepted: 02/22/2010] [Indexed: 12/28/2022] Open
Abstract
Some patients admitted to the intensive care unit (ICU) because of an acute illness, complicated surgery, or multiple traumas develop muscle weakness affecting the limbs and respiratory muscles during acute care in the ICU. This condition is referred to as ICU-acquired weakness (ICUAW), and can be evoked by critical illness polyneuropathy (CIP), critical illness myopathy (CIM), or critical illness polyneuromyopathy (CIPNM). ICUAW is diagnosed using the Medical Research Council (MRC) sum score based on bedside manual muscle testing in cooperative patients. The MRC sum score is the sum of the strengths of the 12 regions on both sides of the upper and lower limbs. ICUAW is diagnosed when the MRC score is less than 48 points. However, some patients require electrodiagnostic studies, such as a nerve conduction study, electromyography, and direct muscle stimulation, to differentiate between CIP and CIM. Pulmonary rehabilitation in the ICU can be divided into modalities intended to remove retained airway secretions and exercise therapies intended to improve respiratory function. Physical rehabilitation, including early mobilization, positioning, and limb exercises, attenuates the weakness that occurs during critical care. To perform mobilization in mechanically ventilated patients, pretreatment by removing secretions is necessary. It is also important to increase the strength of respiratory muscles and to perform lung recruitment to improve mobilization in patients who are weaned from the ventilator. For these reasons, pulmonary rehabilitation is important in addition to physical therapy. Early recognition of CIP, CIM, and CIPNM and early rehabilitation in the ICU might improve patients’ functional recovery and outcomes.
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Affiliation(s)
- Myung Hun Jang
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Myung-Jun Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.,Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Korea
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