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Acosta CM, Poliotto S, Abrego D, Bradley D, de Esteban S, Mir F, Ricci L, Natal M, Wallin M, Hallbäck M, Sipmann FS, Tusman G. Effect of an Individualized Lung Protective Ventilation on Lung Strain and Stress in Children Undergoing Laparoscopy: An Observational Cohort Study. Anesthesiology 2024; 140:430-441. [PMID: 38064715 DOI: 10.1097/aln.0000000000004856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Exaggerated lung strain and stress could damage lungs in anesthetized children. The authors hypothesized that the association of capnoperitoneum and lung collapse in anesthetized children increases lung strain-stress. Their primary aim was to describe the impact of capnoperitoneum on lung strain-stress and the effects of an individualized protective ventilation during laparoscopic surgery in children. METHODS The authors performed an observational cohort study in healthy children aged 3 to 7 yr scheduled for laparoscopic surgery in a community hospital. All received standard protective ventilation with 5 cm H2O of positive end-expiratory pressure (PEEP). Children were evaluated before capnoperitoneum, during capnoperitoneum before and after lung recruitment and optimized PEEP (PEEP adjusted to get end-expiratory transpulmonary pressure of 0), and after capnoperitoneum with optimized PEEP. The presence of lung collapse was evaluated by lung ultrasound, positive Air-Test (oxygen saturation measured by pulse oximetry 96% or less breathing 21% O2 for 5 min), and negative end-expiratory transpulmonary pressure. Lung strain was calculated as tidal volume/end-expiratory lung volume measured by capnodynamics, and lung stress as the end-inspiratory transpulmonary pressure. RESULTS The authors studied 20 children. Before capnoperitoneum, mean lung strain was 0.20 ± 0.07 (95% CI, 0.17 to 0.23), and stress was 5.68 ± 2.83 (95% CI, 4.44 to 6.92) cm H2O. During capnoperitoneum, 18 patients presented lung collapse and strain (0.29 ± 0.13; 95% CI, 0.23 to 0.35; P < 0.001) and stress (5.92 ± 3.18; 95% CI, 4.53 to 7.31 cm H2O; P = 0.374) increased compared to before capnoperitoneum. During capnoperitoneum and optimized PEEP, children presenting lung collapse were recruited and optimized PEEP was 8.3 ± 2.2 (95% CI, 7.3 to 9.3) cm H2O. Strain returned to values before capnoperitoneum (0.20 ± 0.07; 95% CI, 0.17 to 0.22; P = 0.318), but lung stress increased (7.29 ± 2.67; 95% CI, 6.12 to 8.46 cm H2O; P = 0.020). After capnoperitoneum, strain decreased (0.18 ± 0.04; 95% CI, 0.16 to 0.20; P = 0.090), but stress remained higher (7.25 ± 3.01; 95% CI, 5.92 to 8.57 cm H2O; P = 0.024) compared to before capnoperitoneum. CONCLUSIONS Capnoperitoneum increased lung strain in healthy children undergoing laparoscopy. Lung recruitment and optimized PEEP during capnoperitoneum decreased lung strain but slightly increased lung stress. This little rise in pulmonary stress was maintained within safe, lung-protective, and clinically acceptable limits. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Cecilia M Acosta
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Sergio Poliotto
- Department of Pediatric Surgery, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Diego Abrego
- Department of Pediatric Surgery, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Dolores Bradley
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Santiago de Esteban
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Francisco Mir
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Lila Ricci
- Department of Mathematics, Facultad de Ciencias Exactas, Universidad Nacional de Mar del Plata, Argentina
| | - Marcela Natal
- Department of Mathematics, Facultad de Ciencias Exactas, Universidad Nacional de Mar del Plata, Argentina
| | - Mats Wallin
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden; Getinge Critical Care AB, Solna, Sweden
| | | | - Fernando Suarez Sipmann
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; CIBERES (Network Biomedical Research Center), Madrid, Spain; Department of Critical Care, Hospital Universitario de La Princesa, Universidad Autonoma de Madrid, Madrid, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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İnci K, Boyacı N, Kara İ, Gürsel G. Assessment of different computing methods of inspiratory transpulmonary pressure in patients with multiple mechanical problems. J Clin Monit Comput 2021; 36:1173-1180. [PMID: 34480238 PMCID: PMC8415196 DOI: 10.1007/s10877-021-00751-8] [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: 04/13/2021] [Accepted: 08/24/2021] [Indexed: 11/15/2022]
Abstract
While plateau airway pressure alone is an unreliable estimate of lung overdistension inspiratory transpulmonary pressure (PL) is an important parameter to reflect it in patients with ARDS and there is no concensus about which computation method should be used to calculate it. Recent studies suggest that different formulas may lead to different tidal volume and PEEP settings. The aim of this study is to compare 3 different inspiratory PL measurement method; direct measurement (PLD), elastance derived (PLE) and release derived (PLR) methods in patients with multiple mechanical abnormalities. 34 patients were included in this prospective observational study. Measurements were obtained during volume controlled mechanical ventilation in sedated and paralyzed patients. During the study day airway and eosephageal pressures, flow, tidal volume were measured and elastance, inspiratory PLE, PLD and PLR were calculated. Mean age of the patients was 67 ± 15 years and APACHE II score was 27 ± 7. Most frequent diagnosis of the patients were pneumonia (71%), COPD exacerbation(56%), pleural effusion (55%) and heart failure(50%). Mean plateau pressure of the patients was 22 ± 5 cmH2O and mean respiratory system elastance was 36.7 ± 13 cmH2O/L. EL/ERS% was 0.75 ± 0.35%. Mean expiratory transpulmonary pressure was 0.54 ± 7.7 cmH2O (min: − 21, max: 12). Mean PLE (18 ± 9 H2O) was significantly higher than PLD (13 ± 9 cmH2O) and PLR methods (11 ± 9 cmH2O). There was a good aggreement and there was no bias between the measurements in Bland–Altman analysis. The estimated bias was similar between the PLD and PLE (− 3.12 ± 11 cmH2O) and PLE and PLR (3.9 ± 10.9 cmH2O) measurements. Our results suggest that standardization of calculation method of inspiratory PL is necessary before using it routinely to estimate alveolar overdistension.
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Affiliation(s)
- Kamil İnci
- Critical Care Training Programme, Division of Critical Care, Department of Internal Medicine, School of Medicine, Gazi University, Ankara, Turkey
| | - Nazlıhan Boyacı
- Critical Care Training Programme, Division of Critical Care, Department of Internal Medicine, School of Medicine, Gazi University, Ankara, Turkey
| | - İskender Kara
- Critical Care Training Programme, Division of Critical Care, Department of Anaesthesiology, School of Medicine, Gazi University, Ankara, Turkey.
| | - Gül Gürsel
- Critical Care Training Programme, Department of Pulmonary Critical Care Medicine, School of Medicine, Gazi University, Ankara, Turkey
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Arellano-Pérez Ó, Castillo Merino F, Torres-Tejeiro R, Ugarte Ubiergo S. An assessment of esophageal balloon use for the titration of airway pressure release ventilation and controlled mechanical ventilation in a patient with extrapulmonary acute respiratory distress syndrome: a case report. J Med Case Rep 2021; 15:435. [PMID: 34399842 PMCID: PMC8367393 DOI: 10.1186/s13256-021-02984-2] [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: 12/09/2020] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Esophageal pressure measurement is a minimally invasive monitoring process that assesses respiratory mechanics in patients with acute respiratory distress syndrome. Airway pressure release ventilation is a relatively new positive pressure ventilation modality, characterized by a series of advantages in patients with acute respiratory distress syndrome. Case presentation We report a case of a 55-year-old chilean female, with preexisting hypertension and recurrent renal colic who entered the cardiosurgical intensive care unit with signs and symptoms of urinary sepsis secondary to a right-sided obstructive urolithiasis. At the time of admission, the patient showed signs of urinary sepsis, a poor overall condition, hemodynamic instability, tachycardia, hypotension, and needed vasoactive drugs. Initially the patient was treated with volume control ventilation. Then, ventilation was with conventional ventilation parameters described by the Acute Respiratory Distress Syndrome Network. However, hemodynamic complications led to reduced airway pressure. Later she presented intraabdominal hypertension that compromised the oxygen supply and her ventilation management. Considering these records, an esophageal manometry was used to measure distending lung pressure, that is, transpulmonary pressure, to protect lungs. Initial use of the esophageal balloon was in a volume-controlled modality (deep sedation), which allowed the medical team to perform inspiratory and expiratory pause maneuvers to monitor transpulmonary plateau pressure as a substitute for pulmonary distension and expiratory pause and determine transpulmonary positive end-expiratory pressure. On the third day of mechanical respiration, the modality was switched to airway pressure release ventilation. The use of airway pressure release ventilation was associated with reduced hemodynamic complications and kept transpulmonary pressure between 0 and 20 cmH2O despite a sustained high positive end-expiratory pressure of 20 cmH2O. Conclusion The application of this technique is shown in airway pressure release ventilation with spontaneous ventilation, which is then compared with a controlled modality that requires a lesser number of sedative doses and vasoactive drugs, without altering the criteria for lung protection as guided by esophageal manometry.
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Affiliation(s)
- Óscar Arellano-Pérez
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile. .,School of Physical Therapy, Faculty of Health, Bernardo O'Higgins University, Santiago, Chile.
| | - Felipe Castillo Merino
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile.,School of Physical Therapy, Faculty of Rehabilitation Sciences, Andrés Bello University, Santiago, Chile
| | - Roberto Torres-Tejeiro
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile.,School of Physical Therapy, Faculty of Rehabilitation Sciences, Andrés Bello University, Santiago, Chile
| | - Sebastián Ugarte Ubiergo
- Adult Patients Critical Center, INDISA Clinic, Santiago, Chile.,Faculty of Medicine, Andrés Bello University, Santiago, Chile.,Latin American Critical Care Trial Investigative Network (LACCTIN), Santiago, Chile
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Ibrahim IM, Yousef A, Sabry A, Khalifa A. Efficacy of transalveolar pressure measurement as a monitoring parameter for lung recruitment in postcardiac surgery hypoxic patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1897202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Ibrahim Mabrouk Ibrahim
- Anaesthesia department, Assistant Lecturer of Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Ahmed Yousef
- Anaesthesia department, Professor of Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Amal Sabry
- Anaesthesia department, Professor of Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Ayman Khalifa
- Anaesthesia department, Assistant Lecturer of Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria, Egypt
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Multimodal non-invasive monitoring to apply an open lung approach strategy in morbidly obese patients during bariatric surgery. J Clin Monit Comput 2019; 34:1015-1024. [PMID: 31654282 DOI: 10.1007/s10877-019-00405-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/14/2019] [Indexed: 01/20/2023]
Abstract
To evaluate the use of non-invasive variables for monitoring an open-lung approach (OLA) strategy in bariatric surgery. Twelve morbidly obese patients undergoing bariatric surgery received a baseline protective ventilation with 8 cmH2O of positive-end expiratory pressure (PEEP). Then, the OLA strategy was applied consisting in lung recruitment followed by a decremental PEEP trial, from 20 to 8 cmH2O, in steps of 2 cmH2O to find the lung's closing pressure. Baseline ventilation was then resumed setting open lung PEEP (OL-PEEP) at 2 cmH2O above this pressure. The multimodal non-invasive variables used for monitoring OLA consisted in pulse oximetry (SpO2), respiratory compliance (Crs), end-expiratory lung volume measured by a capnodynamic method (EELVCO2), and esophageal manometry. OL-PEEP was detected at 15.9 ± 1.7 cmH2O corresponding to a positive end-expiratory transpulmonary pressure (PL,ee) of 0.9 ± 1.1 cmH2O. ROC analysis showed that SpO2 was more accurate (AUC 0.92, IC95% 0.87-0.97) than Crs (AUC 0.76, IC95% 0.87-0.97) and EELVCO2 (AUC 0.73, IC95% 0.64-0.82) to detect the lung's closing pressure according to the change of PL,ee from positive to negative values. Compared to baseline ventilation with 8 cmH2O of PEEP, OLA increased EELVCO2 (1309 ± 517 vs. 2177 ± 679 mL) and decreased driving pressure (18.3 ± 2.2 vs. 10.1 ± 1.7 cmH2O), estimated shunt (17.7 ± 3.4 vs. 4.2 ± 1.4%), lung strain (0.39 ± 0.07 vs. 0.22 ± 0.06) and lung elastance (28.4 ± 5.8 vs. 15.3 ± 4.3 cmH2O/L), respectively; all p < 0.0001. The OLA strategy can be monitored using noninvasive variables during bariatric surgery. This strategy decreased lung strain, elastance and driving pressure compared with standard protective ventilatory settings.Clinical trial number NTC03694665.
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Suarez-Sipmann F, Ferrando C, Villar J. PEEP titration guided by transpulmonary pressure: lessons from a negative trial. J Thorac Dis 2019; 11:S1957-S1962. [PMID: 31632797 DOI: 10.21037/jtd.2019.08.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Fernando Suarez-Sipmann
- Department of Critical Care Medicine, Hospital Universitario de La Princesa, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Anesthesiology and Critical Care, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Multidisciplinary Organ Dysfunction Evaluation Research Network (MODERN), Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain.,Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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