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Fiedler MO, Muellenbach RM, Rolfes C, Lotz C, Nickel F, Müller-Stich BP, Supady A, Lepper PM, Weigand MA, Meybohm P, Kalenka A, Reyher C. Pumpless Extracorporeal Hemadsorption Technique (pEHAT): A Proof-of-Concept Animal Study. J Clin Med 2022; 11:jcm11226815. [PMID: 36431292 PMCID: PMC9692831 DOI: 10.3390/jcm11226815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Extracorporeal hemadsorption eliminates proinflammatory mediators in critically ill patients with hyperinflammation. The use of a pumpless extracorporeal hemadsorption technique allows its early usage prior to organ failure and the need for an additional medical device. In our animal model, we investigated the feasibility of pumpless extracorporeal hemadsorption over a wide range of mean arterial pressures (MAP). Methods: An arteriovenous shunt between the femoral artery and femoral vein was established in eight pigs. The hemadsorption devices were inserted into the shunt circulation; four pigs received CytoSorb® and four Oxiris® hemadsorbers. Extracorporeal blood flow was measured in a range between mean arterial pressures of 45-85 mmHg. Mean arterial pressures were preset using intravenous infusions of noradrenaline, urapidil, or increased sedatives. Results: Extracorporeal blood flows remained well above the minimum flows recommended by the manufacturers throughout all MAP steps for both devices. Linear regression resulted in CytoSorb® blood flow [mL/min] = 4.226 × MAP [mmHg] - 3.496 (R-square 0.8133) and Oxiris® blood flow [mL/min] = 3.267 × MAP [mmHg] + 57.63 (R-square 0.8708), respectively. Conclusion: Arteriovenous pumpless extracorporeal hemadsorption resulted in sufficient blood flows through both the CytoSorb® and Oxiris® devices over a wide range of mean arterial blood pressures and is likely an intriguing therapeutic option in the early phase of septic shock or hyperinflammatory syndromes.
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Affiliation(s)
- Mascha O. Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-(0)62221-56-39434
| | - Ralf M. Muellenbach
- Department of Anesthesiology, Critical Care Medicine, Emergency Medicine and Pain Therapy, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
| | - Caroline Rolfes
- Department of Anesthesiology, Critical Care Medicine, Emergency Medicine and Pain Therapy, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
| | - Christopher Lotz
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Beat P. Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Alexander Supady
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany
- Heidelberg Institute of Global Health, University of Heidelberg, 69117 Heidelberg, Germany
| | - Philipp M. Lepper
- Department of Internal Medicine V—Pneumology, Allergology and Critical Care Medicine, University Medical Centre, Saarland University, 66424 Homburg, Germany
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Armin Kalenka
- Department of Anesthesiology and Intensive Care Medicine, Hospital Bergstrasse, 64646 Heppenheim, Germany
| | - Christian Reyher
- Department of Anesthesiology, Critical Care Medicine, Emergency Medicine and Pain Therapy, Campus Kassel of the University of Southampton, 34125 Kassel, Germany
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Miller AG, Tan HL, Smith BJ, Rotta AT, Lee JH. The Physiological Basis of High-Frequency Oscillatory Ventilation and Current Evidence in Adults and Children: A Narrative Review. Front Physiol 2022; 13:813478. [PMID: 35557962 PMCID: PMC9087180 DOI: 10.3389/fphys.2022.813478] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/08/2022] [Indexed: 12/12/2022] Open
Abstract
High-frequency oscillatory ventilation (HFOV) is a type of invasive mechanical ventilation that employs supra-physiologic respiratory rates and low tidal volumes (VT) that approximate the anatomic deadspace. During HFOV, mean airway pressure is set and gas is then displaced towards and away from the patient through a piston. Carbon dioxide (CO2) is cleared based on the power (amplitude) setting and frequency, with lower frequencies resulting in higher VT and CO2 clearance. Airway pressure amplitude is significantly attenuated throughout the respiratory system and mechanical strain and stress on the alveoli are theoretically minimized. HFOV has been purported as a form of lung protective ventilation that minimizes volutrauma, atelectrauma, and biotrauma. Following two large randomized controlled trials showing no benefit and harm, respectively, HFOV has largely been abandoned in adults with ARDS. A multi-center clinical trial in children is ongoing. This article aims to review the physiologic rationale for the use of HFOV in patients with acute respiratory failure, summarize relevant bench and animal models, and discuss the potential use of HFOV as a primary and rescue mode in adults and children with severe respiratory failure.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Respiratory Care Services, Durham, NC, United States
| | - Herng Lee Tan
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore
| | - Brian J Smith
- University of California, Davis, Respiratory Care Services, Sacramento, CA, United States
| | - Alexandre T Rotta
- Duke University Medical Center, Division of Pediatric Critical Care Medicine, Durham, NC, United States
| | - Jan Hau Lee
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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Laviola M, Rafl J, Rozanek M, Kudrna P, Roubik K. Models of PaO2response to the continuous distending pressure maneuver during high frequency oscillatory ventilation in healthy and ARDS lung model pigs. Exp Lung Res 2016; 42:87-94. [DOI: 10.3109/01902148.2016.1145307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Johannes A, Zollhoefer B, Eujen U, Kredel M, Rauch S, Roewer N, Muellenbach RM. Deviation of tracheal pressure from airway opening pressure during high-frequency oscillatory ventilation in a porcine lung model. Exp Lung Res 2013; 39:130-5. [PMID: 23458472 DOI: 10.3109/01902148.2013.772680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Oxygenation during high-frequency oscillatory ventilation is secured by a high level of mean airway pressure. Our objective was to identify a pressure difference between the airway opening of the respiratory circuit and the trachea during application of different oscillatory frequencies. Six female Pietrain pigs (57.1 ± 3.6 kg) were first ventilated in a conventional mechanical ventilation mode. Subsequently, the animals were switched to high-frequency oscillatory ventilation by setting mean airway opening pressure 5 cmH(2)O above the one measured during controlled mechanical ventilation. Measurements at the airway opening and at tracheal levels were performed in healthy lungs and after induction of acute lung injury by surfactant depletion. During high-frequency oscillatory ventilation, the airway opening pressure was set at a constant level. The pressure amplitude was fixed at 90 cmH(2)O. Starting from an oscillatory frequency of 3 Hz, the frequency was increased in steps of 3 Hz to 15 Hz and then decreased accordingly. At each frequency, measurements were performed in the trachea through a side-lumen of the endotracheal tube and the airway opening pressure was recorded. The pressure difference was calculated. At every oscillatory frequency, a pressure loss towards the trachea could be shown. This pressure difference increased with higher oscillatory frequencies (3 Hz 2.2 ± 2.1 cmH(2)O vs. 15 Hz 7.5 ± 1.8 cmH(2)O). The results for healthy and injured lungs were similar. Tracheal pressures decreased with higher oscillatory frequencies. This may lead to pulmonary derecruitment. This has to be taken into consideration when increasing oscillatory frequencies and differentiated pressure settings are mandatory.
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Affiliation(s)
- Amélie Johannes
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
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Kredel M, Muellenbach RM, Johannes A, Brederlau J, Roewer N, Wunder C. Hepatic effects of lung-protective pressure-controlled ventilation and a combination of high-frequency oscillatory ventilation and extracorporeal lung assist in experimental lung injury. Med Sci Monit 2012; 17:BR275-81. [PMID: 21959601 PMCID: PMC3539465 DOI: 10.12659/msm.881974] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Ventilation with high positive end-expiratory pressure (PEEP) can lead to hepatic dysfunction. The aim of this study was to investigate the hepatic effects of strategies using high airway pressures either in pressure-controlled ventilation (PCV) or in high-frequency oscillatory ventilation (HFOV) combined with an arteriovenous extracorporeal lung assist (ECLA). Material/Methods Pietrain pigs underwent induction of lung injury by saline lavage. Ventilation was continued for 24 hours either as PCV with tidal volumes of 6 ml/kg and PEEP 3 cmH2O above the lower inflection point of the pressure-volume curve or as HFOV (≥12 Hz) with a mean tracheal airway pressure 3 cmH2O above the lower inflection point combined with arteriovenous ECLA (HFOV+ECLA). Fluids and norepinephrine stabilized the circulation. The indocyanine green plasma disappearance rate, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, γ-glutamyltransferase, alkaline phosphatase, glutamate dehydrogenase, lactate dehydrogenase and creatine kinase were determined repeatedly. Finally, liver neutrophils were counted and liver cell apoptosis was assessed by terminal deoxynucleotidyl transferase nick end labeling (TUNEL). Results Aspartate aminotransferase increased in the PCV group about three-fold and in the HFOV+ECLA group five-fold (p<0.001). Correspondingly, creatine kinase increased about two-fold and four-fold, respectively (p<0.001). Lactate dehydrogenase was increased in the HFOV+ECLA group (p<0.028). The number of neutrophils infiltrating the liver tissue and the apoptotic index were low. Conclusions High airway pressure PCV and HFOV with ECLA in the treatment of lavage-induced lung injury in pigs did not cause liver dysfunction or damage. The detected elevation of enzymes might be of extrahepatic origin.
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Affiliation(s)
- Markus Kredel
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
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High-frequency oscillatory ventilation with and without arteriovenous extracorporeal lung assist in patients with severe respiratory failure. J Crit Care 2011; 27:182-91. [PMID: 22033057 DOI: 10.1016/j.jcrc.2011.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 07/26/2011] [Accepted: 08/09/2011] [Indexed: 01/08/2023]
Abstract
PURPOSE Elimination of carbon dioxide by an arteriovenous extracorporeal lung assist (av-ECLA) can facilitate the lung protective capabilities of high-frequency oscillatory ventilation (HFOV). This case series describes patients treated with HFOV because of severe respiratory failure with and without additional av-ECLA. METHODS A retrospective analysis of 31 patients regarding patient characteristics, gas exchange, respirator settings, hemodynamics, and outcome. In 18 patients, av-ECLA was started before, together with, or during HFOV. RESULTS The initial arterial carbon dioxide tension before HFOV and av-ECLA was higher in patients who received av-ECLA compared with patients without (P = .043): 65 (48-84) mm Hg and 50 (44-60) mmHg (median and interquartile range). The initial arterial oxygen tension (Pao(2))/inspiratory oxygen fraction (Fio(2)) index in patients who received av-ECLA was 79 (63-133) mm Hg. The Pao(2)/Fio(2) index immediately before HFOV was 84 (65-124) mm Hg (av-ECLA) and 121 (68-150) mmHg (no av-ECLA) and improved to 149 (89-231) mm Hg and 200 (117-233) mmHg during HFOV. Similarly, the oxygenation index improved. No statistically significant differences among groups were detected for Pao(2)/Fio(2) index, oxygenation index, and arterial carbon dioxide tension immediately before and during HFOV. The hospital mortality was 39% (av-ECLA) and 69% (no av-ECLA). CONCLUSIONS High-frequency oscillatory ventilation improved the oxygenation in patients with severe respiratory failure. Additional av-ECLA may facilitate using lung protective HFOV settings in more severe lung injury and hypercapnia.
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