1
|
D'Albo R, Pozzi T, Nicolardi RV, Galizia M, Catozzi G, Ghidoni V, Donati B, Romitti F, Herrmann P, Busana M, Gattarello S, Collino F, Sonzogni A, Camporota L, Marini JJ, Moerer O, Meissner K, Gattinoni L. Mechanical power ratio threshold for ventilator-induced lung injury. Intensive Care Med Exp 2024; 12:65. [PMID: 39080225 PMCID: PMC11289208 DOI: 10.1186/s40635-024-00649-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024] Open
Abstract
RATIONALE Mechanical power (MP) is a summary variable incorporating all causes of ventilator-induced-lung-injury (VILI). We expressed MP as the ratio between observed and normal expected values (MPratio). OBJECTIVE To define a threshold value of MPratio leading to the development of VILI. METHODS In a population of 82 healthy pigs, a threshold of MPratio for VILI, as assessed by histological variables and confirmed by using unsupervised cluster analysis was 4.5. The population was divided into two groups with MPratio above or below the threshold. MEASUREMENTS AND MAIN RESULTS We measured physiological variables every six hours. At the end of the experiment, we measured lung weight and wet-to-dry ratio to quantify edema. Histological samples were analyzed for alveolar ruptures, inflammation, alveolar edema, atelectasis. An MPratio threshold of 4.5 was associated with worse injury, lung weight, wet-to-dry ratio and fluid balance (all p < 0.001). After 48 h, in the two MPratio clusters (above or below 4.5), respiratory system elastance, mean pulmonary artery pressure and physiological dead space differed by 32%, 36% and 22%, respectively (all p < 0.001), being worse in the high MPratio group. Also, the changes in driving pressure, lung elastance, pulmonary artery occlusion pressure, central venous pressure differed by 17%, 64%, 8%, 25%, respectively (all p < 0.001). LIMITATIONS The main limitation of this study is its retrospective design. In addition, the computation for the expected MP in pigs is based on arbitrary criteria. Different values of expected MP may change the absolute value of MP ratio but will not change the concept of the existence of an injury threshold. CONCLUSIONS The concept of MPratio is a physiological and intuitive way to quantify the risk of ventilator-induced lung injury. Our results suggest that a mechanical power ratio > 4.5 MPratio in healthy lungs subjected to 48 h of mechanical ventilation appears to be a threshold for the development of ventilator-induced lung injury, as indicated by the convergence of histological, physiological, and anatomical alterations. In humans and in lungs that are already injured, this threshold is likely to be different.
Collapse
Affiliation(s)
- Rosanna D'Albo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Rosmery V Nicolardi
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Galizia
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Giulia Catozzi
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Valentina Ghidoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Beatrice Donati
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "City of Health and Science" Hospital, Turin, Italy
| | | | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany.
| |
Collapse
|
2
|
Gattinoni L, Collino F, Camporota L. Ventilator induced lung injury: a case for a larger umbrella? Intensive Care Med 2024; 50:275-278. [PMID: 38172299 PMCID: PMC10907410 DOI: 10.1007/s00134-023-07296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Piemonte, Turin, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Centre for Human and Applied Physiological Sciences, Guy's and St. Thomas' NHS Foundation Trust, King's College London, London, UK
| |
Collapse
|
3
|
Thornton LT, Kummer RL, Marini JJ. The place of positive end expiratory pressure in ventilator-induced lung injury generation. Curr Opin Crit Care 2024; 30:4-9. [PMID: 38085885 DOI: 10.1097/mcc.0000000000001118] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW Describe the rationale for concern and accumulating pathophysiologic evidence regarding the adverse effects of high-level positive end expiratory pressure (PEEP) on excessive mechanical stress and ventilator-induced lung injury (VILI). RECENT FINDINGS Although the inclusion of PEEP in numerical estimates of mechanical power may be theoretically debated, its potential to increase stress, strain, and mean airway pressure are not. Recent laboratory data in a variety of animal models demonstrate that higher levels of PEEP coupled with additional fluids needed to offset its impediment of hemodynamic function are associated with increased VILI. Moreover, counteracting end-tidal hyperinflation by external chest wall pressure may paradoxically improve respiratory mechanics, indicating that lower PEEP helps protect the small 'baby lung' of advanced acute respiratory distress syndrome (ARDS). SUMMARY The potentially adverse effects of PEEP on VILI can be considered in three broad categories. First, the contribution of PEEP to total mechanical energy expressed through mechanical power, raised mean airway pressure, and end-tidal hyperinflation; second, the hemodynamic consequences of altered cardiac loading, heightened pulmonary vascular stress and total lung water; and third, the ventilatory consequences of compromised carbon dioxide eliminating efficiency. Minimizing ventilation demands, optimized body positioning and care to avoid unnecessary PEEP are central to lung protection in all stages of ARDS.
Collapse
Affiliation(s)
- Lauren T Thornton
- University of Minnesota, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Minneapolis, St. Paul, Minnesota, USA
| | | | | |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Zheng G, Harms AK, Tail M, Zhang H, Nimmo A, Skutella T, Kiening K, Unterberg A, Zweckberger K, Younsi A. Effects of a neurokinin-1 receptor antagonist in the acute phase after thoracic spinal cord injury in a rat model. Front Mol Neurosci 2023; 16:1128545. [PMID: 37251648 PMCID: PMC10213275 DOI: 10.3389/fnmol.2023.1128545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/17/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Disruption of the blood-spinal cord barrier (BSCB) with subsequent edema formation and further neuroinflammation contributes to aggravation of spinal cord injury (SCI). We aimed to observe the effect of antagonizing the binding of the neuropeptide Substance-P (SP) to its neurokinin-1 (NK1) receptor in a rodent SCI model. Methods Female Wistar rats were subjected to a T9 laminectomy with or without (Sham) a T9 clip-contusion/compression SCI, followed by the implantation of an osmotic pump for the continuous, seven-day-long infusion of a NK1 receptor antagonist (NRA) or saline (vehicle) into the intrathecal space. The animals were assessed via MRI, and behavioral tests were performed during the experiment. 7 days after SCI, wet & dry weight and immunohistological analyses were conducted. Results Substance-P inhibition via NRA showed limited effects on reducing edema. However, the invasion of T-lymphocytes and the number of apoptotic cells were significantly reduced with the NRA treatment. Moreover, a trend of reduced fibrinogen leakage, endothelial and microglial activation, CS-GAG deposition, and astrogliosis was found. Nevertheless, only insignificant general locomotion recovery could be observed in the BBB open field score and the Gridwalk test. In contrast, the CatWalk gait analysis showed an early onset of recovery in several parameters. Conclusion Intrathecal administration of NRA might reinforce the integrity of the BSCB in the acute phase after SCI, potentially attenuating aspects of neurogenic inflammation, reducing edema formation, and improving functional recovery.
Collapse
Affiliation(s)
- Guoli Zheng
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anna-Kathrin Harms
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohamed Tail
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Hao Zhang
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Alan Nimmo
- College of Medicine and Dentistry, James Cook University, Cairns, QLD, Australia
| | - Thomas Skutella
- Department of Neuroanatomy, Institute for Anatomy and Cell Biology, University of Heidelberg, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
6
|
Calero Rodriguez A, Oostrom H, Grauw J. Long‐term mechanical ventilation of an 8‐week‐old dog with idiopathic polyradiculoneuritis. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Abraham Calero Rodriguez
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
| | - Hugo Oostrom
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
| | - Janny Grauw
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
| |
Collapse
|
7
|
Gattinoni L, Marini JJ. In search of the Holy Grail: identifying the best PEEP in ventilated patients. Intensive Care Med 2022; 48:728-731. [PMID: 35513707 PMCID: PMC9205826 DOI: 10.1007/s00134-022-06698-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/06/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - John J. Marini
- Pulmonary and Critical Care Medicine, Regions Hospital and University of Minnesota, St. Paul, MN USA
| |
Collapse
|
8
|
Palumbo P, Palumbo MM, Bruno F, Picchi G, Iacopino A, Acanfora C, Sgalambro F, Arrigoni F, Ciccullo A, Cosimini B, Splendiani A, Barile A, Masedu F, Grimaldi A, Di Cesare E, Masciocchi C. Automated Quantitative Lung CT Improves Prognostication in Non-ICU COVID-19 Patients beyond Conventional Biomarkers of Disease. Diagnostics (Basel) 2021; 11:2125. [PMID: 34829472 PMCID: PMC8624922 DOI: 10.3390/diagnostics11112125] [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: 10/14/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 12/22/2022] Open
Abstract
(1) Background: COVID-19 continues to represent a worrying pandemic. Despite the high percentage of non-severe illness, a wide clinical variability is often reported in real-world practice. Accurate predictors of disease aggressiveness, however, are still lacking. The purpose of our study was to evaluate the impact of quantitative analysis of lung computed tomography (CT) on non-intensive care unit (ICU) COVID-19 patients' prognostication; (2) Methods: Our historical prospective study included fifty-five COVID-19 patients consecutively submitted to unenhanced lung CT. Primary outcomes were recorded during hospitalization, including composite ICU admission for the need of mechanical ventilation and/or death occurrence. CT examinations were retrospectively evaluated to automatically calculate differently aerated lung tissues (i.e., overinflated, well-aerated, poorly aerated, and non-aerated tissue). Scores based on the percentage of lung weight and volume were also calculated; (3) Results: Patients who reported disease progression showed lower total lung volume. Inflammatory indices correlated with indices of respiratory failure and high-density areas. Moreover, non-aerated and poorly aerated lung tissue resulted significantly higher in patients with disease progression. Notably, non-aerated lung tissue was independently associated with disease progression (HR: 1.02; p-value: 0.046). When different predictive models including clinical, laboratoristic, and CT findings were analyzed, the best predictive validity was reached by the model that included non-aerated tissue (C-index: 0.97; p-value: 0.0001); (4) Conclusions: Quantitative lung CT offers wide advantages in COVID-19 disease stratification. Non-aerated lung tissue is more likely to occur with severe inflammation status, turning out to be a strong predictor for disease aggressiveness; therefore, it should be included in the predictive model of COVID-19 patients.
Collapse
Affiliation(s)
- Pierpaolo Palumbo
- Department of Diagnostic Imaging, Area of Cardiovascular and Interventional Imaging, Abruzzo Health Unit 1, Via Saragat, Località Campo di Pile, 67100 L’Aquila, Italy;
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy;
| | - Maria Michela Palumbo
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of The Sacred Heart, 00168 Rome, Italy;
| | - Federico Bruno
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy;
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| | - Giovanna Picchi
- Infectious Disease Unit, San Salvatore Hospital, Via Lorenzo Natali, 1-Località Coppito, 67100 L’Aquila, Italy; (G.P.); (A.C.); (A.G.)
| | - Antonio Iacopino
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| | - Chiara Acanfora
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| | - Ferruccio Sgalambro
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| | - Francesco Arrigoni
- Department of Diagnostic Imaging, Area of Cardiovascular and Interventional Imaging, Abruzzo Health Unit 1, Via Saragat, Località Campo di Pile, 67100 L’Aquila, Italy;
| | - Arturo Ciccullo
- Infectious Disease Unit, San Salvatore Hospital, Via Lorenzo Natali, 1-Località Coppito, 67100 L’Aquila, Italy; (G.P.); (A.C.); (A.G.)
| | - Benedetta Cosimini
- Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (B.C.); (E.D.C.)
| | - Alessandra Splendiani
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| | - Antonio Barile
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| | - Francesco Masedu
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| | - Alessandro Grimaldi
- Infectious Disease Unit, San Salvatore Hospital, Via Lorenzo Natali, 1-Località Coppito, 67100 L’Aquila, Italy; (G.P.); (A.C.); (A.G.)
| | - Ernesto Di Cesare
- Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (B.C.); (E.D.C.)
| | - Carlo Masciocchi
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy; (A.I.); (C.A.); (F.S.); (A.S.); (F.M.); (C.M.)
| |
Collapse
|