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Songsangvorn N, Xu Y, Lu C, Rotstein O, Brochard L, Slutsky AS, Burns KEA, Zhang H. Electrical impedance tomography-guided positive end-expiratory pressure titration in ARDS: a systematic review and meta-analysis. Intensive Care Med 2024; 50:617-631. [PMID: 38512400 PMCID: PMC11078723 DOI: 10.1007/s00134-024-07362-2] [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: 12/16/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE Assessing efficacy of electrical impedance tomography (EIT) in optimizing positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) patients to enhance respiratory system mechanics and prevent ventilator-induced lung injury (VILI), compared to traditional methods. METHODS We carried out a systematic review and meta-analysis, spanning literature from January 2012 to May 2023, sourced from Scopus, PubMed, MEDLINE (Ovid), Cochrane, and LILACS, evaluated EIT-guided PEEP strategies in ARDS versus conventional methods. Thirteen studies (3 randomized, 10 non-randomized) involving 623 ARDS patients were analyzed using random-effects models for primary outcomes (respiratory mechanics and mechanical power) and secondary outcomes (PaO2/FiO2 ratio, mortality, stays in intensive care unit (ICU), ventilator-free days). RESULTS EIT-guided PEEP significantly improved lung compliance (n = 941 cases, mean difference (MD) = 4.33, 95% confidence interval (CI) [2.94, 5.71]), reduced mechanical power (n = 148, MD = - 1.99, 95% CI [- 3.51, - 0.47]), and lowered driving pressure (n = 903, MD = - 1.20, 95% CI [- 2.33, - 0.07]) compared to traditional methods. Sensitivity analysis showed consistent positive effect of EIT-guided PEEP on lung compliance in randomized clinical trials vs. non-randomized studies pooled (MD) = 2.43 (95% CI - 0.39 to 5.26), indicating a trend towards improvement. A reduction in mortality rate (259 patients, relative risk (RR) = 0.64, 95% CI [0.45, 0.91]) was associated with modest improvements in compliance and driving pressure in three studies. CONCLUSIONS EIT facilitates real-time, individualized PEEP adjustments, improving respiratory system mechanics. Integration of EIT as a guiding tool in mechanical ventilation holds potential benefits in preventing ventilator-induced lung injury. Larger-scale studies are essential to validate and optimize EIT's clinical utility in ARDS management.
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Affiliation(s)
- Nickjaree Songsangvorn
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Yonghao Xu
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Cong Lu
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Ori Rotstein
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen E A Burns
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Haibo Zhang
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Physiology, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
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Simonte R, Cammarota G, Vetrugno L, De Robertis E, Longhini F, Spadaro S. Advanced Respiratory Monitoring during Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:2541. [PMID: 38731069 PMCID: PMC11084162 DOI: 10.3390/jcm13092541] [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: 03/17/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Advanced respiratory monitoring encompasses a diverse range of mini- or noninvasive tools used to evaluate various aspects of respiratory function in patients experiencing acute respiratory failure, including those requiring extracorporeal membrane oxygenation (ECMO) support. Among these techniques, key modalities include esophageal pressure measurement (including derived pressures), lung and respiratory muscle ultrasounds, electrical impedance tomography, the monitoring of diaphragm electrical activity, and assessment of flow index. These tools play a critical role in assessing essential parameters such as lung recruitment and overdistention, lung aeration and morphology, ventilation/perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator synchrony. In contrast to conventional methods, advanced respiratory monitoring offers a deeper understanding of pathological changes in lung aeration caused by underlying diseases. Moreover, it allows for meticulous tracking of responses to therapeutic interventions, aiding in the development of personalized respiratory support strategies aimed at preserving lung function and respiratory muscle integrity. The integration of advanced respiratory monitoring represents a significant advancement in the clinical management of acute respiratory failure. It serves as a cornerstone in scenarios where treatment strategies rely on tailored approaches, empowering clinicians to make informed decisions about intervention selection and adjustment. By enabling real-time assessment and modification of respiratory support, advanced monitoring not only optimizes care for patients with acute respiratory distress syndrome but also contributes to improved outcomes and enhanced patient safety.
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Affiliation(s)
- Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Università della Magna Graecia, 88100 Catanzaro, Italy
- Anesthesia and Intensive Care Unit, “R. Dulbecco” University Hospital, 88100 Catanzaro, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44100 Ferrara, Italy;
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Frerichs I, Schädler D, Becher T. Setting positive end-expiratory pressure by using electrical impedance tomography. Curr Opin Crit Care 2024; 30:43-52. [PMID: 38085866 DOI: 10.1097/mcc.0000000000001117] [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 This review presents the principles and possibilities of setting positive end-expiratory pressure (PEEP) using electrical impedance tomography (EIT). It summarizes the major findings of recent studies where EIT was applied to monitor the effects of PEEP on regional lung function and to guide the selection of individualized PEEP setting. RECENT FINDINGS The most frequent approach of utilizing EIT for the assessment of PEEP effects and the PEEP setting during the time period from January 2022 till June 2023 was based on the analysis of pixel tidal impedance variation, typically acquired during stepwise incremental and/or decremental PEEP variation. The most common EIT parameters were the fraction of ventilation in various regions of interest, global inhomogeneity index, center of ventilation, silent spaces, and regional compliance of the respiratory system. The studies focused mainly on the spatial and less on the temporal distribution of ventilation. Contrast-enhanced EIT was applied in a few studies for the estimation of ventilation/perfusion matching. SUMMARY The availability of commercial EIT devices resulted in an increase in clinical studies using this bedside imaging technology in neonatal, pediatric and adult critically ill patients. The clinical interest in EIT became evident but the potential of this method in clinical decision-making still needs to be fully exploited.
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Affiliation(s)
- Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Heines SJH, Becher TH, van der Horst ICC, Bergmans DCJJ. Clinical Applicability of Electrical Impedance Tomography in Patient-Tailored Ventilation: A Narrative Review. Tomography 2023; 9:1903-1932. [PMID: 37888742 PMCID: PMC10611090 DOI: 10.3390/tomography9050150] [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: 08/30/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Electrical Impedance Tomography (EIT) is a non-invasive bedside imaging technique that provides real-time lung ventilation information on critically ill patients. EIT can potentially become a valuable tool for optimising mechanical ventilation, especially in patients with acute respiratory distress syndrome (ARDS). In addition, EIT has been shown to improve the understanding of ventilation distribution and lung aeration, which can help tailor ventilatory strategies according to patient needs. Evidence from critically ill patients shows that EIT can reduce the duration of mechanical ventilation and prevent lung injury due to overdistension or collapse. EIT can also identify the presence of lung collapse or recruitment during a recruitment manoeuvre, which may guide further therapy. Despite its potential benefits, EIT has not yet been widely used in clinical practice. This may, in part, be due to the challenges associated with its implementation, including the need for specialised equipment and trained personnel and further validation of its usefulness in clinical settings. Nevertheless, ongoing research focuses on improving mechanical ventilation and clinical outcomes in critically ill patients.
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Affiliation(s)
- Serge J. H. Heines
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands; (I.C.C.v.d.H.); (D.C.J.J.B.)
| | - Tobias H. Becher
- Department of Anesthesiology and Intensive Care Medicine, Campus Kiel, University Medical Centre Schleswig-Holstein, 24118 Kiel, Germany;
| | - Iwan C. C. van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands; (I.C.C.v.d.H.); (D.C.J.J.B.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands; (I.C.C.v.d.H.); (D.C.J.J.B.)
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6229 ER Maastricht, The Netherlands
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Giani M, Pozzi M, Rona R. Lessons from the COVID-19 Pandemic. J Clin Med 2023; 12:5791. [PMID: 37762732 PMCID: PMC10531926 DOI: 10.3390/jcm12185791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
The COVID-19 pandemic was an unprecedented global crisis that significantly impacted around the world [...].
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Affiliation(s)
- Marco Giani
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy;
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
| | - Matteo Pozzi
- Department of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy;
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
| | - Roberto Rona
- Department of Emergency and Intensive Care, IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
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Prone Positioning Decreases Inhomogeneity and Improves Dorsal Compliance in Invasively Ventilated Spontaneously Breathing COVID-19 Patients—A Study Using Electrical Impedance Tomography. Diagnostics (Basel) 2022; 12:diagnostics12102281. [PMID: 36291970 PMCID: PMC9600133 DOI: 10.3390/diagnostics12102281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/16/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: We studied prone positioning effects on lung aeration in spontaneously breathing invasively ventilated patients with coronavirus disease 2019 (COVID-19). Methods: changes in lung aeration were studied prospectively by electrical impedance tomography (EIT) from before to after placing the patient prone, and back to supine. Mixed effect models with a random intercept and only fixed effects were used to evaluate changes in lung aeration. Results: fifteen spontaneously breathing invasively ventilated patients were enrolled, and remained prone for a median of 19 [17 to 21] hours. At 16 h the global inhomogeneity index was lower. At 2 h, there were neither changes in dorsal nor in ventral compliance; after 16 h, only dorsal compliance (βFe +18.9 [95% Confidence interval (CI): 9.1 to 28.8]) and dorsal end-expiratory lung impedance (EELI) were increased (βFe, +252 [95% CI: 13 to 496]); at 2 and 16 h, dorsal silent spaces was unchanged (βFe, –4.6 [95% CI: –12.3 to +3.2]). The observed changes induced by prone positioning disappeared after turning patients back to supine. Conclusions: in this cohort of spontaneously breathing invasively ventilated COVID-19 patients, prone positioning decreased inhomogeneity, increased lung volumes, and improved dorsal compliance.
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Severe COVID-19 ARDS Treated by Bronchoalveolar Lavage with Diluted Exogenous Pulmonary Surfactant as Salvage Therapy: In Pursuit of the Holy Grail? J Clin Med 2022; 11:jcm11133577. [PMID: 35806862 PMCID: PMC9267619 DOI: 10.3390/jcm11133577] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 12/27/2022] Open
Abstract
Background: Severe pneumonia caused by coronavirus disease 2019 (COVID-19) is characterized by inflammatory lung injury, progressive parenchymal stiffening and consolidation, alveolar and airway collapse, altered vascular permeability, diffuse alveolar damage, and surfactant deficiency. COVID-19 causes both pneumonia and acute respiratory distress syndrome (COVID-19 ARDS). COVID-19 ARDS is characterized by severe refractory hypoxemia and high mortality. Despite extensive research, the treatment of COVID-19 ARDS is far from satisfactory. Some treatments are recommended for exhibiting some clinically positive impacts on COVID-19 patients although there are already several drugs in clinical trials, some of which are already demonstrating promising results in addressing COVID-19. Few studies have demonstrated beneficial effects in non-COVID-19 ARDS treatment of exogenous surfactant, and there is no evidence-based, proven method for the procedure of surfactant administration. Aim: The aim of this work is to underline the key role of ATII cells and reduced surfactant levels in COVID-19 ARDS and to emphasize the rational basis for exogenous surfactant therapy in COVID-19 ARDS, providing insights for future research. Methods: In this article, we describe and support via the literature the decision to administer large volumes of surfactant to two patients via bronchoalveolar lavage to maximize its distribution in the respiratory tract. Results: In this study, we report on two cases of COVID-19 ARDS in patients who have been successfully treated with diluted surfactants by bronchoalveolar lavage, followed by a low-dose bolus of surfactant. Conclusion: Combining the administration of diluted, exogenous pulmonary surfactant via bronchoalveolar lavage along with the standard therapy for SARS-CoV-2-induced ARDS may be a promising way of improving the management of ARDS.
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