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Ernest EE, Bhattacharjee S, Baidya DK, Anand RK, Ray BR, Bansal VK, Subramaniam R, Maitra S. Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial. J Clin Monit Comput 2024; 38:445-454. [PMID: 37968546 DOI: 10.1007/s10877-023-01091-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/08/2023] [Indexed: 11/17/2023]
Abstract
Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.
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Affiliation(s)
- Emmanuel Easterson Ernest
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Sulagna Bhattacharjee
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Rahul K Anand
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Bikash R Ray
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Virinder K Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India.
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Karthik AR, Gupta N, Garg R, Bharati SJ, Ray MD, Hadda V, Pahuja S, Mishra S, Bhatnagar S, Kumar V. Comparison of lung aeration loss in open abdominal oncologic surgeries after ventilation with electrical impedance tomography-guided PEEP versus conventional PEEP: a pilot feasibility study. Korean J Anesthesiol 2024:kja.23858. [PMID: 38438222 DOI: 10.4097/kja.23858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/15/2024] [Indexed: 03/06/2024] Open
Abstract
Background Existing literature lacks high-quality evidence regarding the ideal intraoperative positive end-expiratory pressure (PEEP) to minimize postoperative pulmonary complications (PPCs). We hypothesized that applying individualized PEEP derived from electrical impedance tomography (EIT) would reduce the severity of postoperative lung aeration loss, deterioration in oxygenation, and PPC incidence. Methods A pilot feasibility study was conducted on 36 patients who underwent open abdominal oncologic surgery. The patients were randomized to receive individualized PEEP or conventional PEEP at 4 cm H2O. The primary outcome was the impact of individualized PEEP on changes in the modified lung ultrasound score (MLUS) derived from preoperative and postoperative lung ultrasonography. A higher MLUS indicated greater lung aeration loss. The secondary outcomes were the PaO2/FIO2 ratio and PPC incidence. Results A significant increase in the postoperative MLUS (12 ± 3.6 vs 7.9 ± 2.1, P < 0.001) and a significant difference between the postoperative and preoperative MLUS values (7.0 ± 3.3 vs 3.0 ± 1.6, P < 0.001) were found in the conventional PEEP group, indicating increased lung aeration loss. In the conventional PEEP group, the intraoperative PaO2/FIO2 ratios were significantly lower but not the postoperative ratios. The PPC incidence was not significantly different between the groups. Post-hoc analysis showed the increase in lung aeration loss and deterioration of intraoperative oxygenation correlated with the deviation from the individualized PEEP. Conclusions Individualized PEEP appears to protect against lung aeration loss and intraoperative oxygenation deterioration. The advantage was greater in patients whose individualized PEEP deviated more from the conventional PEEP.
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Affiliation(s)
- A R Karthik
- Department of Anaesthesiology, Cancer Institute (WIA), Adyar, Chennai, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BR.A. Institute Rotary Cancer Hospital, AIIMS, Ansari Nagar, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BR.A. Institute Rotary Cancer Hospital, AIIMS, Ansari Nagar, New Delhi, India
| | - Sachidanand Jee Bharati
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BR.A. Institute Rotary Cancer Hospital, AIIMS, Ansari Nagar, New Delhi, India
| | - M D Ray
- Department of Surgical Oncology, Dr. BR.A. Institute Rotary Cancer Hospital, AIIMS, Ansari Nagar, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, Ansari Nagar, New Delhi, India
| | - Sourabh Pahuja
- Department of Pulmonary Medicine, Amrita Hospital, Faridabad, India
| | - Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BR.A. Institute Rotary Cancer Hospital, AIIMS, Ansari Nagar, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BR.A. Institute Rotary Cancer Hospital, AIIMS, Ansari Nagar, New Delhi, India
| | - Vinod Kumar
- Department of Anaesthesiology, University of Minnesota Medical School, Minneapolis, MN, USA
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Pavlovsky B, Desprez C, Richard JC, Fage N, Lesimple A, Chean D, Courtais A, Mauri T, Mercat A, Beloncle F. Bedside personalized methods based on electrical impedance tomography or respiratory mechanics to set PEEP in ARDS and recruitment-to-inflation ratio: a physiologic study. Ann Intensive Care 2024; 14:1. [PMID: 38180544 PMCID: PMC10769993 DOI: 10.1186/s13613-023-01228-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Various Positive End-Expiratory Pressure (PEEP) titration strategies have been proposed to optimize ventilation in patients with acute respiratory distress syndrome (ARDS). We aimed to compare PEEP titration strategies based on electrical impedance tomography (EIT) to methods derived from respiratory system mechanics with or without esophageal pressure measurements, in terms of PEEP levels and association with recruitability. METHODS Nineteen patients with ARDS were enrolled. Recruitability was assessed by the estimated Recruitment-to-Inflation ratio (R/Iest) between PEEP 15 and 5 cmH2O. Then, a decremental PEEP trial from PEEP 20 to 5 cmH2O was performed. PEEP levels determined by the following strategies were studied: (1) plateau pressure 28-30 cmH2O (Express), (2) minimal positive expiratory transpulmonary pressure (Positive PLe), (3) center of ventilation closest to 0.5 (CoV) and (4) intersection of the EIT-based overdistension and lung collapse curves (Crossing Point). In addition, the PEEP levels determined by the Crossing Point strategy were assessed using different PEEP ranges during the decremental PEEP trial. RESULTS Express and CoV strategies led to higher PEEP levels than the Positive PLe and Crossing Point ones (17 [14-17], 20 [17-20], 8 [5-11], 10 [8-11] respectively, p < 0.001). For each strategy, there was no significant association between the optimal PEEP level and R/Iest (Crossing Point: r2 = 0.073, p = 0.263; CoV: r2 < 0.001, p = 0.941; Express: r2 < 0.001, p = 0.920; Positive PLe: r2 = 0.037, p = 0.461). The PEEP level obtained with the Crossing Point strategy was impacted by the PEEP range used during the decremental PEEP trial. CONCLUSIONS CoV and Express strategies led to higher PEEP levels than the Crossing Point and Positive PLe strategies. Optimal PEEP levels proposed by these four methods were not associated with recruitability. Recruitability should be specifically assessed in ARDS patients to optimize PEEP titration.
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Affiliation(s)
- Bertrand Pavlovsky
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France.
| | - Christophe Desprez
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Nicolas Fage
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Arnaud Lesimple
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Dara Chean
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Antonin Courtais
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research, Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alain Mercat
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - François Beloncle
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
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Shu B, Zhang Y, Ren Q, Zheng X, Zhang Y, Liu Q, Li S, Chen J, Chen Y, Duan G, Huang H. Optimal positive end-expiratory pressure titration of intraoperative mechanical ventilation in different operative positions of female patients under general anesthesia. Heliyon 2023; 9:e20552. [PMID: 37822628 PMCID: PMC10562915 DOI: 10.1016/j.heliyon.2023.e20552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
Objective This study aimed to compare the effectiveness and safety of different titrated methods used to determine individual positive end-expiratory pressure (PEEP) for intraoperative mechanical ventilation in female patients undergoing general anesthesia in different operative positions, and provide reference ranges of optimal PEEP values based on the titration. Methods A total of 123 female patients who underwent elective open abdominal surgery under general anesthesia were included in this study. After endotracheal intubation, patients' body position was adjusted to the supine position, Trendelenburg positions at 10° and 20° respectively. PEEP was titrated from 20 cmH2O to 4 cmH2O, decreasing by 2 cmH2O every 1 min. Electrical impedance tomography (EIT), hemodynamic and respiratory mechanics parameters were continuously monitored and recorded. Optimal PEEP values and reference ranges were respectively calculated based on optimal EIT parameters, mean arterial pressure (MAP), and lung dynamic compliance (Cdyn). Results EIT-guided optimal PEEP was found to have higher values than those of the MAP-guided and Cdyn-guided methods for all three body positions (P < 0.001), and it was observed to more significantly inhibit hemodynamics (P < 0.05). The variable coefficients of EIT-guided optimal PEEP values were smaller than those of the other two methods, and this technique could provide better ventilation uniformity for dorsal/ventral lung fields and better balance for pulmonary atelectasis/collapse. The 95% reference ranges of EIT-guided optimal PEEP values were 4.6-13.8 cmH2O, 7.0-15.0 cmH2O and 8.6-17.0 cmH2O for the supine position, Trendelenburg 10°, and Trendelenburg 20° positions, respectively. Conclusion EIT-guided optimal PEEP titration was found to be a superior method for lung protective ventilation in different operative positions under general anesthesia. The calculated reference ranges of PEEP values based on the EIT-guided method can be used as a reference for intraoperative mechanical ventilation.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qian Ren
- Department of Anesthesiology, Chongqing University Three Gorges Hospital, Chongqing, 404000, China
| | - Xuemei Zheng
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yamei Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qi Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Shiqi Li
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Jie Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yuanjing Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - He Huang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
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Novaes APLD, Campos SL, Leite WS, Morais CC, de Andrade ADFD, Gonçalves ACE, Moraes F, Brandão DC. Comparison Among Three PEEP Titration Methods Monitored by Electrical Impedance Tomography in COVID-19. Respir Care 2023; 69:respcare.10627. [PMID: 37580123 PMCID: PMC10753601 DOI: 10.4187/respcare.10627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Affiliation(s)
| | - Shirley Lima Campos
- Physiotherapy Department, Universidade Federal de Pernambuco, Recife, Brazil
| | - Wagner Souza Leite
- Physiotherapy Department, Universidade Federal de Pernambuco, Recife, Brazil
| | - Caio Ca Morais
- Physiotherapy Department, Universidade Federal de Pernambuco, Recife, Brazil
| | | | | | - Fernando Moraes
- Departamento de Cirurgia, Federal University of Pernambuco, Recife, Brazil
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Zeng C, Zhu M, Motta-Ribeiro G, Lagier D, Hinoshita T, Zang M, Grogg K, Winkler T, Vidal Melo MF. Dynamic lung aeration and strain with positive end-expiratory pressure individualized to maximal compliance versus ARDSNet low-stretch strategy: a study in a surfactant depletion model of lung injury. Crit Care 2023; 27:307. [PMID: 37537654 PMCID: PMC10401825 DOI: 10.1186/s13054-023-04591-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) individualized to a maximal respiratory system compliance directly implies minimal driving pressures with potential outcome benefits, yet, raises concerns on static and dynamic overinflation, strain and cyclic recruitment. Detailed accurate assessment and understanding of these has been hampered by methodological limitations. We aimed to investigate the effects of a maximal compliance-guided PEEP strategy on dynamic lung aeration, strain and tidal recruitment using current four-dimensional computed tomography (CT) techniques and analytical methods of tissue deformation in a surfactant depletion experimental model of acute respiratory distress syndrome (ARDS). METHODS ARDS was induced by saline lung lavage in anesthetized and mechanically ventilated healthy sheep (n = 6). Animals were ventilated in a random sequence with: (1) ARDSNet low-stretch protocol; (2) maximal compliance PEEP strategy. Lung aeration, strain and tidal recruitment were acquired with whole-lung respiratory-gated high-resolution CT and quantified using registration-based techniques. RESULTS Relative to the ARDSNet low-stretch protocol, the maximal compliance PEEP strategy resulted in: (1) improved dynamic whole-lung aeration at end-expiration (0.456 ± 0.064 vs. 0.377 ± 0.101, P = 0.019) and end-inspiration (0.514 ± 0.079 vs. 0.446 ± 0.083, P = 0.012) with reduced non-aerated and increased normally-aerated lung mass without associated hyperinflation; (2) decreased aeration heterogeneity at end-expiration (coefficient of variation: 0.498 ± 0.078 vs. 0.711 ± 0.207, P = 0.025) and end-inspiration (0.419 ± 0.135 vs. 0.580 ± 0.108, P = 0.014) with higher aeration in dorsal regions; (3) tidal aeration with larger inspiratory increases in normally-aerated and decreases in poorly-aerated areas, and negligible in hyperinflated lung (Aeration × Strategy: P = 0.026); (4) reduced tidal strains in lung regions with normal-aeration (Aeration × Strategy: P = 0.047) and improved regional distributions with lower tidal strains in middle and ventral lung (Region-of-interest [ROI] × Strategy: P < 0.001); and (5) less tidal recruitment in middle and dorsal lung (ROI × Strategy: P = 0.044) directly related to whole-lung tidal strain (r = 0.751, P = 0.007). CONCLUSIONS In well-recruitable ARDS models, a maximal compliance PEEP strategy improved end-expiratory/inspiratory whole-lung aeration and its homogeneity without overinflation. It further reduced dynamic strain in middle-ventral regions and tidal recruitment in middle-dorsal areas. These findings suggest the maximal compliance strategy minimizing whole-lung dynamically quantified mechanisms of ventilator-induced lung injury with less cyclic recruitment and no additional overinflation in large heterogeneously expanded and recruitable lungs.
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Affiliation(s)
- Congli Zeng
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | - Min Zhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriel Motta-Ribeiro
- Biomedical Engineering Program, Alberto Luiz Coimbra Institute for Graduate Studies and Research in Engineering, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - David Lagier
- Department of Cardiovascular Anesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France
| | | | - Mingyang Zang
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Kira Grogg
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Tilo Winkler
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Depta F, Euliano NR, Zdravkovic M, Török P, Gentile MA. Time constant to determine PEEP levels in mechanically ventilated COVID-19 ARDS: a feasibility study. BMC Anesthesiol 2022; 22:387. [PMID: 36513978 PMCID: PMC9745286 DOI: 10.1186/s12871-022-01935-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We hypothesized that the measured expiratory time constant (TauE) could be a bedside parameter for the evaluation of positive end-expiratory pressure (PEEP) settings in mechanically ventilated COVID-19 patients during pressure-controlled ventilation (PCV). METHODS A prospective study was conducted including consecutively admitted adults (n = 16) with COVID-19-related ARDS requiring mechanical ventilation. A PEEP titration using PCV with a fixed driving pressure of 14 cmH2O was performed and TauE recorded at each PEEP level (0 to 18 cmH2O) in prone (n = 29) or supine (n = 24) positions. The PEEP setting with the highest TauE (TauEMAX) was considered to represent the best tradeoff between recruitment and overdistention. RESULTS Two groups of patterns were observed in the TauE plots: recruitable (R) (75%) and nonrecruitable (NR) (25%). In the R group, the optimal PEEP and PEEP ranges were 8 ± 3 cmH2O and 6-10 cmH2O for the prone position and 9 ± 3 cmH2O and 7-12 cmH2O for the supine position. In the NR group, the optimal PEEP and PEEP ranges were 4 ± 4 cmH2O and 1-8 cmH2O for the prone position and 5 ± 3 cmH2O and 1-7 cmH2O for the supine position, respectively. The R group showed significantly higher optimal PEEP (p < 0.004) and PEEP ranges (p < 0.001) than the NR group. Forty-five percent of measurements resulted in the most optimal PEEP being significantly different between the positions (p < 0.01). Moderate positive correlation has been found between TauE vs CRS at all PEEP levels (r2 = 0.43, p < 0.001). CONCLUSIONS TauE may be a novel method to assess PEEP levels. There was wide variation in patient responses to PEEP, which indicates the need for personalized evaluation.
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Affiliation(s)
- Filip Depta
- Department of Critical Care, East Slovak Institute for Cardiovascular Diseases, Košice, Slovakia ,grid.11175.330000 0004 0576 0391Faculty of Medicine, Pavol Jozef Šafárik University, Košice, Slovakia
| | - Neil R. Euliano
- grid.421520.00000 0004 0482 7339Convergent Engineering, Gainesville, FL USA
| | - Marko Zdravkovic
- grid.412415.70000 0001 0685 1285Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia ,grid.8954.00000 0001 0721 6013Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Pavol Török
- Department of Critical Care, East Slovak Institute for Cardiovascular Diseases, Košice, Slovakia ,grid.11175.330000 0004 0576 0391Faculty of Medicine, Pavol Jozef Šafárik University, Košice, Slovakia
| | - Michael A. Gentile
- grid.189509.c0000000100241216Department of Anesthesiology, Duke University Medical Center, Durham, NC USA
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He H, Chi Y, Yang Y, Yuan S, Long Y, Zhao P, Frerichs I, Fu F, Möller K, Zhao Z. Early individualized positive end-expiratory pressure guided by electrical impedance tomography in acute respiratory distress syndrome: a randomized controlled clinical trial. Crit Care 2021; 25:230. [PMID: 34193224 PMCID: PMC8243615 DOI: 10.1186/s13054-021-03645-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/16/2021] [Indexed: 12/16/2022]
Abstract
Background Individualized positive end-expiratory pressure (PEEP) by electrical impedance tomography (EIT) has potential interest in the optimization of ventilation distribution in acute respiratory distress syndrome (ARDS). The aim of the study was to determine whether early individualized titration of PEEP with EIT improved outcomes in patients with ARDS. Methods A total of 117 ARDS patients receiving mechanical ventilation were randomly assigned to EIT group (n = 61, PEEP adjusted based on ventilation distribution) or control group (n = 56, low PEEP/FiO2 table). The primary outcome was 28-day mortality. Secondary and exploratory outcomes were ventilator-free days, length of ICU stay, incidence of pneumothorax and barotrauma, and difference in Sequential Organ Failure Assessment (SOFA) score at day 1 (ΔD1-SOFA) and day 2 (ΔD2-SOFA) compared with baseline. Measurements and main results There was no statistical difference in the value of PEEP between the EIT group and control group, but the combination of PEEP and FiO2 was different between groups. In the control group, a significantly positive correlation was found between the PEEP value and the corresponding FiO2 (r = 0.47, p < 0.00001) since a given matched table was used for PEEP settings. Diverse combinations of PEEP and FiO2 were found in the EIT group (r = 0.05, p = 0.68). There was no significant difference in mortality rate (21% vs. 27%, EIT vs. control, p = 0.63), ICU length of stay (13.0 (7.0, 25.0) vs 10.0 (7.0, 14.8), median (25th–75th percentile); p = 0.17), and ventilator-free days at day 28 (14.0 (2.0, 23.0) vs 19.0 (0.0, 24.0), p = 0.55) between the two groups. The incidence of new barotrauma was zero. Compared with control group, significantly lower ΔD1-SOFA and ΔD2-SOFA were found in the EIT group (p < 0.001) in a post hoc comparison. Moreover, the EIT group exhibited a significant decrease of SOFA at day 2 compared with baseline (paired t-test, difference by − 1 (− 3.5, 0), p = 0.001). However, the control group did show a similar decrease (difference by 1 (− 2, 2), p = 0.131). Conclusion Our study showed a 6% absolute decrease in mortality in the EIT group: a statistically non-significant, but clinically non-negligible result. This result along with the showed improvement in organ function might justify further reserach to validate the beneficial effect of individualized EIT-guided PEEP setting on clinical outcomes of patients with ARDS. Trial registration: ClinicalTrials, NCT02361398. Registered 11 February 2015—prospectively registered, https://clinicaltrials.gov/show/NCT02361398.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yingying Yang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyi Yuan
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Pengyu Zhao
- Department of Administration, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China. .,Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany.
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9
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Sang L, Zheng X, Zhao Z, Zhong M, Jiang L, Huang Y, Liu X, Li Y, Zhang D. Lung Recruitment, Individualized PEEP, and Prone Position Ventilation for COVID-19-Associated Severe ARDS: A Single Center Observational Study. Front Med (Lausanne) 2021; 7:603943. [PMID: 33553203 PMCID: PMC7862746 DOI: 10.3389/fmed.2020.603943] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/17/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Patients with coronavirus disease 2019 (COVID-19) may develop severe acute respiratory distress syndrome (ARDS). The aim of the study was to explore the lung recruitability, individualized positive end-expiratory pressure (PEEP), and prone position in COVID-19-associated severe ARDS. Methods: Twenty patients who met the inclusion criteria were studied retrospectively (PaO2/FiO2 68.0 ± 10.3 mmHg). The patients were ventilated under volume-controlled mode with tidal volume of 6 mL/kg predicted body weight. The lung recruitability was assessed via the improvement of PaO2, PaCO2, and static respiratory system compliance (Cstat) from low to high PEEP (5-15 cmH2O). Patients were considered recruitable if two out of three parameters improved. Subsequently, PEEP was titrated according to the best Cstat. The patients were turned to prone position for further 18-20 h. Results: For recruitability assessment, average value of PaO2 was slightly improved at PEEP 15 cmH2O (68.0 ± 10.3 vs. 69.7 ± 7.9 mmHg, baseline vs. PEEP 15 cmH2O; p = 0.31). However, both PaCO2 and Cstat worsened (PaCO2: 72.5 ± 7.1 vs. 75.1 ± 9.0 mmHg; p < 0.01. Cstat: 17.5 ± 3.5 vs. 16.6 ± 3.9 ml/cmH2O; p = 0.05). Only four patients (20%) were considered lung recruitable. Individually titrated PEEP was higher than the baseline PEEP (8.0 ± 2.1 cmH2O vs. 5 cmH2O, p < 0.001). After 18-20 h of prone positioning, investigated parameters were significantly improved compared to the baseline (PaO2: 82.4 ± 15.5 mmHg. PaCO2: 67.2 ± 6.4 mmHg. Cstat: 20.6 ± 4.4 ml/cmH2O. All p < 0.001 vs. baseline). Conclusions: Lung recruitability was very low in COVID-19-associated severe ARDS. Individually titrated PEEP and prone positioning might improve lung mechanics and blood gasses.
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Affiliation(s)
- Ling Sang
- State Key Lab of Respiratory Diseases, Department of Critical Care Medicine, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xia Zheng
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China.,Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Min Zhong
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongbo Huang
- State Key Lab of Respiratory Diseases, Department of Critical Care Medicine, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoqing Liu
- State Key Lab of Respiratory Diseases, Department of Critical Care Medicine, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yimin Li
- State Key Lab of Respiratory Diseases, Department of Critical Care Medicine, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Dingyu Zhang
- Research Center for Translational Medicine, Wuhan Jinyintan Hospital, Wuhan, China.,Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology and Wuhan Jinyintan Hospital, Chinese Academy of Sciences, Wuhan, China
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10
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Wrigge H, Glien C. [Specific treatment of acute lung failure]. Anaesthesist 2020; 69:847-56. [PMID: 32965509 DOI: 10.1007/s00101-020-00844-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Wegen der hohen Heterogenität und Dynamik des Krankheitsverlaufes stellt die Behandlung des akuten Lungenversagens Intensivmediziner vor außerordentliche Herausforderungen. Nachdem die aktuelle Definition, Pathophysiologie und die Differenzialdiagnosen in der vorliegenden Zeitschrift bereits dargestellt wurden, werden im Folgenden Möglichkeiten der spezifischen und individualisierten Therapie behandelt. Die Beatmungstherapie mit Limitierung der Tidalvolumina und Druckamplitude zeigt einen Vorteil hinsichtlich der Letalität, ist aber aufgrund der vielfältigen Ätiologie des akuten Lungenversagens im Kontext mit den unterschiedlichen Gegebenheiten individuell anzupassen. In den letzten Jahren wurde die Bedeutung der Bauchlage, der möglichst frühzeitigen Spontanatmung und der Frühmobilisation für den positiven Krankheitsverlauf erkannt. Eine individualisierte Therapie sollte die Besonderheiten des Patienten und den spezifischen Krankheitsverlauf berücksichtigen.
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11
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Weber J, Gutjahr J, Schmidt J, Lozano-Zahonero S, Borgmann S, Schumann S, Wirth S. Effect of individualized PEEP titration guided by intratidal compliance profile analysis on regional ventilation assessed by electrical impedance tomography - a randomized controlled trial. BMC Anesthesiol 2020; 20:42. [PMID: 32079526 PMCID: PMC7033933 DOI: 10.1186/s12871-020-00960-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 02/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background The application of positive end-expiratory pressure (PEEP) may reduce dynamic strain during mechanical ventilation. Although numerous approaches for PEEP titration have been proposed, there is no accepted strategy for titrating optimal PEEP. By analyzing intratidal compliance profiles, PEEP may be individually titrated for patients. Methods After obtaining informed consent, 60 consecutive patients undergoing general anesthesia were randomly allocated to mechanical ventilation with PEEP 5 cmH2O (control group) or PEEP individually titrated, guided by an analysis of the intratidal compliance profile (intervention group). The primary endpoint was the frequency of each nonlinear intratidal compliance (CRS) profile of the respiratory system (horizontal, increasing, decreasing, and mixed). The secondary endpoints measured were respiratory mechanics, hemodynamic variables, and regional ventilation, which was assessed via electrical impedance tomography. Results The frequencies of the CRS profiles were comparable between the groups. Besides PEEP [control: 5.0 (0.0), intervention: 5.8 (1.1) cmH2O, p < 0.001], the respiratory and hemodynamic variables were comparable between the two groups. The compliance profile analysis showed no significant differences between the two groups. The loss of ventral and dorsal regional ventilation was higher in the control [ventral: 41.0 (16.3)%; dorsal: 25.9 (13.8)%] than in the intervention group [ventral: 29.3 (17.6)%; dorsal: 16.4 (12.7)%; p (ventral) = 0.039, p (dorsal) = 0.028]. Conclusions Unfavorable compliance profiles indicating tidal derecruitment were found less often than in earlier studies. Individualized PEEP titration resulted in slightly higher PEEP. A slight global increase in aeration associated with this was indicated by regional gain and loss analysis. Differences in dorsal to ventral ventilation distribution were not found. Trial registration This clinical trial was registered at the German Register for Clinical Trials (DRKS00008924) on August 10, 2015.
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Affiliation(s)
- Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Jan Gutjahr
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Sara Lozano-Zahonero
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Silke Borgmann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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12
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Kim KT, Morton S, Howe S, Chiew YS, Knopp JL, Docherty P, Pretty C, Desaive T, Benyo B, Szlavecz A, Moeller K, Shaw GM, Chase JG. Model-based PEEP titration versus standard practice in mechanical ventilation: a randomised controlled trial. Trials 2020; 21:130. [PMID: 32007099 PMCID: PMC6995650 DOI: 10.1186/s13063-019-4035-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/29/2019] [Indexed: 11/12/2022] Open
Abstract
Background Positive end-expiratory pressure (PEEP) at minimum respiratory elastance during mechanical ventilation (MV) in patients with acute respiratory distress syndrome (ARDS) may improve patient care and outcome. The Clinical utilisation of respiratory elastance (CURE) trial is a two-arm, randomised controlled trial (RCT) investigating the performance of PEEP selected at an objective, model-based minimal respiratory system elastance in patients with ARDS. Methods and design The CURE RCT compares two groups of patients requiring invasive MV with a partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio ≤ 200; one criterion of the Berlin consensus definition of moderate (≤ 200) or severe (≤ 100) ARDS. All patients are ventilated using pressure controlled (bi-level) ventilation with tidal volume = 6–8 ml/kg. Patients randomised to the control group will have PEEP selected per standard practice (SPV). Patients randomised to the intervention will have PEEP selected based on a minimal elastance using a model-based computerised method. The CURE RCT is a single-centre trial in the intensive care unit (ICU) of Christchurch hospital, New Zealand, with a target sample size of 320 patients over a maximum of 3 years. The primary outcome is the area under the curve (AUC) ratio of arterial blood oxygenation to the fraction of inspired oxygen over time. Secondary outcomes include length of time of MV, ventilator-free days (VFD) up to 28 days, ICU and hospital length of stay, AUC of oxygen saturation (SpO2)/FiO2 during MV, number of desaturation events (SpO2 < 88%), changes in respiratory mechanics and chest x-ray index scores, rescue therapies (prone positioning, nitric oxide use, extracorporeal membrane oxygenation) and hospital and 90-day mortality. Discussion The CURE RCT is the first trial comparing significant clinical outcomes in patients with ARDS in whom PEEP is selected at minimum elastance using an objective model-based method able to quantify and consider both inter-patient and intra-patient variability. CURE aims to demonstrate the hypothesized benefit of patient-specific PEEP and attest to the significance of real-time monitoring and decision-support for MV in the critical care environment. Trial registration Australian New Zealand Clinical Trial Registry, ACTRN12614001069640. Registered on 22 September 2014. (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366838&isReview=true) The CURE RCT clinical protocol and data usage has been granted by the New Zealand South Regional Ethics Committee (Reference number: 14/STH/132).
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Affiliation(s)
- Kyeong Tae Kim
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand.
| | - Sophie Morton
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Sarah Howe
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | | | - Jennifer L Knopp
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Paul Docherty
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Christopher Pretty
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium
| | - Balazs Benyo
- Department of Control Engineering and Information, Budapest University of Technology and Economics, Budapest, Hungary
| | - Akos Szlavecz
- Department of Control Engineering and Information, Budapest University of Technology and Economics, Budapest, Hungary
| | - Knut Moeller
- Institute of Technical Medicine (ITeM), HFU Furtwangen University, Villingen-Schwenningen, Germany
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - J Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
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13
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Bergez M, Fritsch N, Tran-Van D, Saghi T, Bounkim T, Gentile A, Labadie P, Fontaine B, Ouattara A, Rozé H. PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure. Ann Intensive Care 2019; 9:81. [PMID: 31312921 PMCID: PMC6635540 DOI: 10.1186/s13613-019-0554-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although lung protection with low tidal volume and limited plateau pressure (Pplat) improves survival in acute respiratory distress syndrome patients (ARDS), the best way to set positive end-expiratory pressure (PEEP) is still debated. METHODS This study aimed to compare two strategies using individual PEEP based on a maximum Pplat (28-30 cmH2O, the Express group) or on keeping end-expiratory transpulmonary pressure positive (0-5 cmH2O, PLexpi group). We estimated alveolar recruitment (Vrec), end-expiratory lung volume and alveolar distension based on elastance-related end-inspiratory transpulmonary pressure (PL,EL). RESULTS Nineteen patients with moderate to severe ARDS (PaO2/FiO2 < 150 mmHg) were included with a baseline PEEP of 7.0 ± 1.8 cmH2O and a PaO2/FiO2 of 91.2 ± 31.2 mmHg. PEEP and oxygenation increased significantly from baseline with both protocols; PEEP Express group was 14.2 ± 3.6 cmH2O versus 16.7 ± 5.9 cmH2O in PLexpi group. No patient had the same PEEP with the two protocols. Vrec was higher with the latter protocol (299 [0 to 875] vs. 222 [47 to 483] ml, p = 0.049) and correlated with improved oxygenation (R2 = 0.45, p = 0.002). Two and seven patients in the Express and PL,expi groups, respectively, had PL,EL > 25 cmH2O. CONCLUSIONS There is a great heterogeneity of PLexpi when Pplat is used to titrate PEEP but with limited risk of over-distension. A PEEP titration for a moderate positive level of PLexpi might slightly improve alveolar recruitment and oxygenation but increases the risk of over-distension in one-third of patients.
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Affiliation(s)
- Marie Bergez
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Nicolas Fritsch
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - David Tran-Van
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Tahar Saghi
- Intensive Care Unit, North Bordeaux Aquitaine Clinic, Bordeaux, France
| | - Tan Bounkim
- Medical and Surgical Intensive Care, Saint Joseph Saint Luc Teaching Hospital, Lyon, France
| | - Ariane Gentile
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Philippe Labadie
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Bruno Fontaine
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Alexandre Ouattara
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France.,Biology of Cardiovascular Diseases, INSERM, UMR 1034, Univ. Bordeaux, 33600, Pessac, France
| | - Hadrien Rozé
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France.
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14
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Reinius H, Borges JB, Engström J, Ahlgren O, Lennmyr F, Larsson A, Fredén F. Optimal PEEP during one-lung ventilation with capnothorax: An experimental study. Acta Anaesthesiol Scand 2019; 63:222-231. [PMID: 30132806 DOI: 10.1111/aas.13247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 07/12/2018] [Accepted: 07/24/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND One-lung ventilation (OLV) with induced capnothorax carries the risk of severely impaired ventilation and circulation. Optimal PEEP may mitigate the physiological perturbations during these conditions. METHODS Right-sided OLV with capnothorax (16 cm H2 O) on the left side was initiated in eight anesthetized, muscle-relaxed piglets. A recruitment maneuver and a decremental PEEP titration from PEEP 20 cm H2 O to zero end-expiratory pressure (ZEEP) was performed. Regional ventilation and perfusion were studied with electrical impedance tomography and computer tomography of the chest was used. End-expiratory lung volume and hemodynamics were recorded and. RESULTS PaO2 peaked at PEEP 12 cm H2 O (49 ± 14 kPa) and decreased to 11 ± 5 kPa at ZEEP (P < 0.001). PaCO2 was 9.5 ± 1.3 kPa at 20 cm H2 O PEEP and did not change when PEEP step-wise was reduced to 12 cm H2 O PaCO2. At lower PEEP, PaCO2 increased markedly. The ventilatory driving pressure was lowest at PEEP 14 cm H2 O (19.6 ± 5.8 cm H2 O) and increased to 38.3 ± 6.1 cm H2 O at ZEEP (P < 0.001). When reducing PEEP below 12-14 cm H2 O ventilation shifted from the dependent to the nondependent regions of the ventilated lung (P = 0.003), and perfusion shifted from the ventilated to the nonventilated lung (P = 0.02). CONCLUSION Optimal PEEP was 12-18 cm H2 O and probably relates to capnothorax insufflation pressure. With suboptimal PEEP, ventilation/perfusion mismatch in the ventilated lung and redistribution of blood flow to the nonventilated lung occurred.
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Affiliation(s)
- Henrik Reinius
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Joao Batista Borges
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
- Laboratório de Pneumologia LIM-09; Disciplina de Pneumologia; Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Joakim Engström
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Oskar Ahlgren
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Fredrik Lennmyr
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
- Department of Cardiothoracic Anesthesia; Uppsala University Hospital; Uppsala Sweden
| | - Anders Larsson
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Filip Fredén
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
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15
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Bhattacharjee S, Soni KD, Maitra S. Recruitment maneuver does not provide any mortality benefit over lung protective strategy ventilation in adult patients with acute respiratory distress syndrome: a meta-analysis and systematic review of the randomized controlled trials. J Intensive Care 2018; 6:35. [PMID: 29983985 PMCID: PMC6019312 DOI: 10.1186/s40560-018-0305-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/11/2018] [Indexed: 01/03/2023] Open
Abstract
Background Clinical benefits of recruitment maneuver in ARDS patients are controversial. A number of previous studies showed possible benefits; a large recent study reported that recruitment maneuver and PEEP titration may even be harmful. This meta-analysis was designed to compare the clinical utility of recruitment maneuver with low tidal volume ventilation in adult patients with ARDS. Methods Randomized controlled trials comparing recruitment maneuver and lung protective ventilation strategy with lung protective strategy ventilation protocol alone in adult patients with ARDS has been included in this meta-analysis. PubMed and Cochrane Central Register of Controlled Trials were searched from inception to 10 November 2017 to identify potentially eligible trials. Pooled risk ratio (RR) and standardized mean difference (SMD) were calculated for binary and continuous variables respectively. Results Data of 2480 patients from 7 randomized controlled trials have been included in this meta-analysis and systemic review. Reported mortality at the longest available follow-up [RR (95% CI) 0.93 (0.80, 1.08); p = 0.33], ICU mortality [RR (95% CI) 0.91 (0.76, 1.10); p = 0.33] and in-hospital mortality [RR (95% CI) 0.95 (0.83, 1.08); p = 0.45] were similar between recruitment maneuver group and standard lung protective ventilation group. Duration of hospital stay [SMD (95% CI) 0.00 (− 0.09, 0.10); p = 0.92] and duration of ICU stays [SMD (95% CI) 0.05 (− 0.09, 0.19); p = 0.49] were also similar between recruitment maneuver group and standard lung protective ventilation group. Risk of barotrauma was also similar. Conclusion Use of recruitment maneuver along with co-interventions such as PEEP titration does not provide any benefit in terms of mortality, length of ICU, and hospital stay in ARDS patients. Electronic supplementary material The online version of this article (10.1186/s40560-018-0305-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sulagna Bhattacharjee
- 1Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No. 5011, 5th Floor Teaching block, Ansari Nagar New Delhi, 110029 India
| | - Kapil D Soni
- 2Department of Trauma Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute Medical Sciences, New Delhi, India
| | - Souvik Maitra
- 1Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No. 5011, 5th Floor Teaching block, Ansari Nagar New Delhi, 110029 India
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16
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Hanson A, Göthberg S, Nilsson K, Hedenstierna G. Recruitment and PEEP level influences long-time aeration in saline-lavaged piglets: an experimental model. Paediatr Anaesth 2012; 22:1072-9. [PMID: 22340954 DOI: 10.1111/j.1460-9592.2012.03817.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate aeration/ventilation in saline-lavaged piglets during a 3-h follow-up after a recruitment maneuver (RM)/PEEP titration compared with PEEP 10 cmH2O without a RM. BACKGROUND Lung recruitment and PEEP titration are used to find a PEEP preventing repetitive opening/collapsing of lung. METHODS Twenty-one lung-lavaged piglets, mean age 7 weeks and mean weight 10 kg; a RM-group and a PEEP10-group, were ventilated at PEEP 5 cmH2O (baseline) followed by zero PEEP ventilation. In the RM-group, tidal elimination of CO2 and dynamic compliance (Cdyn) guided recruitment and PEEP titration, respectively. A final 3-h ventilation followed using PEEP 2 cmH2O above the first decline of Cdyn and end-inspiratory pressure (EIP) for a target tidal volume (VT) of 10 ml · kg(-1). In the PEEP10-group, PEEP 10 cmH2O without a RM was used during the final 3-h ventilation. CT scans and blood gases were repeated every 30 min. Airway pressures, Cdyn and hemodynamics were continuously recorded. RESULTS Aeration improved without differences between groups. The RM-group PEEP level of 10 ± 0.6 cmH2O did not differ from the PEEP10-group. Compared to baseline EIP was lower in the RM-group after 3-h ventilation. In both groups, driving pressure (DP) was lower and Cdyn higher than baseline. In the RM-group, final EIP and DP were lower and Cdyn higher than in the PEEP10-group. CONCLUSIONS Both RM/PEEP titration and PEEP elevation resulted in improved aeration without differences between groups at the end point. Lung aeration was achieved at lower EIP and DP and higher Cdyn in the RM-group than in the PEEP10-group.
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Affiliation(s)
- Angela Hanson
- The Department of Paediatric Anaesthesia and Intensive Care, The Queen Silvia Children's Hospital, University of Gothenburg, Göteborg, Sweden.
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