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Zaidi SF, Shaikh A, Khan DA, Surani S, Ratnani I. Driving pressure in mechanical ventilation: A review. World J Crit Care Med 2024; 13:88385. [PMID: 38633474 PMCID: PMC11019631 DOI: 10.5492/wjccm.v13.i1.88385] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024] Open
Abstract
Driving pressure (∆P) is a core therapeutic component of mechanical ventilation (MV). Varying levels of ∆P have been employed during MV depending on the type of underlying pathology and severity of injury. However, ∆P levels have also been shown to closely impact hard endpoints such as mortality. Considering this, conducting an in-depth review of ∆P as a unique, outcome-impacting therapeutic modality is extremely important. There is a need to understand the subtleties involved in making sure ∆P levels are optimized to enhance outcomes and minimize harm. We performed this narrative review to further explore the various uses of ∆P, the different parameters that can affect its use, and how outcomes vary in different patient populations at different pressure levels. To better utilize ∆P in MV-requiring patients, additional large-scale clinical studies are needed.
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Affiliation(s)
- Syeda Farheen Zaidi
- Department of Medicine, Queen Mary University, London E1 4NS, United Kingdom
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Sindh, Karachi 74500, Pakistan
| | - Daniyal Aziz Khan
- Department of Medicine, Jinnah Postgraduate Medical Center, Sindh, Karachi 75510, Pakistan
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A and M University, College Station, TX 77843, United States
| | - Iqbal Ratnani
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, TX 77030, United States
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2
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Mingote Á, Marrero García R, Santos González M, Castejón R, Salas Antón C, Vargas Nuñez JA, García-Fernández J. Individualizing mechanical ventilation: titration of driving pressure to pulmonary elastance through Young's modulus in an acute respiratory distress syndrome animal model. Crit Care 2022; 26:316. [PMID: 36258235 PMCID: PMC9578179 DOI: 10.1186/s13054-022-04184-w] [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: 08/01/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022] Open
Abstract
Background Mechanical ventilation increases the risk of lung injury (VILI). Some authors propose that the way to reduce VILI is to find the threshold of driving pressure below which VILI is minimized. In this study, we propose a method to titrate the driving pressure to pulmonary elastance in an acute respiratory distress syndrome model using Young’s modulus and its consequences on ventilatory-induced lung injury.
Material and methods 20 Wistar Han male rats were used. After generating an acute respiratory distress syndrome, two groups were studied: (a) standard protective mechanical ventilation: 10 rats received 150 min of mechanical ventilation with driving pressure = 14 cm H2O, tidal volume < 6 mL/kg) and (b) individualized mechanical ventilation: 10 rats received 150 min of mechanical ventilation with an individualized driving pressure according to their Young’s modulus. In both groups, an individualized PEEP was programmed in the same manner. We analyzed the concentration of IL-6, TNF-α, and IL-1ß in BAL and the acute lung injury score in lung tissue postmortem.
Results Global driving pressure was different between the groups (14 vs 11 cm H2O, p = 0.03). The individualized mechanical ventilation group had lower concentrations in bronchoalveolar lavage of IL-6 (270 pg/mL vs 155 pg/mL, p = 0.02), TNF-α (292 pg/mL vs 139 pg/mL, p < 0.01) and IL-1ß (563 pg/mL vs 131 pg/mL, p = 0.05). They presented lower proportion of lymphocytes (96% vs 79%, p = 0.05) as well as lower lung injury score (6.0 points vs 2.0 points, p = 0.02). Conclusion In our model, individualization of DP to pulmonary elastance through Young’s modulus decreases lung inflammation and structural lung injury without a significant impact on oxygenation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04184-w.
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Affiliation(s)
- Álvaro Mingote
- grid.411171.30000 0004 0425 3881Anaesthesia, Critical Care and Pain Unit, Puerta de Hierro Majadahonda Universitary Hospital, Majadahonda. c/Manuel de Falla, 1, 28222 Madrid, Spain ,grid.5515.40000000119578126Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Ramsés Marrero García
- grid.410458.c0000 0000 9635 9413Anaesthesia, Critical Care Department and Pain Unit, Clinic Hospital, Barcelona, Spain
| | - Martín Santos González
- grid.411171.30000 0004 0425 3881Medical and Surgical Research Unit, Puerta de Hierro Majadahonda Universitary Hospital, Madrid, Spain
| | - Raquel Castejón
- Internal Medicine Laboratory, Puerta de Hierro Majadahonda Universitary Hospital Research Institute, Madrid, Spain
| | - Clara Salas Antón
- grid.411171.30000 0004 0425 3881Pathology Unit, Puerta de Hierro Majadahonda Universitary Hospital, Madrid, Spain
| | - Juan Antonio Vargas Nuñez
- grid.411171.30000 0004 0425 3881Internal Medicine Unit, Puerta de Hierro Majadahonda Universitary Hospital, Madrid, Spain ,grid.5515.40000000119578126Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Javier García-Fernández
- grid.411171.30000 0004 0425 3881Anaesthesia, Critical Care and Pain Unit, Puerta de Hierro Majadahonda Universitary Hospital, Majadahonda. c/Manuel de Falla, 1, 28222 Madrid, Spain ,grid.5515.40000000119578126Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
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3
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Busana M, Zinnato C, Romitti F, Palumbo M, Gattarello S, Sonzogni A, Gersmann AK, Richter A, Herrmann P, Hahn G, Brusatori S, Maj R, Velati M, Moerer O, Meissner K, Barnes T, Quintel M, Marini JJ, Gattinoni L. Energy dissipation during expiration and Ventilator Induced Lung Injury: an experimental animal study. J Appl Physiol (1985) 2022; 133:1212-1219. [PMID: 36173324 DOI: 10.1152/japplphysiol.00426.2022] [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] [Indexed: 11/22/2022] Open
Abstract
The amount of energy delivered to the respiratory system is recognized as a cause of Ventilator Induced Lung Injury (VILI). How energy dissipation within the lung causes damage is still a matter of debate. Expiratory flow control has been proposed as a strategy to reduce the energy dissipated into the respiratory system during expiration and, possibly, VILI. We studied 22 healthy pigs (29±2 kg), which were randomized into a control (n=11) and a valve group (n=11), where the expiratory flow was controlled through a variable resistor. Both groups were ventilated with the same tidal volume, PEEP and inspiratory flow. Electric impedance tomography was continuously acquired. At completion, lung weight, wet to dry ratios and histology were evaluated. The total mechanical power was similar in the control and valve groups (8.54±0.83 J min-1 and 8.42±0.54 J min-1 respectively, p=0.552). The total energy dissipated within the whole system (circuit + respiratory system) was remarkably different (4.34±0.66 vs 2.62±0.31 J/min, p<0.001). However, most of this energy was dissipated across the endotracheal tube (2.87±0.3 vs 1.88±0.2 J/min, p<0.001). The amount dissipated into the respiratory system averaged 1.45±0.5 in controls vs 0.73±0.16 J min-1 in the valve group, p<0.001. Although respiratory mechanics, gas exchange, hemodynamics, wet to dry ratios and histology were similar in the two groups, the decrease of end-expiratory lung impedance was significantly greater in the control group (p=0.02). We conclude that with our experimental conditions, the reduction of energy dissipated in the respiratory system did not lead to appreciable differences in VILI.
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Affiliation(s)
- Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michela Palumbo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aurelio Sonzogni
- Department of Pathology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ann-Kathrin Gersmann
- Institute of Pathology, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
| | - Annika Richter
- Institute of Pathology, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Günter Hahn
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Tom Barnes
- University of Greenwich, Park Row, London, United Kingdom
| | - Michael Quintel
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, Minnesota, United States
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Spinelli E, Mauri T. Reply to: Addition of 5% CO2 to Inspiratory Gas in Preventing Lung Injury Due to Pulmonary Artery Ligation. Am J Respir Crit Care Med 2021; 205:587-588. [PMID: 34890535 PMCID: PMC8906477 DOI: 10.1164/rccm.202111-2500le] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Tommaso Mauri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milano, Italy;
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Sun Q, Chase JG, Zhou C, Tawhai MH, Knopp JL, Möller K, Shaw GM. Over-distension prediction via hysteresis loop analysis and patient-specific basis functions in a virtual patient model. Comput Biol Med 2021;:105022. [PMID: 34801244 DOI: 10.1016/j.compbiomed.2021.105022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Recruitment maneuvers (RMs) with subsequent positive-end-expiratory-pressure (PEEP) have proven effective in recruiting lung volume and preventing alveolar collapse. However, a suboptimal PEEP could induce undesired injury in lungs by insufficient or excessive breath support. Thus, a predictive model for patient response under PEEP changes could improve clinical care and lower risks. METHODS This research adds novel elements to a virtual patient model to identify and predict patient-specific lung distension to optimise and personalise care. Model validity and accuracy are validated using data from 18 volume-controlled ventilation (VCV) patients at 7 different baseline PEEP levels (0-12cmH2O), yielding 623 prediction cases. Predictions were made up to ΔPEEP = 12cmH2O ahead covering 6x2cmH2O PEEP steps. RESULTS Using the proposed lung distension model, 90% of absolute peak inspiratory pressure (PIP) prediction errors compared to clinical measurement are within 3.95cmH2O, compared with 4.76cmH2O without this distension term. Comparing model-predicted and clinically measured distension had high correlation increasing to R2 = 0.93-0.95 if maximum ΔPEEP ≤ 6cmH2O. Predicted dynamic functional residual capacity (Vfrc) changes as PEEP rises yield 0.013L median prediction error for both prediction groups and overall R2 of 0.84. CONCLUSIONS Overall results demonstrate nonlinear distension mechanics are accurately captured in virtual lung mechanics patients for mechanical ventilation, for the first time. This result can minimise the risk of lung injury by predicting its potential occurrence of distension before changing ventilator settings. The overall outcomes significantly extend and more fully validate this virtual mechanical ventilation patient model.
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6
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Abstract
During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.
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Affiliation(s)
- Mairi Ziaka
- Department of Internal Medicine, Thun General Hospital, Thun, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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7
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Paudel R, Trinkle CA, Waters CM, Robinson LE, Cassity E, Sturgill JL, Broaddus R, Morris PE. Mechanical Power: A New Concept in Mechanical Ventilation. Am J Med Sci 2021:S0002-9629(21)00331-1. [PMID: 34597688 DOI: 10.1016/j.amjms.2021.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/26/2021] [Accepted: 09/24/2021] [Indexed: 11/22/2022]
Abstract
Mechanical ventilation is a potentially life-saving therapy for patients with acute lung injury, but the ventilator itself may cause lung injury. Ventilator-induced lung injury (VILI) is sometimes an unfortunate consequence of mechanical ventilation. It is not clear however how best to minimize VILI through adjustment of various parameters including tidal volume, plateau pressure, driving pressure, and positive end expiratory pressure (PEEP). No single parameter provides a clear indication for onset of lung injury attributable exclusively to the ventilator. There is currently interest in quantifying how static and dynamic parameters contribute to VILI. One concept that has emerged is the consideration of the amount of energy transferred from the ventilator to the respiratory system per unit time, which can be quantified as mechanical power. This review article reports on recent literature in this emerging field and future roles for mechanical power assessments in prospective studies.
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8
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Derraugh G, Levesque M, Schantz D, Sesha M, Minski J, Baier J, Morris MI, Shawyer AC, Balshaw R, Lum Min SA, Keijzer R. High-frequency vs. conventional ventilation at the time of CDH repair is not associated with higher mortality and oxygen dependency: a retrospective cohort study. Pediatr Surg Int 2020; 36:1275-80. [PMID: 32939579 DOI: 10.1007/s00383-020-04740-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The VICI-trial reported that in patients with congenital diaphragmatic hernia (CDH), mortality or bronchopulmonary dysplasia (BPD) were equivalent using conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation. The purpose of this study was to determine if the mode of ventilation at the time of CDH repair affected mortality or oxygen dependence at 28 days. METHODS We performed a retrospective cohort study of infants born wih CDH from 1991 to 2015. A generalized linear model was applied to the data using a propensity score analysis. RESULTS Eighty patients met the inclusion criteria; at the time of surgery 39 (48.8%) patients were on HFV and 41 (51.3%) patients were on CMV. In the HFV group, 16 (47.1%) patients remained oxygen dependent and there were 5 (12.8%) deaths at 28 days. In the CMV group, 5 (12.2%) patients remained oxygen dependent at 28 days but none had died. The base model demonstrated that the HFV group had increased rates of oxygen dependence [OR = 6.40 (2.13, 22.2), p = 0.002]. However, after propensity score analysis, we found no difference between HFV and CMV. CONCLUSION Our study suggests that in infants with CDH, there is no significant difference between HFV and CMV in oxygen dependency or death.
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9
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Bersten AD, Krupa M, Griggs K, Dixon DL. Reduced Surfactant Contributes to Increased Lung Stiffness Induced by Rapid Inspiratory Flow. Lung 2020; 198:43-52. [PMID: 31915922 DOI: 10.1007/s00408-019-00317-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 06/05/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The mechanism of fast inspiratory flow rate (VI') induced lung injury is unclear. As fast VI' increases hysteresis, a measure of surface tension at the air-liquid interface, surfactant release or function may be important. This experimental study examines the contribution of impaired surfactant release or function to dynamic-VILI. METHODS Isolated perfused lungs from male Sprague Dawley rats were randomly allocated to four groups: a long or short inspiratory time (Ti = 0.5 s; slow VI' or Ti = 0.1 s; fast VI') at PEEP of 2 or 10 cmH2O. Tidal volume was constant (7 ml/kg), with f = 60 breath/min. Forced impedance mechanics (tissue elastance (Htis), tissue resistance (Gtis) and airway resistance (Raw) were measured at 30, 60 and 90 min following which the lung was lavaged for surfactant phospholipids (PL) and disaturated PL (DSP). RESULTS Fast VI' resulted in a stiffer lung. Concurrently, PL and DSP were decreased in both tubular myelin rich and poor fractions. Phospholipid decreases were similar with PEEP. In a subsequent cohort, laser confocal microscopy-based assessment demonstrated increased cellular injury with increased VI' at both 30 and 90 min ventilation. CONCLUSION Rapid VI' may contribute to ventilator induced lung injury (VILI) through reduced surfactant release and/or more rapid reuptake despite unchanged tidal stretch.
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Affiliation(s)
- Andrew D Bersten
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, SA, Australia.,Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia
| | - Malgorzata Krupa
- Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia
| | - Kim Griggs
- Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia
| | - Dani-Louise Dixon
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, SA, Australia. .,Department of Critical Care Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, 5001, Australia.
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10
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Khemani RG, Hotz JC, Klein MJ, Kwok J, Park C, Lane C, Smith E, Kohler K, Suresh A, Bornstein D, Elkunovich M, Ross PA, Deakers T, Beltramo F, Nelson L, Shah S, Bhalla A, Curley MAQ, Newth CJL. A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management). Contemp Clin Trials 2019; 88:105893. [PMID: 31740425 DOI: 10.1016/j.cct.2019.105893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 08/06/2019] [Revised: 11/05/2019] [Accepted: 11/14/2019] [Indexed: 11/18/2022]
Abstract
Lung Protective Mechanical Ventilation (MV) of critically ill adults and children is lifesaving but it may decrease diaphragm contraction and promote Ventilator Induced Diaphragm Dysfunction (VIDD). An ideal MV strategy would balance lung and diaphragm protection. Building off a Phase I pilot study, we are conducting a Phase II controlled clinical trial that seeks to understand the evolution of VIDD in critically ill children and test whether a novel computer-based approach (Real-time Effort Driven ventilator management (REDvent)) can balance lung and diaphragm protective ventilation to reduce time on MV. REDvent systematically adjusts PEEP, FiO2, inspiratory pressure, tidal volume and rate, and uses real-time measures from esophageal manometry to target normal levels of patient effort of breathing. This trial targets 276 children with pulmonary parenchymal disease. Patients are randomized to REDvent vs. usual care for the acute phase of MV (intubation to first Spontaneous Breathing Trial (SBT)). Patients in either group who fail their first SBT will be randomized to REDvent vs usual care for weaning phase management (interval from first SBT to passing SBT). The primary clinical outcome is length of weaning, with several mechanistic outcomes. Upon completion, this study will provide important information on the pathogenesis and timing of VIDD during MV in children and whether this computerized protocol targeting lung and diaphragm protection can lead to improvement in intermediate clinical outcomes. This will form the basis for a larger, Phase III multi-center study, powered for key clinical outcomes such as 28-day ventilator free days. Clinical Trials Registration: NCT03266016.
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Affiliation(s)
- Robinder G Khemani
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America.
| | - Justin C Hotz
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Margaret J Klein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Jeni Kwok
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Caron Park
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Christianne Lane
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Erin Smith
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Kristen Kohler
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Anil Suresh
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Dinnel Bornstein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Marsha Elkunovich
- University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America; Children's Hospital of Los Angeles, Department of Emergency Medicine, United States of America
| | - Patrick A Ross
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Timothy Deakers
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Fernando Beltramo
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Lara Nelson
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Shilpa Shah
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Anoopindar Bhalla
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Martha A Q Curley
- Children's Hospital Philadelphia, University of Pennsylvania, United States of America
| | - Christopher J L Newth
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
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11
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Berg S, Bittner EA, Berra L, Kacmarek RM, Sonny A. Independent lung ventilation: Implementation strategies and review of literature. World J Crit Care Med 2019; 8:49-58. [PMID: 31667133 PMCID: PMC6817931 DOI: 10.5492/wjccm.v8.i4.49] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/21/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023] Open
Abstract
Independent lung ventilation, though infrequently used in the critical care setting, has been reported as a rescue strategy for patients in respiratory failure resulting from severe unilateral lung pathology. This involves isolating and ventilating the right and left lung differently, using separate ventilators. Here, we describe our experience with independent lung ventilation in a patient with unilateral diffuse alveolar hemorrhage, who presented with severe hypoxemic respiratory failure despite maximal ventilatory support. Conventional ventilation in this scenario leads to preferential distribution of tidal volume to the non-diseased lung causing over distension and inadvertent volume trauma. Since each lung has a different compliance and respiratory mechanics, instituting separate ventilation strategies to each lung could potentially minimize lung injury. Based on review of literature, we provide a detailed description of indications and procedures for establishing independent lung ventilation, and also provide an algorithm for management and weaning a patient from independent lung ventilation.
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Affiliation(s)
- Sheri Berg
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Lorenzo Berra
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Abraham Sonny
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
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12
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Fang M, Fan S, Yao X, Liu N, Gao J, Wang Z, Xu T, Xian X, Li W. Transfection of Sox11 plasmid alleviates ventilator-induced lung injury via Sox11 and FAK. Biochem Biophys Res Commun 2019; 512:182-188. [PMID: 30879763 DOI: 10.1016/j.bbrc.2019.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 02/22/2019] [Accepted: 03/08/2019] [Indexed: 12/15/2022]
Abstract
Background Ventilator-induced lung injury (VILI) is the most common complication in the mechanical ventilation in clinic. The pathogenesis of VILI has not been well understood. The SRY related High Mobility Group box group-F family member 11(Sox11) is a protein associated with lung development. The focal adhesion kinase(FAK) is a cytoplasmic tyrosine kinase and is regulated by Sox11. The present study, therefore, was undertaken to explore the potential role of Sox11 and FAK in VILI. Methods High volume mechanical ventilation(HMV) was used to establish mouse VILI model under anesthesia. The lung injury was evaluated by analyzing the lung weight, bronchoalveolar lavage fluid, histopathological changes and apoptosis of the lung. The Sox11 and FAK expressions in the lung were investigated by real-time qPCR, western blot and immunohistochemistry analysis. Results HMV induced VILI simultaneously companied with decreased expressions of Sox11 and FAK in alveolar epithelial and interstitial cells either in gene and protein levels. Transfection of Sox11 plasmid significantly upregulated expressions of Sox11 and FAK in gene and protein levels in the lung and particularly effectively alleviated VILI. Furthermore, FAK antagonism by PF562271(FAK antagonist) blocked the alleviating effect of Sox11 plasmid transfection on the VILI. Conclusion The dysregulation in the Sox11 and FAK after HMV play an important role in the pathogenesis of VILI, and facilitating the activity of Sox11and FAK might be an effective target and potential option in the prevention and treatment of VILI in clinic.
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Affiliation(s)
- Mingxing Fang
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China; Department of Intensive Care Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shujuan Fan
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Xiaoguang Yao
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China; College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang, China
| | - Na Liu
- Department of Emergency, The Forth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junxia Gao
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Zhiyong Wang
- Department of Intensive Care Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Tieling Xu
- Department of Emergency, Hebei General Hospital, Shijiazhuang, China
| | - Xiaohui Xian
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Wenbin Li
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China.
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Ganatra HA, Shamim D, Farnan A, Deshpande G. Favorable outcome with early initiation of VV-ECMO for unilateral lung disease in children. Respir Med Case Rep 2019; 26:73-7. [PMID: 30555780 DOI: 10.1016/j.rmcr.2018.11.019] [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] [Received: 10/17/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 11/20/2022] Open
Abstract
Unilateral lung diseases such as unilateral pneumonia, trauma or pulmonary hemorrhage can cause profound hypoxemic respiratory failure necessitating mechanical ventilation. These disorders are characterized by marked asymmetry in lung mechanics, with the affected lung having a lower compliance compared to the healthier lung, and management involves complex strategies such as simultaneous independent lung ventilation. However, such strategies can be challenging in pediatric populations due to technical limitations, and also lead to ventilator induced lung injury. We report two unique cases that support the use of venovenous extracorporeal membrane oxygenation as an alternative strategy for management of unilateral lung disease in children.
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Barnes T, van Asseldonk D, Enk D. Minimisation of dissipated energy in the airways during mechanical ventilation by using constant inspiratory and expiratory flows - Flow-controlled ventilation (FCV). Med Hypotheses 2018; 121:167-176. [PMID: 30396474 DOI: 10.1016/j.mehy.2018.09.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 07/03/2018] [Revised: 09/16/2018] [Accepted: 09/22/2018] [Indexed: 12/16/2022]
Abstract
It has been suggested that energy dissipation in the airways during mechanical ventilation is associated with an increased probability of ventilator induced lung injury (VILI). We hypothesise that energy dissipation in the airways may be minimised by ventilating with constant flow during both the inspiration and expiration phases of the respiratory cycle. We present a simple analysis and numerical calculations that support our hypothesis and show that for ventilation with minimum dissipated energy not only should the flows during inspiration and expiration be controlled to be constant and continuous, but the ventilation should also be undertaken with an I:E ratio that is close to 1:1.
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Affiliation(s)
- Tom Barnes
- University of Greenwich, Park Row, London SE10 9LE, United Kingdom.
| | - Dirk van Asseldonk
- Ventinova Medical, Meerenakkerplein 7, 5652 BJ Eindhoven, The Netherlands
| | - Dietmar Enk
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Münster (UKM), Albert-Schweitzer-Campus 1, 48149 Münster, Germany; University of Greenwich, Park Row, London SE10 9LE, United Kingdom
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15
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Ren R, Mao Y, Ruan Z, Wang Y, Zhang Y, Du J, Yu W. Celastrol attenuates ventilator induced lung injury in mouse through inhibition of MAPK pathway. Int J Clin Exp Pathol 2017; 10:9302-9309. [PMID: 31966802 PMCID: PMC6965913] [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] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 07/20/2017] [Indexed: 06/10/2023]
Abstract
PURPOSE Previous studies have shown that celastrol has anti-inflammatory, anti-oxidative and anti-tumor activities, but little is known about its protective effects on ventilator induced lung injury (VILI). This study is aimed to investigate the effects of celastrol on VILI and explore its potential mechanism. METHODS A total of 40 ICR male mice aged 7-9 weeks were randomly divided into 4 groups (n=10 per group): control group (Con), control + celastrol group (Con+Ce), mechanical ventilation group (Ven) and mechanical ventilation + celastrol group (Ven+Ce). The lungs were collected for histological examination, detection of W/D, and MPO, MDA, SOD, inflammatory cytokines (IL-1β, IL-6, IL-10 and TNF-α) by ELISA, p-P38 and p-JNK 1/2 protein by Western blotting, and collagen-1 and TGF-β mRNA expression by RT-PCR. RESULTS The W/D in the Ven group was significantly higher than the W/D in the Con group and the Ven+Ce group (both P<0.01). Mechanical ventilation for 4 h markedly increased lung MPO and MDA activity, TNF-α, IL-1β and IL-6, but dramatically reduced SOD and IL-10 (all P<0.01). However, celastrol pre-treatment compromised the increased MPO, MDA, TNF-α, IL-1β, IL-6 (all P<0.01) and significantly increased SOD (P=0.035<0.05) and IL-10 (P<0.01). In addition, mRNA level of collagen-1 and TGF-β as well as p-P38 and p-JNK 1/2 protein expression increased significantly (P<0.01) after mechanical ventilation, which however were markedly reduced in the presence of celastrol pre-treatment. CONCLUSION Celastrol pre-treatment may exert anti-oxidative and anti-inflammatory effects and related lung fibrosis to attenuate VILI in mice, which may be related to the inhibition of p-P38 and p-JNK 1/2 by MAPK pathway.
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Affiliation(s)
- Rongrong Ren
- Department of Anesthesiology, The Eastern Hepatobiliary Surgery Hospital, The Second Military Medical UniversityShanghai 200438, China
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghai 200092, China
| | - Yanfei Mao
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghai 200092, China
| | - Zhengshang Ruan
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghai 200092, China
| | - Yan Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghai 200092, China
| | - Yan Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghai 200092, China
| | - Junming Du
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong UniversityShanghai 200092, China
| | - Weifeng Yu
- Department of Anesthesiology, The Eastern Hepatobiliary Surgery Hospital, The Second Military Medical UniversityShanghai 200438, China
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Tanaka T, Saito Y, Matsuda K, Kamio K, Abe S, Kubota K, Azuma A, Gemma A. Cyclic mechanical stretch-induced oxidative stress occurs via a NOX-dependent mechanism in type II alveolar epithelial cells. Respir Physiol Neurobiol 2017; 242:108-116. [PMID: 28442445 DOI: 10.1016/j.resp.2017.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 12/09/2016] [Revised: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 12/17/2022]
Abstract
Cyclic mechanical stretching (CMS) of the alveolar epithelium is thought to contribute to alveolar epithelial injury through an increase in oxidative stress. The aim of this study was to investigate the mechanisms of CMS-induced oxidative stress in alveolar epithelial cells (AECs). A549 cells were subjected to CMS, and the levels of 8-isoprostane and 3-nytrotyrosine were measured. Twenty-four hours of CMS induced a significant increase in the levels of 8-isoprostane and 3-nytrotyrosine. Although CMS did not increase the xanthine oxidase activity or the mitochondrial production of reactive oxygen species, it upregulated the expression of nicotine adenine dinucleotide phosphate oxidase (NOX) 2, 4, 5 and DUOX2. The NOX inhibitors DPI and GKT137831 significantly attenuated CMS-induced oxidative stress. Furthermore, the measurement of annexin V/propidium iodide by flow cytometry showed that CMS induced late-phase apoptosis/necrosis, which was also attenuated by both DPI and GKT137831. These data suggest that CMS mainly induces oxidative stress, which may lead to cell injury by activating NOX in AECs.
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Affiliation(s)
- Toru Tanaka
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan
| | - Yoshinobu Saito
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan.
| | - Kuniko Matsuda
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan
| | - Koichiro Kamio
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan
| | - Shinji Abe
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan
| | - Kaoru Kubota
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan
| | - Arata Azuma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan
| | - Akihiko Gemma
- Department of Pulmonary Medicine and Oncology, Graduate School of Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, 113-8603 Tokyo, Japan
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Karadottir H, Kulkarni NN, Gudjonsson T, Karason S, Gudmundsson GH. Cyclic mechanical stretch down-regulates cathelicidin antimicrobial peptide expression and activates a pro-inflammatory response in human bronchial epithelial cells. PeerJ 2015; 3:e1483. [PMID: 26664810 PMCID: PMC4675098 DOI: 10.7717/peerj.1483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 09/21/2015] [Accepted: 11/18/2015] [Indexed: 12/25/2022] Open
Abstract
Mechanical ventilation (MV) of patients can cause damage to bronchoalveolar epithelium, leading to a sterile inflammatory response, infection and in severe cases sepsis. Limited knowledge is available on the effects of MV on the innate immune defense system in the human lung. In this study, we demonstrate that cyclic stretch of the human bronchial epithelial cell lines VA10 and BCi NS 1.1 leads to down-regulation of cathelicidin antimicrobial peptide (CAMP) gene expression. We show that treatment of VA10 cells with vitamin D3 and/or 4-phenyl butyric acid counteracted cyclic stretch mediated down-regulation of CAMP mRNA and protein expression (LL-37). Further, we observed an increase in pro-inflammatory responses in the VA10 cell line subjected to cyclic stretch. The mRNA expression of the genes encoding pro-inflammatory cytokines IL-8 and IL-1β was increased after cyclic stretching, where as a decrease in gene expression of chemokines IP-10 and RANTES was observed. Cyclic stretch enhanced oxidative stress in the VA10 cells. The mRNA expression of toll-like receptor (TLR) 3, TLR5 and TLR8 was reduced, while the gene expression of TLR2 was increased in VA10 cells after cyclic stretch. In conclusion, our in vitro results indicate that cyclic stretch may differentially modulate innate immunity by down-regulation of antimicrobial peptide expression and increase in pro-inflammatory responses.
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Affiliation(s)
- Harpa Karadottir
- Biomedical Center and Department of Life and Environmental Sciences, University of Iceland, Reykjavik, Iceland
| | - Nikhil Nitin Kulkarni
- Biomedical Center and Department of Life and Environmental Sciences, University of Iceland, Reykjavik, Iceland
| | - Thorarinn Gudjonsson
- Stem Cell Research Unit, Biomedical Center, Department of Anatomy, Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Laboratory Hematology, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care and Faculty of Medicine, Landspitali University Hospital and University of Iceland, Reykjavik, Iceland
| | - Gudmundur Hrafn Gudmundsson
- Biomedical Center and Department of Life and Environmental Sciences, University of Iceland, Reykjavik, Iceland
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18
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Nieman GF, Gatto LA, Habashi NM. Reducing acute respiratory distress syndrome occurrence using mechanical ventilation. World J Respirol 2015; 5:188-198. [DOI: 10.5320/wjr.v5.i3.188] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023] Open
Abstract
The standard treatment for acute respiratory distress syndrome (ARDS) is supportive in the form of low tidal volume ventilation applied after significant lung injury has already developed. Nevertheless, ARDS mortality remains unacceptably high (> 40%). Indeed, once ARDS is established it becomes refractory to treatment, and therefore avoidance is key. However, preventive techniques and therapeutics to reduce the incidence of ARDS in patients at high-risk have not been validated clinically. This review discusses the current data suggesting that preemptive application of the properly adjusted mechanical breath can block progressive acute lung injury and significantly reduce the occurrence of ARDS.
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19
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Abstract
In adult respiratory distress syndrome (ARDS), life-threatening hypoxemia may occur, dictating the need for differentiated ventilator strategies. Pronounced consolidation and/or atelectasis have been well documented in ARDS, but the contribution of regional perfusion to oxygenation has been poorly addressed. Evidence has accumulated that, in ARDS, regional perfusion is extremely variable and may affect oxygenation, independently from the amount of atelectatic-consolidated lung regions. Thus, the response in oxygenation to different ventilatory settings, both during controlled and assisted mechanical ventilation, should be interpreted with caution. In fact, gas exchange may be not determined solely by changes in aeration, but also redistribution of perfusion. Furthermore, regional perfusion can play an important role in worsening of lung injury due to increased transmural pressures. In addition, distribution of perfusion in lungs might affect the delivery of drugs through the pulmonary circulation, including antibiotics. In recent years, several techniques have been developed to determine pulmonary blood flow with increasing level of spatial resolution, allowing a better understanding of normal physiology and various pathophysiological conditions, but most of them are restricted to experimental or clinical research. Lung ultrasound and novel algorithms for electrical impedance tomography represent new promising techniques that could enable physicians to assess the distribution of pulmonary blood flow at the bedside. In ARDS, we cannot afford missing regional lung perfusion! Please see related article: http://dx.doi.org/10.1186/s12871-015-0013-0.
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Affiliation(s)
- Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus; Technische Universität Dresden, Dresden, Germany
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