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Karthika M, Al Enezi FA, Pillai LV, Arabi YM. Rate of Change of Rapid Shallow Breathing Index and Extubation Outcome in Mechanically Ventilated Patients. Crit Care Res Pract 2023; 2023:9141441. [PMID: 37795474 PMCID: PMC10547562 DOI: 10.1155/2023/9141441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background Rapid shallow breathing index (RSBI) has been widely used as a predictor of extubation outcome in mechanically ventilated patients. We hypothesize that the rate of change of RSBI between the beginning and end of a 120-minute spontaneous breathing trial (SBT) could be a better predictor of extubation outcome than a single RSBI measured at the end of SBT in mechanically ventilated patients. Methodology. In this prospective observational study, we enrolled 193 patients who met the inclusion criteria, of whom 33 patients were unable to tolerate a 120-minute SBT and were excluded from the study. The study population consisted of 160 patients, categorized into three subgroups: patients with normal lung (no reported history of respiratory diseases), patients with airway disease, and patients with parenchymal disease who completed 120 minutes of SBT on low levels of pressure support ventilation. RSBI was obtained from the ventilator display at the 5th and the 120th minutes of SBT. The rate of change of RSBI (RSBI 5-120) was calculated as (RSBI 2-RSBI 1)/RSBI 1 × 100. Receiver-operating characteristic (ROC) curves were plotted for RSBI 5-120 and RSBI 120 in all patients and among the three subgroups (normal group, airway group, and parenchymal group) to compare the superiority of their best thresholds in predicting extubation failure. Results The RSBI 5-120 threshold for extubation failure in the entire patient group was 23% with an overall accuracy of 88% (AUC = 0.933, sensitivity = 91%, and specificity = 86%) and the threshold of RSBI 120 for extubation failure in the entire patient group was 70 breaths/min/L with an overall accuracy of 82% (AUC = 0.899, sensitivity = 85%, and specificity = 81%). In patients in the normal lung group, the threshold of RSBI 5-120 was 22%, with an overall accuracy of 89% (AUC = 0.892, sensitivity = 87.5%, and specificity = 90%), and the RSBI 120 threshold was 70 breaths/min/L, with an overall accuracy of 89% (AUC = 0.956, sensitivity = 88%, and specificity = 90%). The RSBI 5-120 threshold in patients with airway disease was 25% with an accuracy of 86% (AUC = 0.892, sensitivity = 85%, and specificity = 86%) and the threshold of RSBI 120 was 73 breaths/min/L with an accuracy of 83% (AUC = 0.874, sensitivity = 85%, and specificity = 82%). In patients in the parenchymal disease group, the threshold of RSBI 5-120 was 24%, with an accuracy of 90% (AUC = 0.966, sensitivity = 92%, and specificity = 89%) and RSBI 120 threshold was 71 breaths/min/L, which was 88% accurate (AUC = 0.893, sensitivity = 85%, and specificity = 89%). Conclusion The rate of change of RSBI between the 5th and 120th minutes was moderately more accurate than the single value of RSBI measured at the 120th minute in predicting extubation outcome.
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Affiliation(s)
- Manjush Karthika
- Faculty of Medical and Health Sciences, Liwa College, Abu Dhabi, UAE
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
| | - Farhan A. Al Enezi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Lalitha V. Pillai
- Faculty of Medical and Health Sciences, Symbiosis Centre for Research and Innovation, Symbiosis International University, Pune, India
- Department of Critical Care Medicine, Aundh Institute of Medical Sciences, Pune, India
| | - Yaseen M. Arabi
- Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Capdevila M, De Jong A, Aarab Y, Vonarb A, Carr J, Molinari N, Capdevila X, Brochard L, Jaber S. Which spontaneous breathing trial to predict effort to breathe after extubation according to five critical illnesses: the cross-over GLOBAL WEAN study protocol. BMJ Open 2023; 13:e070931. [PMID: 37438068 DOI: 10.1136/bmjopen-2022-070931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Readiness to be freed from ventilatory support can be evaluated by spontaneous breathing trial (SBT) assessing the patient's ability to sustain respiratory effort after extubation. Current SBT practices are heterogenous and there are few physiological studies on the topic. The objective of this study is to assess which SBT best reproduces inspiratory effort to breathe after extubation depending on the patient's illness. METHODS AND ANALYSIS This will be a multicentre randomised cross-over physiological study, in a large population, in the era of modern intensive care units using last generation modern ventilators. Each included patient will perform three 15-minute SBTs in a random order: pressure support ventilation (PSV) level of 7 cmH2O with positive end expiratory pressure (PEEP) level of 0 cmH2O, PSV 0 cmH2O with PEEP 0 cmH2O and T-piece trial. A rest period of baseline state ventilation will be observed between the SBTs (10 min) and before extubation (30 min). Primary outcome will be the inspiratory muscle effort, reflected by pressure time product per minute (PTPmin). This will be calculated from oesophageal pressure measurements at baseline state, before and after each SBT and 20 min after extubation. Secondary outcomes will be PTPmin at 24 hours and 48 hours after extubation, changes in physiological variables and respiratory parameters at each step, postextubation respiratory management and the rate of successful extubation. One hundred patients with at least 24 hours of invasive mechanical ventilation will be analysed, divided into five categories of critical illness: abdominal surgery, brain injury, chest trauma, chronic obstructive pulmonary disease and miscellaneous (pneumonia, sepsis, heart disease). ETHICS AND DISSEMINATION The study project was approved by the appropriate ethics committee (2019-A01063-54, Comité de Protection des Personnes TOURS - Région Centre - Ouest 1, France). Informed consent is required, for all patients or surrogate in case of inability to give consent. TRIAL REGISTRATION NUMBER NCT04222569.
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Affiliation(s)
- Mathieu Capdevila
- Department of Anaesthesiology and Critical Care Medicine B, University Hospital Centre Montpellier, Montpellier, France
- Department of critical care patient acquired muscle weakness, INSERM U1046, Montpellier, France
| | - Audrey De Jong
- Department of Anaesthesiology and Critical Care Medicine B, University Hospital Centre Montpellier, Montpellier, France
- Department of critical care patient acquired muscle weakness, INSERM U1046, Montpellier, France
| | - Yassir Aarab
- Department of Anaesthesiology and Critical Care Medicine B, University Hospital Centre Montpellier, Montpellier, France
| | - Aurelie Vonarb
- Department of Anaesthesiology and Critical Care Medicine B, University Hospital Centre Montpellier, Montpellier, France
| | - Julie Carr
- Department of Anaesthesiology and Critical Care Medicine B, University Hospital Centre Montpellier, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, University Hospital Centre Montpellier, Montpellier, France
| | - Xavier Capdevila
- Department of Anaesthesiology and Critical Care Medicine A, University Hospital Centre Montpellier, Montpellier, France
- Montpellier NeuroSciences Institute, INSERM U1051, Montpellier, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St.Michael's Hospital, Toronto, Ontario, Canada
| | - Samir Jaber
- Department of Anaesthesiology and Critical Care Medicine B, University Hospital Centre Montpellier, Montpellier, France
- Department of critical care patient acquired muscle weakness, INSERM U1046, Montpellier, France
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van Hasselt TJ, Webster K, Gale C, Draper ES, Seaton SE. Children born preterm admitted to paediatric intensive care for bronchiolitis: a systematic review and meta-analysis. BMC Pediatr 2023; 23:326. [PMID: 37386478 PMCID: PMC10308614 DOI: 10.1186/s12887-023-04150-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND To undertake a systematic review of studies describing the proportion of children admitted to a paediatric intensive care unit (PICU) for respiratory syncytial virus (RSV) and/or bronchiolitis who were born preterm, and compare their outcomes in PICU with children born at term. METHODS We searched Medline, Embase and Scopus. Citations and references of included articles were searched. We included studies published from the year 2000 onwards, from high-income countries, that examined children 0-18 years of age, admitted to PICU from the year 2000 onwards for RSV and/or bronchiolitis. The primary outcome was the percentage of PICU admissions born preterm, and secondary outcomes were observed relative risks of invasive mechanical ventilation and mortality within PICU. We used the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies to assess risk of bias. RESULTS We included 31 studies, from 16 countries, including a total of 18,331 children. Following meta-analysis, the pooled estimate for percentage of PICU admissions for RSV/bronchiolitis who were born preterm was 31% (95% confidence interval: 27% to 35%). Children born preterm had a greater risk of requiring invasive ventilation compared to children born at term (relative risk 1.57, 95% confidence interval 1.25 to 1.97, I2 = 38%). However, we did not observe a significant increase in the relative risk for mortality within PICU for preterm-born children (relative risk 1.10, 95% confidence interval: 0.70 to 1.72, I2 = 0%), although the mortality rate was low across both groups. The majority of studies (n = 26, 84%) were at high risk of bias. CONCLUSIONS Among PICU admissions for bronchiolitis, preterm-born children are over-represented compared with the preterm birth rate (preterm birth rate 4.4% to 14.4% across countries included in review). Preterm-born children are at higher risk of mechanical ventilation compared to those born at term.
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Affiliation(s)
- Tim J van Hasselt
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK.
| | - Kirstin Webster
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Chelsea and Westminster Hospital Campus, Imperial College London, London, UK
| | - Elizabeth S Draper
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK
| | - Sarah E Seaton
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK
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Broad individual immersion-scattering of respiratory compliance likely substantiates dissimilar breathing mechanics. Sci Rep 2021; 11:9434. [PMID: 33941815 PMCID: PMC8093428 DOI: 10.1038/s41598-021-88925-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 04/19/2021] [Indexed: 11/30/2022] Open
Abstract
Head-out water immersion alters respiratory compliance which underpins defining pressure at a “Lung centroid” and the breathing “Static Lung Load”. In diving medicine as in designing dive-breathing devices a single value of lung centroid pressure is presumed as everyone’s standard. On the contrary, we considered that immersed respiratory compliance is disparate among a homogenous adult group (young, healthy, sporty). We wanted to substantiate this ample scattering for two reasons: (i) it may question the European standard used in designing dive-breathing devices; (ii) it may contribute to understand the diverse individual figures of immersed work of breathing. Resting spirometric measurements of lung volumes and the pressure–volume curve of the respiratory system were assessed for 18 subjects in two body positions (upright Up, and supine Sup). Measurements were taken in air (Air) and with subjects immersed up to the sternal notch (Imm). Compliance of the respiratory system (Crs) was calculated from pressure–volume curves for each condition. A median 60.45% reduction in Crs was recorded between Up-Air and Up-Imm (1.68 vs 0.66 L/kPa), with individual reductions ranging from 16.8 to 82.7%. We hypothesize that the previously disregarded scattering of immersion-reduced respiratory compliance might participate to substantial differences in immersed work of breathing.
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Alan N, Khorshid L. The effects of different positions on saturation and vital signs in patients. Nurs Crit Care 2019; 26:28-34. [PMID: 31659840 DOI: 10.1111/nicc.12477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/27/2019] [Accepted: 09/04/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient positioning is an independent nursing intervention and may increase peripheral oxygenation for patients with lung disease. Few studies have been conducted on the effect of body positions on oxygenation in patients with lung disease. AIMS AND OBJECTIVES To investigate the effects of five different positions on peripheral oxygen saturation (SpO2 ) and vital signs in patients with lung disease. DESIGN A semi-experimental study was conducted. METHODS Consecutive samples were recorded from critical care patients followed in the chest clinic of a university hospital. A total of 109 patients with lung disease were recruited. Patients who were able to lie in all positions, and who had unilateral or bilateral lung disease documented by a medical diagnosis by a physician were included in this study. The SpO2 and vital signs were measured at each position three times. RESULTS For patients with right, left, and bilateral lung disease, lying on the right side of the body at 45 in bed, the SpO2 was higher, but this difference was not statistically significant. There was a significant difference at 40 minutes between the pulse rate in patients with left and bilateral lung disease, but not in patients with right lung disease. No significant differences were found between respiratory rates and body temperature in patients in any of the three groups at 10, 25, and 40 minutes. CONCLUSIONS Although this difference was not statistically significant, lying on the right side of the body at 45 in bed can be an effective position for improving oxygenation in all patients with lung disease. RELEVANCE TO CLINICAL PRACTICE As there is insufficient evidence to suggest a specific position, further studies are needed. This study provides evidence that the best oxygenation in patients with unilateral and bilateral lung disease can be obtained by determining the appropriate position for critical care nurses.
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Affiliation(s)
- Nurten Alan
- Dokuz Eylül University Nursing Faculty, İnciraltı, İzmir, Turkey
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Evans D, Shure D, Clark L, Criner GJ, Dres M, de Abreu MG, Laghi F, McDonagh D, Petrof B, Nelson T, Similowski T. Temporary transvenous diaphragm pacing vs. standard of care for weaning from mechanical ventilation: study protocol for a randomized trial. Trials 2019; 20:60. [PMID: 30654837 PMCID: PMC6337771 DOI: 10.1186/s13063-018-3171-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is a life-saving technology that restores or assists breathing. Like any treatment, MV has side effects. In some patients it can cause diaphragmatic atrophy, injury, and dysfunction (ventilator-induced diaphragmatic dysfunction, VIDD). Accumulating evidence suggests that VIDD makes weaning from MV difficult, which involves increased morbidity and mortality. METHODS AND ANALYSIS This paper describes the protocol of a randomized, controlled, open-label, multicenter trial that is designed to investigate the safety and effectiveness of a novel therapy, temporary transvenous diaphragm pacing (TTVDP), to improve weaning from MV in up to 88 mechanically ventilated adult patients who have failed at least two spontaneous breathing trials over at least 7 days. Patients will be randomized (1:1) to TTVDP (treatment) or standard of care (control) groups. The primary efficacy endpoint is time to successful extubation with no reintubation within 48 h. Secondary endpoints include maximal inspiratory pressure and ultrasound-measured changes in diaphragm thickness and diaphragm thickening fraction over time. In addition, observational data will be collected and analyzed, including 30-day mortality and time to discharge from the intensive care unit and from the hospital. The hypothesis to be tested postulates that more TTVDP patients than control patients will be successfully weaned from MV within the 30 days following randomization. DISCUSSION This study is the first large-scale clinical trial of a novel technology (TTVDP) aimed at accelerating difficult weaning from MV. The technology tested provides the first therapy directed specifically at VIDD, an important cause of delayed weaning from MV. Its results will help delineate the place of this therapeutic approach in clinical practice and help design future studies aimed at defining the indications and benefits of TTVDP. TRIAL REGISTRATION ClinicalTrials.gov, NCT03096639 . Registered on 30 March 2017.
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Affiliation(s)
- Douglas Evans
- Lungpacer Medical Incorporated, Burnaby, BC, Canada.,Lungpacer Medical, 260 Sierra Drive, Exton, PA, 19335, USA
| | | | - Linda Clark
- Lungpacer Medical Incorporated, Burnaby, BC, Canada
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique and AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale du Département R3S, Paris, France
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital Hines, Loyola University, Maywood, IL, USA
| | - David McDonagh
- Departments of Anesthesiology and Pain Management, Neurological surgery, Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Basil Petrof
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, Montreal, QC, Canada
| | | | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique and AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale du Département R3S, Paris, France.
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Mezidi M, Guérin C. Effects of patient positioning on respiratory mechanics in mechanically ventilated ICU patients. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:384. [PMID: 30460258 DOI: 10.21037/atm.2018.05.50] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Changes in the body position of patients receiving mechanical ventilation in intensive care unit are frequent. Contrary to healthy humans, little data has explored the physiological impact of position on respiratory mechanics. The objective of present paper is to review the available data on the effect of changing body position on respiratory mechanics in ICU patients receiving mechanical ventilation. Supine position (lying flat) or lateral position do not seem beneficial for critically ill patients in terms of respiratory mechanics. The sitting position (with thorax angulation >30° from the horizontal plane) is associated with improvement of functional residual capacity (FRC), oxygenation and reduction of work of breathing. There is a critical angle of inclination in the seated position above which the increase in abdominal pressure contributes to increase chest wall elastance and offset the increase in FRC. The impact of prone position on respiratory mechanics is complex, but the increase in chest wall elastance is a central mechanism. To sum up, both sitting and prone positions provides beneficial impact on respiratory mechanics of mechanically ventilated patients as compared to supine position.
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Affiliation(s)
- Mehdi Mezidi
- Service de réanimation médicale, Hôpital de la Croix Rousse, Hospices civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
| | - Claude Guérin
- Service de réanimation médicale, Hôpital de la Croix Rousse, Hospices civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France.,Institut Mondor de Recherche Biomédicale, INSERM 955, Créteil, France
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Walterspacher S, Gückler J, Pietsch F, Walker DJ, Kabitz HJ, Dreher M. Activation of respiratory muscles during weaning from mechanical ventilation. J Crit Care 2017; 38:202-208. [DOI: 10.1016/j.jcrc.2016.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/24/2016] [Accepted: 11/27/2016] [Indexed: 11/25/2022]
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Maffei P, Wiramus S, Bensoussan L, Bienvenu L, Haddad E, Morange S, Fathallah M, Hardwigsen J, Viton JM, Le Treut YP, Albanese J, Gregoire E. Intensive Early Rehabilitation in the Intensive Care Unit for Liver Transplant Recipients: A Randomized Controlled Trial. Arch Phys Med Rehabil 2017; 98:1518-1525. [PMID: 28279659 DOI: 10.1016/j.apmr.2017.01.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/18/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To validate the feasibility and tolerance of an intensive rehabilitation protocol initiated during the postoperative period in an intensive care unit (ICU) in liver transplant recipients. DESIGN Prospective randomized study. SETTING ICU. PARTICIPANTS Liver transplant recipients over a period of 1 year (N=40). INTERVENTIONS The "usual treatment group" (n=20), which benefited from the usual treatment applied in the ICU (based on physician prescription for the physiotherapist, with one session a day), and the experimental group (n=20), which followed a protocol of early and intensive rehabilitation (based on a written protocol validated by physicians and an evaluation by physiotherapist, with 2 sessions a day), were compared. MAIN OUTCOME MEASURES Our primary aims were tolerance, assessed from the number of adverse events during rehabilitation sessions, and feasibility, assessed from the number of sessions discontinued. RESULTS The results revealed a small percentage of adverse events (1.5% in the usual treatment group vs 1.06% in the experimental group) that were considered to be of low intensity. Patients in the experimental group sat on the edge of their beds sooner (2.6 vs 9.7d; P=.048) and their intestinal transit resumed earlier (5.6 vs 3.7d; P=.015) than patients in the usual treatment group. There was no significant difference between the 2 arms regarding length of stay (LOS), despite a decrease in duration in the experimental group. CONCLUSIONS The introduction of an intensive early rehabilitation program for liver transplant recipients was well tolerated and feasible in the ICU. We noted that the different activities proposed were introduced sooner in the experimental group. Moreover, there is a tendency to decreased LOS in the ICU for the experimental group. These results now need to be confirmed by studies on a larger scale.
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Affiliation(s)
- Pierre Maffei
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of Physical Medicine and Rehabilitation, Hôpital de la Conception, Marseille, France
| | - Sandrine Wiramus
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Intensive Care Department, Hôpital de la Conception, Marseille, France
| | - Laurent Bensoussan
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of Physical Medicine and Rehabilitation, Hôpital de la Conception, Marseille, France
| | - Laurence Bienvenu
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of Physical Medicine and Rehabilitation, Hôpital de la Conception, Marseille, France
| | - Eric Haddad
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of Physical Medicine and Rehabilitation, Hôpital de la Conception, Marseille, France
| | - Sophie Morange
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Clinical Evaluation Unit, Hôpital de la Conception, Marseille, France
| | - Mohamed Fathallah
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Clinical Evaluation Unit, Hôpital de la Conception, Marseille, France
| | - Jean Hardwigsen
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of General Surgery and Liver Transplantation, Hôpital de la Conception, Marseille, France
| | - Jean-Michel Viton
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of Physical Medicine and Rehabilitation, Hôpital de la Conception, Marseille, France
| | - Y Patrice Le Treut
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of General Surgery and Liver Transplantation, Hôpital de la Conception, Marseille, France
| | - Jacques Albanese
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Intensive Care Department, Hôpital de la Conception, Marseille, France
| | - Emilie Gregoire
- Aix-Marseille University, Assistance Publique des Hôpitaux de Marseille, Department of General Surgery and Liver Transplantation, Hôpital de la Conception, Marseille, France.
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Mahul M, Jung B, Galia F, Molinari N, de Jong A, Coisel Y, Vaschetto R, Matecki S, Chanques G, Brochard L, Jaber S. Spontaneous breathing trial and post-extubation work of breathing in morbidly obese critically ill patients. Crit Care 2016; 20:346. [PMID: 27784322 PMCID: PMC5081985 DOI: 10.1186/s13054-016-1457-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/16/2016] [Indexed: 11/10/2022] Open
Abstract
Background Predicting whether an obese critically ill patient can be successfully extubated may be specially challenging. Several weaning tests have been described but no physiological study has evaluated the weaning test that would best reflect the post-extubation inspiratory effort. Methods This was a physiological randomized crossover study in a medical and surgical single-center Intensive Care Unit, in patients with body mass index (BMI) >35 kg/m2 who were mechanically ventilated for more than 24 h and underwent a weaning test. After randomization, 17 patients were explored using five settings : pressure support ventilation (PSV) 7 and positive end-expiratory pressure (PEEP) 7 cmH2O; PSV 0 and PEEP 7cmH2O; PSV 7 and PEEP 0 cmH2O; PSV 0 and PEEP 0 cmH2O; and a T piece, and after extubation. To further minimize interaction between each setting, a period of baseline ventilation was performed between each step of the study. We hypothesized that the post-extubation work of breathing (WOB) would be similar to the T-tube WOB. Results Respiratory variables and esophageal and gastric pressure were recorded. Inspiratory muscle effort was calculated as the esophageal and trans-diaphragmatic pressure time products and WOB. Sixteen obese patients (BMI 44 kg/m2 ± 8) were included and successfully extubated. Post-extubation inspiratory effort, calculated by WOB, was 1.56 J/L ± 0.50, not statistically different from the T piece (1.57 J/L ± 0.56) or PSV 0 and PEEP 0 cmH2O (1.58 J/L ± 0.57), whatever the index of inspiratory effort. The three tests that maintained pressure support statistically underestimated post-extubation inspiratory effort (WOB 0.69 J/L ± 0.31, 1.15 J/L ± 0.39 and 1.09 J/L ± 0.49, respectively, p < 0.001). Respiratory mechanics and arterial blood gases did not differ between the five tests and the post-extubation condition. Conclusions In obese patients, inspiratory effort measured during weaning tests with either a T-piece or a PSV 0 and PEEP 0 was not different to post-extubation inspiratory effort. In contrast, weaning tests with positive pressure overestimated post-extubation inspiratory effort. Trial registration Clinical trial.gov (reference NCT01616901), 2012, June 4th Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1457-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Mahul
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 80 avenue Augustin Fliche, F-34295, Montpellier, Cedex 5, France
| | - Boris Jung
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 80 avenue Augustin Fliche, F-34295, Montpellier, Cedex 5, France.,Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM U-1046), Montpellier University, Montpellier, France
| | - Fabrice Galia
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 80 avenue Augustin Fliche, F-34295, Montpellier, Cedex 5, France
| | - Nicolas Molinari
- Department of Statistics, University of Montpellier Lapeyronie Hospital, UMR 729 MISTEA, Montpellier, France
| | - Audrey de Jong
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 80 avenue Augustin Fliche, F-34295, Montpellier, Cedex 5, France
| | - Yannaël Coisel
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 80 avenue Augustin Fliche, F-34295, Montpellier, Cedex 5, France.,Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM U-1046), Montpellier University, Montpellier, France
| | - Rosanna Vaschetto
- Anaesthesia and Intensive Care Medicine, Maggiore della Carità Hospital, Novara, Italy
| | - Stefan Matecki
- Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM U-1046), Montpellier University, Montpellier, France
| | - Gérald Chanques
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 80 avenue Augustin Fliche, F-34295, Montpellier, Cedex 5, France.,Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM U-1046), Montpellier University, Montpellier, France
| | - Laurent Brochard
- Keenan Research Centre, St Michael's Hospital, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Samir Jaber
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 80 avenue Augustin Fliche, F-34295, Montpellier, Cedex 5, France. .,Centre National de la Recherche Scientifique (CNRS 9214) - Institut National de la Santé et de la Recherche Médicale (INSERM U-1046), Montpellier University, Montpellier, France.
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11
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Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. [Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]. Anaesthesist 2016; 64:596-611. [PMID: 26260196 DOI: 10.1007/s00101-015-0060-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
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Affiliation(s)
- T Bein
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, 93042, Regensburg, Deutschland,
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12
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Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). Anaesthesist 2015; 64 Suppl 1:1-26. [PMID: 26335630 PMCID: PMC4712230 DOI: 10.1007/s00101-015-0071-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
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Affiliation(s)
- Th Bein
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany.
| | - M Bischoff
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - U Brückner
- Physiotherapy Department, Clinic Donaustauf, Centre for Pneumology, 93093, Donaustauf, Germany
| | - K Gebhardt
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - D Henzler
- Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine, Pain Management, Klinikum Herford, 32049, Herford, Germany
| | - C Hermes
- HELIOS Clinic Siegburg, 53721, Siegburg, Germany
| | - K Lewandowski
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Elisabeth Hospital Essen, 45138, Essen, Germany
| | - M Max
- Centre Hospitalier, Soins Intensifs Polyvalents, 1210, Luxembourg, Luxemburg
| | - M Nothacker
- Association of Scientific Medical Societies (AWMF), 35043, Marburg, Germany
| | - Th Staudinger
- University Hospital for Internal Medicine I, Medical University of Wien, General Hospital of Vienna, 1090, Vienna, Austria
| | - M Tryba
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Klinikum Kassel, 34125, Kassel, Germany
| | - S Weber-Carstens
- Clinic for Anaesthesiology and Surgical Intensive Care Medicine, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, 13353, Berlin, Germany
| | - H Wrigge
- Clinic and Policlinic for Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103, Leipzig, Germany
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13
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Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A, Albaladejo P, Chanques G, Molinari N, Jaber S. Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive Care Med 2015; 42:853-861. [DOI: 10.1007/s00134-015-4125-2] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/26/2015] [Indexed: 11/24/2022]
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Abstract
BACKGROUND Elevating the hospital head of bed (HOB) to at least 30° is recommended practice to reduce the risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. However, this common practice prescribes the position of the bed and not of the patient, which could be significantly different. OBJECTIVE The aim of this research was to determine the relationship between patient migration in bed and anatomic torso angle. METHODS Ten healthy participants were positioned in a hospital bed that was raised from flat to 30° and 45° HOB elevations. Prior to bed movement, participants were aligned to different locations along the length of the bed to represent different amounts of migration. A motion capture system was used to measure torso angle and migration toward the foot of the bed. The relationship between torso angle and migration was estimated by linear regression. RESULTS Patient migration resulted in lower torso angles for both 30° and 45° HOB articulations. A migration of 10 cm resulted in a loss of 9.1° and 13.0° of torso angle for HOB articulations of 30° and 45°, respectively (for 30° articulations: (Equation is included in full-text article.)= -0.91, R = .96; for 45° articulations: (Equation is included in full-text article.)= -1.30, R = .98). DISCUSSION Migration toward the foot of the bed flattens the torso. To maintain a torso angle that is likely to protect against VAP, healthcare providers need to manage both HOB angle and migration. Protocols and equipment that minimize patient migration will help support effective clinical practice. Future research on patient migration, as it relates to VAP or other outcomes, should measure patient torso angle to allow accurate translation of the results to care practice.
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15
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Abstract
The ramifications of patient migration toward the foot of the bed in intensive care units are not well understood. Migration may cause shear and friction between the patient and the mattress, reduce elevation of the patient's torso, and require frequent repositioning of the patient. This study assesses how bed design impacts both the amount of migration that patients undergo during head section articulation to 30° and 45° and the extent of torso compression following the articulation.
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16
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Abstract
PURPOSE OF REVIEW Spontaneous breathing has been shown to induce both positive and negative effects on the function and on injury of lungs and diaphragm during critical illness; thus, monitoring of the breathing effort generated by the patient might be valuable for a better understanding of the mechanisms of disease and to set properly ventilation. The purpose of this review is to summarize the recent findings on the different techniques available to measure the patient's breathing effort, mainly during spontaneous assisted ventilation. RECENT FINDINGS Although esophageal pressure measurement remains the solid reference technique to quantitate the breathing effort, other tools have been developed and tested. These include the diaphragmatic electromyogram, whose voltage is linearly related to the pressure generated by the diaphragm, ultrasound, which relies on the measurement of diaphragmatic displacement or thickening, and other approaches, which derive breathing effort solely from the airway flow and pressure tracings. SUMMARY The development of measurement techniques and their introduction in clinical practice will allow us to understand the role of spontaneous breathing effort in the pathophysiology of lung injury and weaning failure, and how to adjust the breathing workload in an individual patient.
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17
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Thomas P, Paratz J, Lipman J. Seated and semi-recumbent positioning of the ventilated intensive care patient - effect on gas exchange, respiratory mechanics and hemodynamics. Heart Lung 2014; 43:105-11. [PMID: 24594247 DOI: 10.1016/j.hrtlng.2013.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To compare the effect of semi-recumbent and sitting positions on gas exchange, respiratory mechanics and hemodynamics in patients weaning from mechanical ventilation. BACKGROUND Upright positions are encouraged during rehabilitation of the critically ill but there effects have not been well described. METHODS A prospective, randomized, cross-over trial was conducted. Subjects were passively mobilized from supine into a seated position (out of bed) and from supine to a semi-recumbent position (>45° backrest elevation in bed). Arterial blood gas (PaO2/FiO2, PaO2, SaO2, PaCO2 and A-a gradient), respiratory mechanics (VE,VT, RR, Cdyn, RR/VT) and hemodynamic measurements (HR, MABP) were collected in supine and at 5 min and 30 min after re-positioning. RESULTS Thirty-four intubated and ventilated subjects were enrolled. The angle of backrest inclination in sitting (67 ± 5°) was greater than gained with semi-recumbent positioning (50 ± 5°, p < 0.001). There were no clinically important changes in arterial blood gas, respiratory mechanic or hemodynamic values due to either position. CONCLUSIONS Neither position resulted in significant changes in respiratory and hemodynamic parameters. Both positions can be applied safely in patients being weaned from ventilation.
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Affiliation(s)
- Peter Thomas
- Department of Physiotherapy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Jennifer Paratz
- Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia
| | - Jeffrey Lipman
- Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
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18
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Year in review in Intensive Care Medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients. Intensive Care Med 2014; 40:305-19. [PMID: 24458282 DOI: 10.1007/s00134-014-3217-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/11/2014] [Indexed: 01/02/2023]
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19
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Galeiras Vázquez R, Rascado Sedes P, Mourelo Fariña M, Montoto Marqués A, Ferreiro Velasco ME. Respiratory management in the patient with spinal cord injury. BIOMED RESEARCH INTERNATIONAL 2013; 2013:168757. [PMID: 24089664 PMCID: PMC3781830 DOI: 10.1155/2013/168757] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/11/2013] [Accepted: 07/30/2013] [Indexed: 12/19/2022]
Abstract
Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriate candidates can sometimes be freed from mechanical ventilation by electrical stimulation. Respiratory muscle training regimens may improve patients' inspiratory function following a SCI.
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Affiliation(s)
- Rita Galeiras Vázquez
- Critical Care Unit, Complexo Hospitalario Universitario A Coruña, CP. 15006, A Coruña, Spain
| | - Pedro Rascado Sedes
- Critical Care Unit, Complexo Hospitalario Universitario de Santiago de Compostela, CP. 15702, Santiago de Compostela, Spain
| | - Mónica Mourelo Fariña
- Critical Care Unit, Complexo Hospitalario Universitario A Coruña, CP. 15006, A Coruña, Spain
| | - Antonio Montoto Marqués
- Spinal Cord Injury Unit, Complexo Hospitalario Universitario A Coruña, CP. 15006, A Coruña, Spain
- Department of Medicine, University of A Coruña, CP. 15006, A Coruña, Spain
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Bonnevie T. Entraînement en force des muscles inspirateurs du patient ventilé — de la dysfonction diaphragmatique au sevrage de la ventilation mécanique. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0694-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Effect of different seated positions on lung volume and oxygenation in acute respiratory distress syndrome. Intensive Care Med 2013; 39:1121-7. [PMID: 23344832 DOI: 10.1007/s00134-013-2827-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 01/07/2013] [Indexed: 10/27/2022]
Abstract
RATIONALE Lung volume available for ventilation is markedly decreased during acute respiratory distress syndrome. Body positioning may contribute to increase lung volume and partial verticalization is simple to perform. This study evaluated whether verticalization had parallel effects on oxygenation and end expiratory lung volume (EELV). METHODS Prospective multicenter study in 40 mechanically ventilated patients with ALI/ARDS in five university hospital MICUs. We evaluated four 45-min successive trunk position epochs (supine slightly elevated at 15°; semi recumbent with trunk elevated at 45°; seated with trunk elevated at 60° and legs down at 45°; back to supine). Arterial blood gases, EELV measured using the nitrogen washin/washout, and static compliance were measured. Responders were defined by a PaO₂/FiO₂ increase >20 % between supine and seated position. Results are median [25th-75th percentiles]. RESULTS With median PEEP = 10 cmH₂O, verticalization increased lung volume but only responders (13 patients, 32 %) had a significant increase in EELV/PBW (predicted body weight) compared to baseline. This increase persisted at least partially when patients were positioned back to supine. Responders had a lower EELV/PBW supine [14 mL/kg (13-15) vs. 18 mL/kg (15-27) (p = 0.005)] and a lower compliance [30 mL/cmH₂O (22-38) vs. 42 (30-46) (p = 0.01)] than non-responders. Strain decreased with verticalization for responders. EELV/PBW increase and PaO₂/FiO₂ increase were not correlated. DISCUSSION Verticalization is easily achieved and improves oxygenation in approximately 32 % of the patients together with an increase in EELV. Nonetheless, effect of verticalization on EELV/PBW is not predictable by PaO₂/FiO₂ increase, its monitoring may be helpful for strain optimization.
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