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Aşar S, Rahim F, Rahimi P, Acicbe Ö, Tontu F, Çukurova Z. Novel Oxygenation and Saturation Indices for Mortality Prediction in COVID-19 ARDS Patients: The Impact of Driving Pressure and Mechanical Power. J Intensive Care Med 2024; 39:595-608. [PMID: 38179691 PMCID: PMC11092301 DOI: 10.1177/08850666231223498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
Background: The oxygenation index (OI) and oxygen saturation index (OSI) are proven mortality predictors in pediatric and adult patients, traditionally using mean airway pressure (Pmean). We introduce novel indices, replacing Pmean with DP (ΔPinsp), MPdyn, and MPtot, assessing their potential for predicting COVID-19 acute respiratory distress syndrome (ARDS) mortality, comparing them to traditional indices. Methods: We studied 361 adult COVID-19 ARDS patients for 7 days, collecting ΔPinsp, MPdyn, and MPtot, OI-ΔPinsp, OI-MPdyn, OI-MPtot, OSI-ΔPinsp, OSI-MPdyn, and OSI-MPtot. We compared these in surviving and non-surviving patients over the first 7 intensive care unit (ICU) days using Mann-Whitney U test. Logistic regression receiver operating characteristic (ROC) analysis assessed AUC and CI values for ICU mortality on day three. We determined cut-off values using Youden's method and conducted multivariate Cox regression on parameter limits. Results: All indices showed significant differences between surviving and non-surviving patients on the third day of ICU care. The AUC values of OI-ΔPinsp were significantly higher than those of P/F and OI-Pmean (P values .0002 and <.0001, respectively). Similarly, AUC and CI values of OSI-ΔPinsp and OSI-MPdyn were significantly higher than those of SpO2/FiO2 and OSI-Pmean values (OSI-ΔPinsp: P < .0001, OSI-MPdyn: P values .047 and .028, respectively). OI-ΔPinsp, OSI-ΔPinsp, OI-MPdyn, OSI-MPdyn, OI-MPtot, and OSI-MPtot had AUC values of 0.72, 0.71, 0.69, 0.68, 0.66, and 0.64, respectively, with cut-off values associated with hazard ratios and P values of 7.06 (HR = 1.84, P = .002), 8.04 (HR = 2.00, P ≤ .0001), 7.12 (HR = 1.68, P = .001), 5.76 (HR = 1.70, P ≤ .0001), 10.43 (HR = 1.52, P = .006), and 10.68 (HR = 1.66, P = .001), respectively. Conclusions: Critical values of all indices were associated to higher ICU mortality rates and extended mechanical ventilation durations. The OI-ΔPinsp, OSI-ΔPinsp, and OSI-MPdyn indices displayed the strongest predictive capabilities for ICU mortality. These novel indices offer valuable insights for intensivists in the clinical management and decision-making process for ARDS patients.
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Affiliation(s)
- Sinan Aşar
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Fatih Rahim
- Department of Industrial Engineering, Koç University, Istanbul, Turkey
| | - Payam Rahimi
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Özlem Acicbe
- Department of Anesthesiology and Reanimation, Şişli HamidiyeEtfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Furkan Tontu
- Department of Anesthesiology and Reanimation, Ağrı Training and Research Hospital, Ağrı, Turkey
| | - Zafer Çukurova
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Serafini SC, van Meenen DMP, Pisani L, Neto AS, Ball L, de Abreu MG, Algera AG, Azevedo L, Bellani G, Dondorp AM, Fan E, Laffey JG, Pham T, Tschernko EM, Schultz MJ, van der Woude MCE. Different ventilation intensities among various categories of patients ventilated for reasons other than ARDS--A pooled analysis of 4 observational studies. J Crit Care 2024; 81:154531. [PMID: 38341938 DOI: 10.1016/j.jcrc.2024.154531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
PURPOSE We investigated driving pressure (ΔP) and mechanical power (MP) and associations with clinical outcomes in critically ill patients ventilated for reasons other than ARDS. MATERIALS AND METHODS Individual patient data analysis of a pooled database that included patients from four observational studies of ventilation. ΔP and MP were compared among invasively ventilated non-ARDS patients with sepsis, with pneumonia, and not having sepsis or pneumonia. The primary endpoint was ΔP; secondary endpoints included MP, ICU mortality and length of stay, and duration of ventilation. RESULTS This analysis included 372 (11%) sepsis patients, 944 (28%) pneumonia patients, and 2040 (61%) patients ventilated for any other reason. On day 1, median ΔP was higher in sepsis (14 [11-18] cmH2O) and pneumonia patients (14 [11-18]cmH2O), as compared to patients not having sepsis or pneumonia (13 [10-16] cmH2O) (P < 0.001). Median MP was also higher in sepsis and pneumonia patients. ΔP, as opposed to MP, was associated with ICU mortality in sepsis and pneumonia patients. CONCLUSIONS The intensity of ventilation differed between patients with sepsis or pneumonia and patients receiving ventilation for any other reason; ΔP was associated with higher mortality in sepsis and pneumonia patients. REGISTRATION This post hoc analysis was not registered; the individual studies that were merged into the used database were registered at clinicaltrials.gov: NCT01268410 (ERICC), NCT02010073 (LUNG SAFE), NCT01868321 (PRoVENT), and NCT03188770 (PRoVENT-iMiC).
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Affiliation(s)
- Simon Corrado Serafini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands.
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Section of Operational Research, Doctors with Africa, Padova, Italy; Department of Anesthesiology and Intensive Care Medicine, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Marcelo Gama de Abreu
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luciano Azevedo
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Department of Emergency Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Centro Interdipartimentale di Scienze Mediche (CISMed), Università di Trento, Italy; UOC anesthesia and Intensive Care 1, Ospedale Santa Chiara, APSS, Trento, Italy
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals Ireland, Galway, Ireland
| | - Tai Pham
- Equipe d'Epidémiologie Respiratoire integrative, Université Paris-Saclay, Paris, France; Department of Intensive Care, Hôpital de Bicêtre, Paris, France
| | - Edda M Tschernko
- Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK; Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
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3
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Boesing C, Krebs J, Conrad AM, Otto M, Beck G, Thiel M, Rocco PRM, Luecke T, Schaefer L. Effects of prone positioning on lung mechanical power components in patients with acute respiratory distress syndrome: a physiologic study. Crit Care 2024; 28:82. [PMID: 38491457 PMCID: PMC10941550 DOI: 10.1186/s13054-024-04867-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Prone positioning (PP) homogenizes ventilation distribution and may limit ventilator-induced lung injury (VILI) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The static and dynamic components of ventilation that may cause VILI have been aggregated in mechanical power, considered a unifying driver of VILI. PP may affect mechanical power components differently due to changes in respiratory mechanics; however, the effects of PP on lung mechanical power components are unclear. This study aimed to compare the following parameters during supine positioning (SP) and PP: lung total elastic power and its components (elastic static power and elastic dynamic power) and these variables normalized to end-expiratory lung volume (EELV). METHODS This prospective physiologic study included 55 patients with moderate to severe ARDS. Lung total elastic power and its static and dynamic components were compared during SP and PP using an esophageal pressure-guided ventilation strategy. In SP, the esophageal pressure-guided ventilation strategy was further compared with an oxygenation-guided ventilation strategy defined as baseline SP. The primary endpoint was the effect of PP on lung total elastic power non-normalized and normalized to EELV. Secondary endpoints were the effects of PP and ventilation strategies on lung elastic static and dynamic power components non-normalized and normalized to EELV, respiratory mechanics, gas exchange, and hemodynamic parameters. RESULTS Lung total elastic power (median [interquartile range]) was lower during PP compared with SP (6.7 [4.9-10.6] versus 11.0 [6.6-14.8] J/min; P < 0.001) non-normalized and normalized to EELV (3.2 [2.1-5.0] versus 5.3 [3.3-7.5] J/min/L; P < 0.001). Comparing PP with SP, transpulmonary pressures and EELV did not significantly differ despite lower positive end-expiratory pressure and plateau airway pressure, thereby reducing non-normalized and normalized lung elastic static power in PP. PP improved gas exchange, cardiac output, and increased oxygen delivery compared with SP. CONCLUSIONS In patients with moderate to severe ARDS, PP reduced lung total elastic and elastic static power compared with SP regardless of EELV normalization because comparable transpulmonary pressures and EELV were achieved at lower airway pressures. This resulted in improved gas exchange, hemodynamics, and oxygen delivery. TRIAL REGISTRATION German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://drks.de/search/en/trial/DRKS00017449.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Alice Marguerite Conrad
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Matthias Otto
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Grietje Beck
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Grotberg JC, Reynolds D, Kraft BD. Management of severe acute respiratory distress syndrome: a primer. Crit Care 2023; 27:289. [PMID: 37464381 DOI: 10.1186/s13054-023-04572-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
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Affiliation(s)
- John C Grotberg
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA.
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
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Azizi BA, Munoz-Acuna R, Suleiman A, Ahrens E, Redaelli S, Tartler TM, Chen G, Jung B, Talmor D, Baedorf-Kassis EN, Schaefer MS. Mechanical power and 30-day mortality in mechanically ventilated, critically ill patients with and without Coronavirus Disease-2019: a hospital registry study. J Intensive Care 2023; 11:14. [PMID: 37024938 PMCID: PMC10077655 DOI: 10.1186/s40560-023-00662-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Previous studies linked a high intensity of ventilation, measured as mechanical power, to mortality in patients suffering from "classic" ARDS. By contrast, mechanically ventilated patients with a diagnosis of COVID-19 may present with intact pulmonary mechanics while undergoing mechanical ventilation for longer periods of time. We investigated whether an association between higher mechanical power and mortality is modified by a diagnosis of COVID-19. METHODS This retrospective study included critically ill, adult patients who were mechanically ventilated for at least 24 h between March 2020 and December 2021 at a tertiary healthcare facility in Boston, Massachusetts. The primary exposure was median mechanical power during the first 24 h of mechanical ventilation, calculated using a previously validated formula. The primary outcome was 30-day mortality. As co-primary analysis, we investigated whether a diagnosis of COVID-19 modified the primary association. We further investigated the association between mechanical power and days being alive and ventilator free and effect modification of this by a diagnosis of COVID-19. Multivariable logistic regression, effect modification and negative binomial regression analyses adjusted for baseline patient characteristics, severity of disease and in-hospital factors, were applied. RESULTS 1,737 mechanically ventilated patients were included, 411 (23.7%) suffered from COVID-19. 509 (29.3%) died within 30 days. The median mechanical power during the first 24 h of ventilation was 19.3 [14.6-24.0] J/min in patients with and 13.2 [10.2-18.0] J/min in patients without COVID-19. A higher mechanical power was associated with 30-day mortality (ORadj 1.26 per 1-SD, 7.1J/min increase; 95% CI 1.09-1.46; p = 0.002). Effect modification and interaction analysis did not support that this association was modified by a diagnosis of COVID-19 (95% CI, 0.81-1.38; p-for-interaction = 0.68). A higher mechanical power was associated with a lower number of days alive and ventilator free until day 28 (IRRadj 0.83 per 7.1 J/min increase; 95% CI 0.75-0.91; p < 0.001, adjusted risk difference - 2.7 days per 7.1J/min increase; 95% CI - 4.1 to - 1.3). CONCLUSION A higher mechanical power is associated with elevated 30-day mortality. While patients with COVID-19 received mechanical ventilation with higher mechanical power, this association was independent of a concomitant diagnosis of COVID-19.
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Affiliation(s)
- Basit A Azizi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Simone Redaelli
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Guanqing Chen
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Boris Jung
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA
| | - Elias N Baedorf-Kassis
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline Ave 330, Boston, MA, USA.
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany.
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Rezoagli E, Laffey JG, Bellani G. Monitoring Lung Injury Severity and Ventilation Intensity during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:346-368. [PMID: 35896391 DOI: 10.1055/s-0042-1748917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure burden by high hospital mortality. No specific pharmacologic treatment is currently available and its ventilatory management is a key strategy to allow reparative and regenerative lung tissue processes. Unfortunately, a poor management of mechanical ventilation can induce ventilation induced lung injury (VILI) caused by physical and biological forces which are at play. Different parameters have been described over the years to assess lung injury severity and facilitate optimization of mechanical ventilation. Indices of lung injury severity include variables related to gas exchange abnormalities, ventilatory setting and respiratory mechanics, ventilation intensity, and the presence of lung hyperinflation versus derecruitment. Recently, specific indexes have been proposed to quantify the stress and the strain released over time using more comprehensive algorithms of calculation such as the mechanical power, and the interaction between driving pressure (DP) and respiratory rate (RR) in the novel DP multiplied by four plus RR [(4 × DP) + RR] index. These new parameters introduce the concept of ventilation intensity as contributing factor of VILI. Ventilation intensity should be taken into account to optimize protective mechanical ventilation strategies, with the aim to reduce intensity to the lowest level required to maintain gas exchange to reduce the potential for VILI. This is further gaining relevance in the current era of phenotyping and enrichment strategies in ARDS.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
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Mechanical power during general anesthesia and postoperative respiratory failure: A multicenter retrospective cohort study. Anesthesiology 2022; 137:41-54. [PMID: 35475882 DOI: 10.1097/aln.0000000000004256] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Mechanical power during ventilation estimates the energy delivered to the respiratory system through integrating inspiratory pressures, tidal volume and respiratory rate into a single value. It has been linked to lung injury and mortality in the acute respiratory distress syndrome, but little evidence exists whether the concept relates to lung injury in patients with healthy lungs. We hypothesized that higher mechanical power is associated with more postoperative respiratory failure requiring reintubation in patients undergoing general anesthesia. METHODS In this multicenter, retrospective study, 230,767 elective, non-cardiac adult surgical out- and inpatients undergoing general anesthesia between 2008 and 2018 at two academic hospital networks in Boston, MA, were included. The risk-adjusted association between the median intraoperative mechanical power (MP), calculated from median values of tidal volume (Vt), respiratory rate (RR), positive end-expiratory pressure (PEEP), plateau pressure (Pplat), and peak inspiratory pressure (Ppeak), using the formula MP (J/min)= 0.098*RR*Vt*[PEEP+½(Pplat-PEEP)+(Ppeak-Pplat)], and postoperative respiratory failure requiring reintubation within 7 days was assessed. RESULTS The median intraoperative mechanical power was 6.63 (interquartile range: 4.62-9.11) J/min. Postoperative respiratory failure occurred in 2,024 (0.9%) patients. The median (IQR) intraoperative mechanical power was higher in patients with postoperative respiratory failure than in patients without (7.67 [5.64-10.11] vs. 6.62 [4.62-9.10] J/min; p<0.001). In adjusted analyses, a higher mechanical power was associated with greater odds of postoperative respiratory failure (adjusted odds ratio [ORadj] 1.31 per 5 J/min increase; 95%CI 1.21-1.42; p<0.001). The association between mechanical power and postoperative respiratory failure was robust to additional adjustment for known drivers of ventilator-induced lung injury, including tidal volume, driving pressure and respiratory rate, and driven by the dynamic elastic component (ORadj 1.35 per 5 J/min; 95%CI 1.05-1.73; p=0.02). CONCLUSIONS Higher mechanical power during ventilation is statistically associated with a greater risk of postoperative respiratory failure requiring reintubation.
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Baedorf Kassis E, Talmor D. Clinical application of esophageal manometry: how I do it. Crit Care 2021; 25:6. [PMID: 33402179 PMCID: PMC7786919 DOI: 10.1186/s13054-020-03453-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/23/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care and Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine and Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
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