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Cicvarić A, Glavaš Tahtler J, Turk T, Škrinjarić-Cincar S, Koulenti D, Nešković N, Edl M, Kvolik S. Ventilation Management in a Patient with Ventilation-Perfusion Mismatch in the Early Phase of Lung Injury and during the Recovery. J Clin Med 2024; 13:871. [PMID: 38337565 PMCID: PMC10856224 DOI: 10.3390/jcm13030871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/23/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
Chest trauma is one of the most serious and difficult injuries, with various complications that can lead to ventilation-perfusion (V/Q) mismatch and systemic hypoxia. We are presenting a case of a 53-year-old male with no chronic therapy who was admitted to the Intensive Care Unit due to severe respiratory failure after chest trauma. He developed a right-sided pneumothorax, and then a thoracic drain was placed. On admission, the patient was hemodynamically unstable and tachypneic. He was intubated and mechanically ventilated, febrile (38.9 °C) and unconscious. A lung CT showed massive non-ventilated areas, predominantly in the right lung, guiding repeated therapeutic and diagnostic bronchoalveolar lavages. He was ventilated with PEEP of 10 cmH2O with a FiO2 of 0.6-0.8. Empirical broad-spectrum antimicrobial therapy was immediately initiated. Both high FiO2 and moderate PEEP were maintained and adjusted according to the current blood gas values and oxygen saturation. He was weaned from mechanical ventilation, and non-invasive oxygenation was continued. After Stenotrophomonas maltophilia was identified and treated with sulfamethoxazole/trimethoprim, a regression of lung infiltrates was observed. In conclusion, both ventilatory and antibiotic therapy were needed to improve the oxygenation and outcome of the patient with S. maltophilia pneumonia and V/Q mismatch.
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Affiliation(s)
- Ana Cicvarić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia; (J.G.T.); (T.T.); (N.N.); (M.E.)
- Department of Anesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, 31000 Osijek, Croatia
| | - Josipa Glavaš Tahtler
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia; (J.G.T.); (T.T.); (N.N.); (M.E.)
- Department of Anesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, 31000 Osijek, Croatia
| | - Tajana Turk
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia; (J.G.T.); (T.T.); (N.N.); (M.E.)
- Department of Radiology, Osijek University Hospital, 31000 Osijek, Croatia
| | | | - Despoina Koulenti
- 2nd Critical Care Department, Attikon University Hospital, 15772 Athens, Greece;
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia
| | - Nenad Nešković
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia; (J.G.T.); (T.T.); (N.N.); (M.E.)
- Department of Anesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, 31000 Osijek, Croatia
| | - Mia Edl
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia; (J.G.T.); (T.T.); (N.N.); (M.E.)
| | - Slavica Kvolik
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia; (J.G.T.); (T.T.); (N.N.); (M.E.)
- Department of Anesthesiology, Resuscitation and Intensive Care, Osijek University Hospital, 31000 Osijek, Croatia
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Gouvea Bogossian E, Cantos J, Farinella A, Nobile L, Njimi H, Coppalini G, Diosdado A, Salvagno M, Oliveira Gomes F, Schuind S, Anderloni M, Robba C, Taccone FS. The effect of increased positive end expiratory pressure on brain tissue oxygenation and intracranial pressure in acute brain injury patients. Sci Rep 2023; 13:16657. [PMID: 37789100 PMCID: PMC10547811 DOI: 10.1038/s41598-023-43703-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/27/2023] [Indexed: 10/05/2023] Open
Abstract
Cerebral hypoxia is an important cause of secondary brain injury. Improving systemic oxygenation may increase brain tissue oxygenation (PbtO2). The effects of increased positive end-expiratory pressure (PEEP) on PbtO2 and intracranial pressure (ICP) needs to be further elucidated. This is a single center retrospective cohort study (2016-2021) conducted in a 34-bed Department of Intensive Care unit. All patients with acute brain injury under mechanical ventilation who were monitored with intracranial pressure and brain tissue oxygenation (PbtO2) catheters and underwent at least one PEEP increment were included in the study. Primary outcome was the rate of PbtO2 responders (increase in PbtO2 > 20% of baseline) after PEEP increase. ΔPEEP was defined as the difference between PEEP at 1 h and PEEP at baseline; similarly ΔPbtO2 was defined as the difference between PbtO2 at 1 h after PEEP incrementation and PbtO2 at baseline. We included 112 patients who underwent 295 episodes of PEEP increase. Overall, the median PEEP increased form 6 (IQR 5-8) to 10 (IQR 8-12) cmH2O (p = 0.001), the median PbtO2 increased from 21 (IQR 16-29) mmHg to 23 (IQR 18-30) mmHg (p = 0.001), while ICP remained unchanged [from 12 (7-18) mmHg to 12 (7-17) mmHg; p = 0.42]. Of 163 episode of PEEP increments with concomitant PbtO2 monitoring, 34 (21%) were PbtO2 responders. A lower baseline PbtO2 (OR 0.83 [0.73-0.96)]) was associated with the probability of being responder. ICP increased in 142/295 episodes of PEEP increments (58%); no baseline variable was able to identify this response. In PbtO2 responders there was a moderate positive correlation between ΔPbtO2 and ΔPEEP (r = 0.459 [95% CI 0.133-0.696]. The response in PbtO2 and ICP to PEEP elevations in brain injury patients is highly variable. Lower PbtO2 values at baseline could predict a significant increase in brain oxygenation after PEEP increase.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Joaquin Cantos
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Anita Farinella
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Hassane Njimi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giacomo Coppalini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Alberto Diosdado
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fernando Oliveira Gomes
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Université Libre de Bruxelles, Brussels, Belgium
| | - Marco Anderloni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, IRCCS Policlinico San Martino, Università di Genova, Genova, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
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Battaglini D, Pelosi P, Robba C. Ten rules for optimizing ventilatory settings and targets in post-cardiac arrest patients. Crit Care 2022; 26:390. [PMID: 36527126 PMCID: PMC9758928 DOI: 10.1186/s13054-022-04268-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Cardiac arrest (CA) is a major cause of morbidity and mortality frequently associated with neurological and systemic involvement. Supportive therapeutic strategies such as mechanical ventilation, hemodynamic settings, and temperature management have been implemented in the last decade in post-CA patients, aiming at protecting both the brain and the lungs and preventing systemic complications. A lung-protective ventilator strategy is currently the standard of care among critically ill patients since it demonstrated beneficial effects on mortality, ventilator-free days, and other clinical outcomes. The role of protective and personalized mechanical ventilation setting in patients without acute respiratory distress syndrome and after CA is becoming more evident. The individual effect of different parameters of lung-protective ventilation, including mechanical power as well as the optimal oxygen and carbon dioxide targets, on clinical outcomes is a matter of debate in post-CA patients. The management of hemodynamics and temperature in post-CA patients represents critical steps for obtaining clinical improvement. The aim of this review is to summarize and discuss current evidence on how to optimize mechanical ventilation in post-CA patients. We will provide ten tips and key insights to apply a lung-protective ventilator strategy in post-CA patients, considering the interplay between the lungs and other systems and organs, including the brain.
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Affiliation(s)
- Denise Battaglini
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Paolo Pelosi
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Dynamic Monitoring of Serum Protein in Acute Respiratory Distress Syndrome Based on Artificial Neural Network. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3542942. [PMID: 36299681 PMCID: PMC9592208 DOI: 10.1155/2022/3542942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is one of the more serious diseases in human lung disease. Reducing its incidence rate is an important task in current clinical research. Dynamic monitoring of serum protein in patients will help to achieve the early diagnosis and treatment of ARDS. In this study, a protein monitoring model based on artificial neural network is proposed. First, surface enhanced laser desorption ionization time-of-flight mass spectrometry is used for protein detection, and then BP neural network is used for protein classification and content analysis. In the experimental analysis, serum samples from patients with acute respiratory distress syndrome in our hospital from November 2020 to August 2021 were selected for experimental testing. The experimental results show that the serum protein monitoring model based on BP neural network has low error and high convergence ability and can monitor individual protein in protein monitoring, and the area under the ROC curve in diagnostic performance reaches 0.854. The above results show that the artificial neural network has a good effect on the dynamic monitoring of serum protein in acute respiratory distress syndrome, and the diagnostic performance evaluation can reach 0.854, which has the ability to significantly improve the clinical diagnosis and treatment of acute respiratory distress syndrome.
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Abstract
Acute respiratory distress syndrome (ARDS) occurs in up to 10% of patients with respiratory failure admitted through the emergency department. Use of noninvasive respiratory support has proliferated in recent years; clinicians must understand the relative merits and risks of these technologies and know how to recognize signs of failure. The cornerstone of ARDS care of the mechanically ventilated patient is low-tidal volume ventilation based on ideal body weight. Adjunctive therapies, such as prone positioning and neuromuscular blockade, may have a role in the emergency department management of ARDS depending on patient and department characteristics.
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Affiliation(s)
- Alin Gragossian
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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Huette P, Guinot PG, Haye G, Moussa MD, Beyls C, Guilbart M, Martineau L, Dupont H, Mahjoub Y, Abou-Arab O. Portal Vein Pulsatility as a Dynamic Marker of Venous Congestion Following Cardiac Surgery: An Interventional Study Using Positive End-Expiratory Pressure. J Clin Med 2021; 10:jcm10245810. [PMID: 34945106 PMCID: PMC8706622 DOI: 10.3390/jcm10245810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 12/22/2022] Open
Abstract
We aimed to assess variations in the portal vein pulsatility index (PI) during mechanical ventilation following cardiac surgery. Method. After ethical approval, we conducted a prospective monocentric study at Amiens University Hospital. Patients under mechanical ventilation following cardiac surgery were enrolled. Doppler evaluation of the portal vein (PV) was performed by transthoracic echography. The maximum velocity (VMAX) and minimum velocity (VMIN) of the PV were measured in pulsed Doppler mode. The PI was calculated using the following formula (VMAX − VMIN)/(VMax). A positive end-expiratory pressure (PEEP) incremental trial was performed from 0 to 15 cmH2O, with increments of 5 cmH2O. The PI (%) was assessed at baseline and PEEP 5, 10, and 15 cmH2O. Echocardiographic and hemodynamic parameters were recorded. Results. In total, 144 patients were screened from February 2018 to March 2019 and 29 were enrolled. Central venous pressure significantly increased for each PEEP increment. Stroke volumes were significantly lower after PEEP incrementation, with 52 mL (50–55) at PEEP 0 cmH2O and 30 mL (25–45) at PEEP 15 cmH2O, (p < 0.0001). The PI significantly increased with PEEP incrementation, from 9% (5–15) at PEEP 0 cmH2O to 15% (5–22) at PEEP 5 cmH2O, 34% (23–44) at PEEP 10 cmH2O, and 45% (25–49) at PEEP 15 cmH2O (p < 0.001). Conclusion. In the present study, PI appears to be a dynamic marker of the interaction between mechanical ventilation and right heart pressure after cardiac surgery. The PI could be a useful noninvasive tool to monitor venous congestion associated with mechanical ventilation.
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Affiliation(s)
- Pierre Huette
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
- Correspondence:
| | - Pierre-Grégoire Guinot
- Anesthesia and Critical Care Medicine Department, Dijon Hospital University, 21000 Dijon, France;
| | - Guillaume Haye
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
| | - Mouhamed Djahoum Moussa
- Anesthesia and Critical Care Medicine Department, Lille Hospital University, 59000 Lille, France;
| | - Christophe Beyls
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
| | - Mathieu Guilbart
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
| | - Lucie Martineau
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
| | - Hervé Dupont
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
| | - Yazine Mahjoub
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
| | - Osama Abou-Arab
- Anesthesia and Critical Care Medicine Department, Amiens Hospital University, 80000 Amiens, France; (G.H.); (C.B.); (M.G.); (L.M.); (H.D.); (Y.M.); (O.A.-A.)
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