1
|
Bastia L, Rozé H, Brochard L. Asymmetrical Lung Injury: Management and Outcome. Semin Respir Crit Care Med 2022; 43:369-378. [PMID: 35785812 DOI: 10.1055/s-0042-1744303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Among mechanically ventilated patients, asymmetrical lung injury is probably extremely frequent in the intensive care unit but the lack of standardized measurements does not allow to describe any prevalence among mechanically ventilated patients. Many past studies have focused only on unilateral injury and have mostly described the effect of lateral positioning. The good lung put downward might receive more perfusion while the sick lung placed upward receive more ventilation than supine. This usually results in better oxygenation but can also promote atelectasis in the healthy lung and no consensus has emerged on the clinical indication of this posture. Recently, electrical impedance tomography (EIT) has allowed for the first time to precisely describe the distribution of ventilation in each lung and to better study asymmetrical lung injury. At low positive-end-expiratory pressure (PEEP), a very heterogeneous ventilation exists between the two lungs and the initial increase in PEEP first helps to recruit the sick lung and protect the healthier lung. However, further increasing PEEP distends the less injured lung and must be avoided. The right level can be found using EIT and transpulmonary pressure. In addition, EIT can show that in the two lungs, airway closure is present but with very different airway opening pressures (AOPs) which cannot be identified on a global assessment. This may suggest a very different PEEP level than on a global assessment. Lastly, epidemiological studies suggest that in hypoxemic patients, the number of quadrants involved has a strong prognostic value. The number of quadrants is more important than the location of the unilateral or bilateral nature of the involvement for the prognosis, and hypoxemic patients with unilateral lung injury should probably be considered as requiring lung protective ventilation as classical acute respiratory distress syndrome.
Collapse
Affiliation(s)
- Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hadrien Rozé
- Thoracic Surgery and Lung Transplant Unit, Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Haut Leveque Hospital, Pessac, France.,Centre de Recherche Cardio Thoracique INSERM 1045, Pessac, France
| | - Laurent Brochard
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Canada
| |
Collapse
|
2
|
Match Me If You Can: The Relationship between Ventilation and Perfusion with Position Changes in Nonhomogenous Lung Injury. Ann Am Thorac Soc 2022; 19:320-326. [PMID: 35103560 DOI: 10.1513/annalsats.202102-210cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
3
|
Templeton TW, Miller SA, Lee LK, Kheterpal S, Mathis MR, Goenaga-Díaz EJ, Templeton LB, Saha AK. Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study. Anesthesiology 2021; 135:842-853. [PMID: 34543405 PMCID: PMC8607983 DOI: 10.1097/aln.0000000000003971] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND One-lung ventilation in children remains a specialized practice with low case numbers even at tertiary centers, preventing an assessment of best practices. The authors hypothesized that certain case factors may be associated with a higher risk of intraprocedural hypoxemia in children undergoing thoracic surgery and one-lung ventilation. METHODS The Multicenter Perioperative Outcomes database and a local quality improvement database were queried for documentation of one-lung ventilation in children 2 months to 3 yr of age inclusive between 2010 and 2020. Patients undergoing vascular or other cardiac procedures were excluded. All records were reviewed electronically for the presence of hypoxemia, oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or more continuously, and severe hypoxemia, Spo2 less than 90% for 5 min or more continuously during one-lung ventilation. Records were also assessed for hypercarbia, end-tidal CO2 greater than 60 mmHg for 5 min or more or a Paco2 greater than 60 on arterial blood gas. Covariates assessed for association with these outcomes included age, weight, American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status 3 or greater, duration of one-lung ventilation, preoperative Spo2 less than 98%, bronchial blocker versus endobronchial intubation, left operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (tidal volume less than or equal to 6 ml/kg plus positive end expiratory pressure greater than or equal to 4 cm H2O for more than 80% of the duration of one-lung ventilation), and type of procedure. RESULTS Three hundred six cases from 15 institutions were included for analysis. Hypoxemia and severe hypoxemia occurred in 81 of 306 (26%) patients and 56 of 306 (18%), respectively. Hypercarbia occurred in 153 of 306 (50%). Factors associated with lower risk of hypoxemia in multivariable analysis included left operative side (odds ratio, 0.45 [95% CI, 0.251 to 0.78]) and bronchial blocker use (odds ratio, 0.351 [95% CI, 0.177 to 0.67]). Additionally, use of a bronchial blocker was associated with a reduced risk of severe hypoxemia (odds ratio, 0.290 [95% CI, 0.125 to 0.62]). CONCLUSIONS Use of a bronchial blocker was associated with a lower risk of hypoxemia in young children undergoing one-lung ventilation. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- T Wesley Templeton
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Scott A Miller
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lisa K Lee
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, California
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Eduardo J Goenaga-Díaz
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Leah B Templeton
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amit K Saha
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
4
|
Meli A, Barbeta Viñas E, Battaglini D, Li Bassi G, Yang H, Yang M, Bobi J, Motos A, Fernández-Barat L, Chiumello D, Pelosi P, Torres A. Lateral position during severe mono-lateral pneumonia: an experimental study. Sci Rep 2020; 10:19372. [PMID: 33168922 PMCID: PMC7653044 DOI: 10.1038/s41598-020-76216-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 09/24/2020] [Indexed: 12/31/2022] Open
Abstract
Patients with mono-lateral pneumonia and severe respiratory failure can be positioned in lateral decubitus, with the healthy lung dependent, to improve ventilation-perfusion coupling. Oxygenation response to this manoeuvre is heterogeneous and derecruitment of dependent lung has not been elucidated. Nine pigs (32.2 ± 1.2 kg) were sedated and mechanically ventilated. Mono-lateral right-sided pneumonia was induced with intrabronchial challenge of Pseudomonas aeruginosa. After 24 h, lungs were recruited and the animals were randomly positioned on right or left side. After 3 h of lateral positioning, the animals were placed supine; another recruitment manoeuvre was performed, and the effects of contralateral decubitus were assessed. Primary outcome was lung ultrasound score (LUS) of the dependent lung after 3-h lateral positioning. LUS of the left non-infected lung worsened while positioned in left-lateral position (from 1.33 ± 1.73 at baseline to 6.78 ± 4.49; p = 0.005). LUS of the right-infected lung improved when placed upward (9.22 ± 2.73 to 6.67 ± 3.24; p = 0.09), but worsened in right-lateral position (7.78 ± 2.86 to 13.33 ± 3.08; p < 0.001). PaO2/FiO2 improved in the left-lateral position (p = 0.005). In an animal model of right-lung pneumonia, left-lateral decubitus improved oxygenation, but collapsed the healthy lung. Right-lateral orientation further collapsed the diseased lung. Our data raise potential clinical concerns for the use of lateral position in mono-lateral pneumonia.
Collapse
Affiliation(s)
- Andrea Meli
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,University of Milan, Milan, Italy
| | - Enric Barbeta Viñas
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Denise Battaglini
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Department of Surgical Sciences and Integrated Diagnostics (DISC), IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - Gianluigi Li Bassi
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,University of Barcelona (UB), Barcelona, Spain
| | - Hua Yang
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Minlan Yang
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Joaquim Bobi
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana Motos
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,University of Barcelona (UB), Barcelona, Spain
| | - Laia Fernández-Barat
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,University of Barcelona (UB), Barcelona, Spain
| | - Davide Chiumello
- University of Milan, Milan, Italy.,Department of Anaesthesia and Critical Care Medicine, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - Antoni Torres
- Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain. .,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain. .,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain. .,University of Barcelona (UB), Barcelona, Spain.
| |
Collapse
|
5
|
Chan ST, Evans KC, Song TY, Selb J, van der Kouwe A, Rosen BR, Zheng YP, Ahn AC, Kwong KK. Dynamic brain-body coupling of breath-by-breath O2-CO2 exchange ratio with resting state cerebral hemodynamic fluctuations. PLoS One 2020; 15:e0238946. [PMID: 32956397 PMCID: PMC7505589 DOI: 10.1371/journal.pone.0238946] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/26/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The origin of low frequency cerebral hemodynamic fluctuations (CHF) in the resting state remains unknown. Breath-by breath O2-CO2 exchange ratio (bER) has been reported to correlate with the cerebrovascular response to brief breath hold challenge at the frequency range of 0.008-0.03Hz in healthy adults. bER is defined as the ratio of the change in the partial pressure of oxygen (ΔPO2) to that of carbon dioxide (ΔPCO2) between end inspiration and end expiration. In this study, we aimed to investigate the contribution of respiratory gas exchange (RGE) metrics (bER, ΔPO2 and ΔPCO2) to low frequency CHF during spontaneous breathing. METHODS Twenty-two healthy adults were included. We used transcranial Doppler sonography to evaluate CHF by measuring the changes in cerebral blood flow velocity (ΔCBFv) in bilateral middle cerebral arteries. The regional CHF were mapped with blood oxygenation level dependent (ΔBOLD) signal changes using functional magnetic resonance imaging. Temporal features and frequency characteristics of RGE metrics during spontaneous breathing were examined, and the simultaneous measurements of RGE metrics and CHF (ΔCBFv and ΔBOLD) were studied for their correlation. RESULTS We found that the time courses of ΔPO2 and ΔPCO2 were interdependent but not redundant. The oscillations of RGE metrics were coherent with resting state CHF at the frequency range of 0.008-0.03Hz. Both bER and ΔPO2 were superior to ΔPCO2 in association with CHF while CHF could correlate more strongly with bER than with ΔPO2 in some brain regions. Brain regions with the strongest coupling between bER and ΔBOLD overlapped with many areas of default mode network including precuneus and posterior cingulate. CONCLUSION Although the physiological mechanisms underlying the strong correlation between bER and CHF are unclear, our findings suggest the contribution of bER to low frequency resting state CHF, providing a novel insight of brain-body interaction via CHF and oscillations of RGE metrics.
Collapse
Affiliation(s)
- Suk-tak Chan
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Karleyton C. Evans
- Department of Psychiatry, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Tian-yue Song
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Juliette Selb
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Andre van der Kouwe
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Bruce R. Rosen
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Yong-ping Zheng
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong Special Administrative Region, China
| | - Andrew C. Ahn
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Kenneth K. Kwong
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| |
Collapse
|
6
|
Chan ST, Evans KC, Song TY, Selb J, van der Kouwe A, Rosen BR, Zheng YP, Ahn A, Kwong KK. Cerebrovascular reactivity assessment with O2-CO2 exchange ratio under brief breath hold challenge. PLoS One 2020; 15:e0225915. [PMID: 32208415 PMCID: PMC7092994 DOI: 10.1371/journal.pone.0225915] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/27/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hypercapnia during breath holding is believed to be the dominant driver behind the modulation of cerebral blood flow (CBF). However, increasing evidence show that mild hypoxia and mild hypercapnia in breath hold (BH) could work synergistically to enhance CBF response. We hypothesized that breath-by-breath O2-CO2 exchange ratio (bER), defined as the ratio of the change in partial pressure of oxygen (ΔPO2) to that of carbon dioxide (ΔPCO2) between end inspiration and end expiration, would be able to better correlate with the global and regional cerebral hemodynamic responses (CHR) to BH challenge. We aimed to investigate whether bER is a more useful index than end-tidal PCO2 to characterize cerebrovascular reactivity (CVR) under BH challenge. METHODS We used transcranial Doppler ultrasound (TCD) to evaluate CHR under BH challenge by measuring cerebral blood flow velocity (CBFv) in the middle cerebral arteries. Regional changes in CHR to BH and exogenous CO2 challenges were mapped with blood oxygenation level dependent (BOLD) signal changes using functional magnetic resonance imaging (fMRI). We correlated respiratory gas exchange (RGE) metrics (bER, ΔPO2, ΔPCO2, end-tidal PCO2 and PO2, and time of breaths) with CHR (CBFv and BOLD) to BH challenge. Temporal features and frequency characteristics of RGE metrics and their coherence with CHR were examined. RESULTS CHR to brief BH epochs and free breathing were coupled with both ΔPO2 and ΔPCO2. We found that bER was superior to either ΔPO2 or ΔPCO2 alone in coupling with the changes of CBFv and BOLD signals under breath hold challenge. The regional CVR results derived by regressing BOLD signal changes on bER under BH challenge resembled those derived by regressing BOLD signal changes on end-tidal PCO2 under exogenous CO2 challenge. CONCLUSION Our findings provide a novel insight on the potential of using bER to better quantify CVR changes under BH challenge.
Collapse
Affiliation(s)
- Suk-tak Chan
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Karleyton C. Evans
- Department of Psychiatry, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Tian-yue Song
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
- Department of Psychiatry, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Juliette Selb
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Andre van der Kouwe
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Bruce R. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Yong-ping Zheng
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong Special Administrative Region, China
| | - Andrew Ahn
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| | - Kenneth K. Kwong
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, United States of America
| |
Collapse
|
7
|
Tusman G, Acosta CM, Böhm SH, Waldmann AD, Ferrando C, Marquez MP, Sipmann FS. Postural lung recruitment assessed by lung ultrasound in mechanically ventilated children. Crit Ultrasound J 2017; 9:22. [PMID: 29030754 PMCID: PMC5640559 DOI: 10.1186/s13089-017-0073-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/20/2017] [Indexed: 01/03/2023] Open
Abstract
Background Atelectasis is a common finding in mechanically ventilated children with healthy lungs. This lung collapse cannot be overcome using standard levels of positive end-expiratory pressure (PEEP) and thus for only individualized lung recruitment maneuvers lead to satisfactory therapeutic results. In this short communication, we demonstrate by lung ultrasound images (LUS) the effect of a postural recruitment maneuver (P-RM, i.e., a ventilatory strategy aimed at reaerating atelectasis by changing body position under constant ventilation). Results Data was collected in the operating room of the Hospital Privado de Comunidad, Mar del Plata, Argentina. Three anesthetized children undergoing mechanical ventilation at constant settings were sequentially subjected to the following two maneuvers: (1) PEEP trial in the supine position PEEP was increased to 10 cmH2O for 3 min and then decreased to back to baseline. (2) P-RM patient position was changed from supine to the left and then to the right lateral position for 90 s each before returning to supine. The total P-RM procedure took approximately 3 min. LUS in the supine position showed similar atelectasis before and after the PEEP trial. Contrarily, atelectasis disappeared in the non-dependent lung when patients were placed in the lateral positions. Both lungs remained atelectasis free even after returning to the supine position. Conclusions We provide LUS images that illustrate the concept and effects of postural recruitment in children. This maneuver has the advantage of achieving recruitment effects without the need to elevate airways pressures. Electronic supplementary material The online version of this article (doi:10.1186/s13089-017-0073-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, 7600, Mar del Plata, Buenos Aires, Argentina.
| | - Cecilia M Acosta
- Department of Anesthesiology, Hospital Privado de Comunidad, 7600, Mar del Plata, Buenos Aires, Argentina
| | | | | | - Carlos Ferrando
- Department of Anesthesiology, University Hospital Valencia, Valencia, Spain
| | - Manuel Perez Marquez
- Department of Intensive Care Medicine, Instituto de Investigación Sanitaria Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | - Fernando Suarez Sipmann
- Hedenstierna Laboratory, Department of Surgical Sciences, Section of Anesthesia and Critical Care, Uppsala University Hospital, Uppsala, Sweden.,CIBERES, Madrid, Spain.,Department of Critical Care, Hospital La Fe, Valencia, Spain
| |
Collapse
|
8
|
Michaelides SA, Michailidis AR, Bablekos GD, Analitis A, Michalatou M, Koulouris N. Does size matter concerning impact of position on oxygenation status in spontaneously breathing patients with unilateral effusion? Postgrad Med J 2017; 94:81-86. [PMID: 28972098 DOI: 10.1136/postgradmedj-2017-135164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/31/2017] [Accepted: 09/09/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Inconsistent and contradictory findings have appeared in the literature concerning the impact of body position on oxygenation in pleural effusion. METHODS We attempted to elucidate whether the size of the pleural effusion in patients with no parenchymal disease is the main determinant of posture-induced alterations in oxygenation parameters. We studied 62 spontaneously breathing patients aged 65.3±7.8 years (mean±SD), of whom 36 had large and massive-sized effusions (Group A) and 26 had small and moderate-sized effusions (Group B). Arterial blood gases were determined in four different body positions: sitting (SIT), supine (SUP), ipsilateral (IPS) and contralateral (CON) to the effusion side, after remaining relaxed for at least 20 min in each position. Separation into groups A and B was deliberately set from the position of the fluid meniscus line on a posteroanterior chest film just above the upper costal margin of the sixth anterior rib. A two-way ANOVA model with outcome variables PaO2, PaCO2 and [A-a] DO2 was used. RESULTS In both groups the best oxygenation was found in SIT. The worst oxygenation (highest [A-a] DO2 value) occurred in group A in CON compared with IPS (59.4±7.6 vs 49.0±7.5 mm Hg, p<0.001) and in group B in IPS compared with CON (51.0±8.7 vs 39.5±9.2 mm Hg, p<0.001). Also, PaCO2 showed significant differences in both groups in IPS compared with CON (p=0.002). CONCLUSIONS Patients with large-sized effusions exhibit the worst oxygenation when lying on the side contralateral to the effusion, while those with small-sized effusions exhibit the worst oxygenation when lying on the side ipsilateral to the effusion.
Collapse
Affiliation(s)
- Stylianos A Michaelides
- Department of Occupational Lung Diseases and Tuberculosis, Sismanogleio-Amalia Fleming General Hospital, Athens, Greece
| | - Avgerinos-Romanos Michailidis
- Department of Occupational Lung Diseases and Tuberculosis, Sismanogleio-Amalia Fleming General Hospital, Athens, Greece.,Department of Medical Laboratories, Faculty of Health and Caring Professions, University of Applied Sciences / Technological Educational Institute (TEI) of Athens, Athens, Greece
| | - George D Bablekos
- Department of Medical Laboratories, Faculty of Health and Caring Professions, University of Applied Sciences / Technological Educational Institute (TEI) of Athens, Athens, Greece
| | - Antonis Analitis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Michalatou
- Department of Physiotherapy, Sismanogleio-Amalia Fleming General Hospital, Athens, Greece
| | - Nikolaos Koulouris
- First Department of Thoracic Medicine, Medical School, National and Kapodistrian University of Athens, Hospital for Diseases of the Chest (Sotiria), Athens, Greece
| |
Collapse
|
9
|
Joosten SA, Landry SA, Sands SA, Terrill PI, Mann D, Andara C, Skuza E, Turton A, Berger P, Hamilton GS, Edwards BA. Dynamic loop gain increases upon adopting the supine body position during sleep in patients with obstructive sleep apnoea. Respirology 2017; 22:1662-1669. [PMID: 28730724 DOI: 10.1111/resp.13108] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/23/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Obstructive sleep apnoea (OSA) is typically worse in the supine versus lateral sleeping position. One potential factor driving this observation is a decrease in lung volume in the supine position which is expected by theory to increase a key OSA pathogenic factor: dynamic ventilatory control instability (i.e. loop gain). We aimed to quantify dynamic loop gain in OSA patients in the lateral and supine positions, and to explore the relationship between change in dynamic loop gain and change in lung volume with position. METHODS Data from 20 patients enrolled in previous studies on the effect of body position on OSA pathogenesis were retrospectively analysed. Dynamic loop gain was calculated from routinely collected polysomnographic signals using a previously validated mathematical model. Lung volumes were measured in the awake state with a nitrogen washout technique. RESULTS Dynamic loop gain was significantly higher in the supine than in the lateral position (0.77 ± 0.15 vs 0.68 ± 0.14, P = 0.012). Supine functional residual capacity (FRC) was significantly lower than lateral FRC (81.0 ± 15.4% vs 87.3 ± 18.4% of the seated FRC, P = 0.021). The reduced FRC we observed on moving to the supine position was predicted by theory to increase loop gain by 10.2 (0.6, 17.1)%, a value similar to the observed increase of 8.4 (-1.5, 31.0)%. CONCLUSION Dynamic loop gain increased by a small but statistically significant amount when moving from the lateral to supine position and this may, in part, contribute to the worsening of OSA in the supine sleeping position.
Collapse
Affiliation(s)
- Simon A Joosten
- Monash Lung and Sleep, Monash Medical Centre, Clayton, VIC, Australia.,School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Monash Partners - Epworth Sleep Centre, Melbourne, VIC, Australia
| | - Shane A Landry
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, VIC, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, VIC, Australia
| | - Scott A Sands
- Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, VIC, Australia.,Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip I Terrill
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Qld, Australia
| | - Dwayne Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Qld, Australia
| | | | - Elizabeth Skuza
- Monash Lung and Sleep, Monash Medical Centre, Clayton, VIC, Australia
| | - Anthony Turton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, VIC, Australia
| | - Philip Berger
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, VIC, Australia
| | - Garun S Hamilton
- Monash Lung and Sleep, Monash Medical Centre, Clayton, VIC, Australia.,School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Monash Partners - Epworth Sleep Centre, Melbourne, VIC, Australia
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Melbourne, VIC, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
10
|
Leech C, Porter K, Steyn R, Laird C, Virgo I, Bowman R, Cooper D. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408616664553] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
‘The pre-hospital management of chest injury: a consensus statement’ was originally published by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in 2007. To update the pre-existing guideline, a consensus meeting of stakeholders was held by the Faculty of Pre-hospital Care in Coventry in November 2013. This paper provides a guideline for the pre-hospital management of patients with the life-threatening chest injuries of tension pneumothorax, open pneumothorax, massive haemothorax, flail chest (including multiple rib fractures), and cardiac tamponade.
Collapse
Affiliation(s)
- Caroline Leech
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Keith Porter
- Academic Department of Clinical Traumatology, University of Birmingham, Birmingham, UK
| | - Richard Steyn
- Department of Thoracic Surgery, Heart of England NHS Trust, Birmingham, UK
| | | | - Imogen Virgo
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Richard Bowman
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - David Cooper
- Emergency Department, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| |
Collapse
|
11
|
Srinivasan C, Kurian GP, Mariappan R. A case of bronchiectasis needing lung isolation for cerebello pontine angle tumor excision: Anesthetic challenges. Saudi J Anaesth 2016; 10:359-61. [PMID: 27375400 PMCID: PMC4916829 DOI: 10.4103/1658-354x.174923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The main goals of neuroanesthesia are the maintenance of adequate cerebral perfusion pressure, avoidance of hypercarbia, hypoxemia, and to provide better brain relaxation. Providing anesthesia for a patient with bronchiectasis needing lung isolation for craniotomy can be challenging. A 56-year-old male patient, case of right lung bronchiectasis with a right cerebello pontine angle tumor underwent excision in the left lateral position. Since he had severe bronchiectasis of the right lung, we had isolated the right lung using right-sided double lumen tube to avoid spillage. Intraoperative split lung test was performed to assess the right lung contribution on carbon dioxide (CO2) elimination and found that there was a significant contribution from the right lung. Hence, both lungs were ventilated to control CO2. The importance of lung isolation to prevent spillage and avoidance of one lung ventilation to control the arterial CO2 are highlighted in this case report. By providing a balanced anesthetic keeping both, the neurosurgical and thoracic concerns are important for better postoperative outcome.
Collapse
Affiliation(s)
- C Srinivasan
- Department of Anesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | - G P Kurian
- Department of Anesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | - R Mariappan
- Department of Anesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
12
|
Abstract
BACKGROUND Critically ill patients require regular body position changes to minimize the adverse effects of bed rest, inactivity and immobilization. However, uncertainty surrounds the effectiveness of lateral positioning for improving pulmonary gas exchange, aiding drainage of tracheobronchial secretions and preventing morbidity. In addition, it is unclear whether the perceived risk levied by respiratory and haemodynamic instability upon turning critically ill patients outweighs the respiratory benefits of side-to-side rotation. Thus, lack of certainty may contribute to variation in positioning practice and equivocal patient outcomes. OBJECTIVES To evaluate effects of the lateral position compared with other body positions on patient outcomes (mortality, morbidity and clinical adverse events) in critically ill adult patients. (Clinical adverse events include hypoxaemia, hypotension, low oxygen delivery and global indicators of impaired tissue oxygenation.) We examined single use of the lateral position (i.e. on the right or left side) and repeat use of the lateral position (i.e. lateral positioning) within a positioning schedule. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (1950 to 23 May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to 23 May 2015), the Allied and Complementary Medicine Database (AMED) (1984 to 23 May 2015), Latin American Caribbean Health Sciences Literature (LILACS) (1901 to 23 May 2015), Web of Science (1945 to 23 May 2015), Index to Theses in Great Britain and Ireland (1950 to 23 May 2015), Trove (2009 to 23 May 2015; previously Australasian Digital Theses Program (1997 to December 2008)) and Proquest Dissertations and Theses (2009 to 23 May 2015; previously Proquest Digital Dissertations (1980 to 23 May 2015)). We handsearched the reference lists of potentially relevant reports and two nursing journals. SELECTION CRITERIA We included randomized and quasi-randomized trials examining effects of lateral positioning in critically ill adults. We included manual or automated turns but limited eligibility to studies that included duration of body position of 10 minutes or longer. We examined each lateral position versus at least one comparator (opposite lateral position and/or another body position) for single therapy effects, and the lateral positioning schedule (repeated lateral turning) versus other positioning schedules for repetitive therapy effects. DATA COLLECTION AND ANALYSIS We pre-specified methods to be used for data collection, risk of bias assessment and analysis. Two independent review authors carried out each stage of selection and data extraction and settled differences in opinion by consensus, or by third party adjudication when disagreements remained unresolved. We planned analysis of pair-wise comparisons under composite time intervals with the aim of considering recommendations based on meta-analyses of studies with low risk of bias. MAIN RESULTS We included 24 studies of critically ill adults. No study reported mortality as an outcome of interest. Two randomized controlled trials (RCTs) examined lateral positioning for pulmonary morbidity outcomes but provided insufficient information for meta-analysis. A total of 22 randomized trials examined effects of lateral positioning (four parallel-group and 18 cross-over designs) by measuring various continuous data outcomes commonly used to detect adverse cardiopulmonary events within critical care areas. However, parallel-group studies were not comparable, and cross-over studies provided limited data as the result of unit of analysis errors. Eight studies provided some data; most of these were single studies with small effects that were imprecise. We pooled partial pressure of arterial oxygen (PaO2) as a measure to detect hypoxaemia from two small studies of participants with unilateral lung disease (n = 19). The mean difference (MD) between lateral positions (bad lung down versus good lung down) was approximately 50 mmHg (MD -49.26 mmHg, 95% confidence interval (CI) -67.33 to -31.18; P value < 0.00001). Despite a lower mean PaO2 for bad lung down, hypoxaemia (mean PaO2 < 60 mmHg) was not consistently reported. Furthermore, pooled data had methodological shortcomings with unclear risk of bias. We had similar doubts regarding internal validity for other studies included in the review. AUTHORS' CONCLUSIONS Review authors could provide no clinical practice recommendations based on the findings of included studies. Available research could not eliminate the uncertainty surrounding benefits and/or risks associated with lateral positioning of critically ill adult patients. Research gaps include the effectiveness of lateral positioning compared with semi recumbent positioning for mechanically ventilated patients, lateral positioning compared with prone positioning for acute respiratory distress syndrome (ARDS) and less frequent changes in body position. We recommend that future research be undertaken to address whether the routine practice of repositioning patients on their side benefits all, some or few critically ill patients.
Collapse
Affiliation(s)
- Nicky Hewitt
- Alfred HealthDeakin Alfred Health Nursing Research Centre55 Commercial Road, PrahanMelbourneVictoriaAustralia3125
- Faculty of Health, Deakin UniversitySchool of Nursing and MidwiferyGeelongAustralia
- St. Vincent's HospitalDepartment of Critical Care MedicinePO Box 2900MelbourneVictoriaAustralia3065
| | - Tracey Bucknall
- Faculty of Health, Deakin UniversitySchool of Nursing and MidwiferyGeelongAustralia
- Alfred HealthDeakin University Centre for Quality and Patient Safety Research ‐ Alfred Health Partnership55 Commercial RoadMelbourneAustralia
| | - Nardene M Faraone
- St. Vincent's HospitalDepartment of Critical Care MedicinePO Box 2900MelbourneVictoriaAustralia3065
| | | |
Collapse
|
13
|
Abstract
Congenital lobar emphysema (CLE) is a rare congenital anomaly of lung causing over aeration of one or more lobes of a histologically normal lung. It presents in infancy with respiratory distress due to compression atelectasis and often associated with mediastinal shift and hypotension. CLE poses a challenge in diagnosis and positive pressure ventilation due to air trapping. We report a case of 8-week-old infant with CLE posted for right lobectomy. Strategies to prevent misdiagnosis, over aeration and use of IPPV have been reviewed.
Collapse
Affiliation(s)
- Manjunath Prabhu
- Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
| | - Tim Thomas Joseph
- Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
| |
Collapse
|
14
|
|
15
|
Abstract
Pulmonary hypertension is a condition that can result in serious complications in patients undergoing any type of anesthesia during the perioperative period. By definition, pulmonary artery hypertension is caused by a persistent rise in mean pulmonary artery pressure ≥25 mm Hg with Pulmonary capillary wedge pressure ≤ 15 mm Hg or exercise mean pulmonary artery pressure ≥35 mm Hg and pulmonary vascular resistance ≥ 3 wood unit's. The severity of the complications depends on the severity of the underlying condition, other comorbidities, and type of procedure, anesthetic technique, and anesthetic drugs. In this article, we briefly review the pulmonary vascular physiology, pathophysiology of the disease, clinical assessment and diagnosis, treatment options, and the anesthetic management of these patients.
Collapse
|
16
|
Effects of positioning on respiratory measures in individuals with cerebral palsy and severe scoliosis. Pediatr Phys Ther 2011; 23:159-69. [PMID: 21552079 DOI: 10.1097/pep.0b013e318218e306] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To examine the effect of positioning on respiratory measurements in individuals with cerebral palsy and severe scoliosis. METHODS Five individuals aged 17 to 37 years participated in an alternating treatment, single-subject design. Oxygen saturation, respiratory rate, heart rate, and chest wall excursion measurements were obtained in supine, sitting, and sidelying positions. RESULTS Level of support for hypotheses varied on the basis of the respiratory measurement and participants' status. Respiratory rate appeared to be most sensitive to change in the positions. Severity of respiratory compromise and age may be associated with less tolerance for supine position versus sitting and sidelying positions. CONCLUSIONS The use of therapeutic positioning in sitting and sidelying positions should be considered as a noninvasive intervention for a population with respiratory compromise. Further research with a larger sample is needed to empirically link specific positions with improved respiratory efficiency.
Collapse
|
17
|
|
18
|
Physiological rationale and current evidence for therapeutic positioning of critically ill patients. AACN Adv Crit Care 2009; 20:228-40; quiz 241-2. [PMID: 19638744 DOI: 10.1097/nci.0b013e3181add8db] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prolonged bed rest is common in critically ill patients, and therapeutic positioning is important to prevent further complications and to improve patient outcomes. Nurses use therapeutic positioning to prevent complications of immobility. This article reviews therapeutic positions including stationary positions (supine, semirecumbent with head of bed elevation, lateral, and prone) and active repositioning (manual, continuous lateral rotation, and kinetic therapy). The physiological rationale and current evidence for each position are described. Applicable evidence-based practice guidelines are summarized. Special considerations for therapeutic positioning of critically ill obese and elderly patients are also discussed.
Collapse
|
19
|
Mulholland C, Lennon S, Graham R. Does prone positioning improve oxygen saturation in a patient with cystic fibrosis? An alternating-treatment single case design. Physiother Theory Pract 2009. [DOI: 10.3109/09593989409036401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
20
|
|
21
|
Propagation prevention: a complementary mechanism for "lung protective" ventilation in acute respiratory distress syndrome. Crit Care Med 2008; 36:3252-8. [PMID: 18936705 DOI: 10.1097/ccm.0b013e31818f0e68] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To describe the clinical implications of an often neglected mechanism through which localized acute lung injury may be propagated and intensified. DATA EXTRACTION AND SYNTHESIS Experimental and clinical evidence from the medical literature relevant to the airway propagation hypothesis and its consequences. CONCLUSIONS The diffuse injury that characterizes acute respiratory distress syndrome is often considered a process that begins synchronously throughout the lung, mediated by inhaled or blood-borne noxious agents. Relatively little attention has been paid to possibility that inflammatory lung injury may also begin focally and propagate sequentially via the airway network, proceeding mouth-ward from distal to proximal. Were this true, modifications of ventilatory pattern and position aimed at geographic containment of the injury process could help prevent its generalization and limit disease severity. The purposes of this communication are to call attention to this seldom considered mechanism for extending lung injury that might further justify implementation of low tidal volume/high positive end-expiratory pressure ventilatory strategies for lung protection and to suggest additional therapeutic measures implied by this broadened conceptual paradigm.
Collapse
|
22
|
Tsai LL, Mair RW, Rosen MS, Patz S, Walsworth RL. An open-access, very-low-field MRI system for posture-dependent 3He human lung imaging. JOURNAL OF MAGNETIC RESONANCE (SAN DIEGO, CALIF. : 1997) 2008; 193:274-85. [PMID: 18550402 PMCID: PMC2572034 DOI: 10.1016/j.jmr.2008.05.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 05/14/2008] [Accepted: 05/14/2008] [Indexed: 05/20/2023]
Abstract
We describe the design and operation of an open-access, very-low-field, magnetic resonance imaging (MRI) system for in vivo hyperpolarized 3He imaging of the human lungs. This system permits the study of lung function in both horizontal and upright postures, a capability with important implications in pulmonary physiology and clinical medicine, including asthma and obesity. The imager uses a bi-planar B(0) coil design that produces an optimized 65 G (6.5 mT) magnetic field for 3He MRI at 210 kHz. Three sets of bi-planar coils produce the x, y, and z magnetic field gradients while providing a 79-cm inter-coil gap for the imaging subject. We use solenoidal Q-spoiled RF coils for operation at low frequencies, and are able to exploit insignificant sample loading to allow for pre-tuning/matching schemes and for accurate pre-calibration of flip angles. We obtain sufficient SNR to acquire 2D 3He images with up to 2.8mm resolution, and present initial 2D and 3D 3He images of human lungs in both supine and upright orientations. 1H MRI can also be performed for diagnostic and calibration reasons.
Collapse
Affiliation(s)
- L. L. Tsai
- Harvard-Smithsonian Center for Astrophysics, Cambridge, MA 02138
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA 02139
- Harvard Medical School, Boston, MA 02115
| | - R. W. Mair
- Harvard-Smithsonian Center for Astrophysics, Cambridge, MA 02138
| | - M. S. Rosen
- Harvard-Smithsonian Center for Astrophysics, Cambridge, MA 02138
- Department of Physics, Harvard University, Cambridge, MA 02138
| | - S. Patz
- Harvard Medical School, Boston, MA 02115
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA 02115
| | - R. L. Walsworth
- Harvard-Smithsonian Center for Astrophysics, Cambridge, MA 02138
- Department of Physics, Harvard University, Cambridge, MA 02138
| |
Collapse
|
23
|
Rauen CA, Chulay M, Bridges E, Vollman KM, Arbour R. Seven Evidence-Based Practice Habits: Putting Some Sacred Cows Out to Pasture. Crit Care Nurse 2008. [DOI: 10.4037/ccn2008.28.2.98] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Carol A. Rauen
- Carol A. Rauen is an independent critical care clinical nurse specialist in Silver Spring, Maryland
| | - Marianne Chulay
- Marianne Chulay is a consultant in clinical research and critical care nursing in Gainesville, Florida
| | - Elizabeth Bridges
- Elizabeth Bridges is an assistant professor at the University of Washington School of Nursing in Seattle and a clinical nurse researcher at the University of Washington Medical Center in Seattle
| | - Kathleen M. Vollman
- Kathleen M. Vollman is a clinical nurse specialist, educator, and consultant at Advancing Nursing LLC in Northville, Michigan
| | - Richard Arbour
- Richard Arbour is a critical care clinical nurse specialist at Albert Einstein Medical Center in Philadelphia, Pennsylvania
| |
Collapse
|
24
|
Sundaraiya S, Kayani I, Biassoni L, Gordon I. Unique role of radionuclide krypton-81m lung ventilation scan in critically ill children on long-term mechanical ventilation. Eur J Nucl Med Mol Imaging 2008; 34:1516-7. [PMID: 17632720 DOI: 10.1007/s00259-007-0462-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Sumati Sundaraiya
- Department of Nuclear Medicine, Royal Sussex Country Hospital, Eastern Road, Brighton, BN2 5BE, East Sussex, UK.
| | | | | | | |
Collapse
|
25
|
Mlcak RP, Suman OE, Herndon DN. Respiratory management of inhalation injury. Burns 2007; 33:2-13. [PMID: 17223484 DOI: 10.1016/j.burns.2006.07.007] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 07/26/2006] [Indexed: 11/21/2022]
Abstract
Advances in the care of patients with major burns have led to a reduction in mortality and a change in the cause of their death. Burn shock, which accounted for almost 20 percent of burn deaths in the 1930s and 1940s, is now treated with early, vigorous fluid resuscitation and is only rarely a cause of death. Burn wound sepsis, which emerged as the primary cause of mortality once burn shock decreased in importance, has been brought under control with the use of topical antibiotics and aggressive surgical debridement. Inhalation injury has now become the most frequent cause of death in burn patients. Although mortality from smoke inhalation alone is low (0-11 percent), smoke inhalation in combination with cutaneous burns is fatal in 30 to 90 percent of patients. It has been recently reported that the presence of inhalation injury increases burn mortality by 20 percent and that inhalation injury predisposes to pneumonia. Pneumonia has been shown to independently increase burn mortality by 40 percent, and the combination of inhalation injury and pneumonia leads to a 60 percent increase in deaths. Children and the elderly are especially prone to pneumonia due to a limited physiologic reserve. It is imperative that a well organized, protocol driven approach to respiratory care of inhalation injury be utilized so that improvements can be made and the morbidity and mortality associated with inhalation injury be reduced.
Collapse
Affiliation(s)
- Ronald P Mlcak
- Respiratory Care Department, Shriners Hospital for Children, Galveston, TX, USA.
| | | | | |
Collapse
|
26
|
Kiryu S, Loring SH, Mori Y, Rofsky NM, Hatabu H, Takahashi M. Quantitative analysis of the velocity and synchronicity of diaphragmatic motion: dynamic MRI in different postures. Magn Reson Imaging 2006; 24:1325-32. [PMID: 17145404 DOI: 10.1016/j.mri.2006.08.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Accepted: 08/26/2006] [Indexed: 11/24/2022]
Abstract
The objectives of this study were to assess the relationship between right and left hemidiaphragmatic motions during breathing in normal subjects and to investigate alterations in lung motion with changes in posture, using dynamic magnetic resonance (MR) imaging. Imaging was conducted with a 1.5-T MR scanner using fast imaging employing steady-state acquisition with a torso coil. Eight healthy subjects were instructed to breathe from end-inspiration to end-expiration as slowly and as deeply as possible. Imaging and breathing were started together to afford sequential images on the coronal plane. Imaging sequences were performed in supine, prone, left lateral decubitus and right lateral decubitus postures. The component of movement of the most cephalic point in the cephalocaudal axis was measured, and the diaphragmatic excursion (maximum hemidiaphragmatic displacement), synchrony and velocity of the right and left hemidiaphragmatic motions were calculated during the expiratory phase and the inspiratory phase, respectively. Excursion was greater in the right hemidiaphragm in most postures, except the left lateral decubitus. In supine and prone postures, both hemidiaphragms moved synchronously in both inspiratory and expiratory phases. In both lateral decubitus postures, the hemidiaphragms moved asynchronously with different velocities in the expiratory phase but with the same velocities in the inspiratory phase. The method described here allowed the assessment of diaphragmatic motions. Motions in the right and left hemidiaphragms changed with posture. In addition, diaphragmatic motion differed between expiratory and inspiratory phases. This study suggests the further potential of dynamic MR imaging for the evaluation of pulmonary functions or deficiencies.
Collapse
Affiliation(s)
- Shigeru Kiryu
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
| | | | | | | | | | | |
Collapse
|
27
|
Abstract
Single-lung ventilation is requested for an increasing spectrum of surgical procedures in infants and children. A clear understanding of the physiology of single-lung ventilation, the techniques of lung separation, and the technical skill necessary to apply these techniques are essential for an anesthesiologist practicing thoracic anesthesia. This article focuses on various devices available for single-lung ventilation in the pediatric age group, the relevant respiratory physiology, and the strategies that optimize oxygenation during one-lung anesthesia.
Collapse
Affiliation(s)
- Dinesh K Choudhry
- Department of Anesthesiology, Alfred I. duPont Hospital for Children, Nemours Children's Clinic, Wilmington, DE 19803, USA.
| |
Collapse
|
28
|
Puri GD, Dutta A, Chinnan NK, Thingnam SKS, Sharma SK, Chari P. Arterial oxygenation changes in valvular heart disease patients with cardiomegaly in different recumbent positions. Eur J Anaesthesiol 2005; 22:834-8. [PMID: 16225717 DOI: 10.1017/s0265021505001407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE We studied the effect of different recumbent positions (supine, left and right lateral decubitus), on arterial oxygenation in 42 valvular heart disease patients planned for cardiac surgery. All patients had cardiomegaly (cardiothoracic ratio > or = 0.5) in their chest X-rays. Their left ventricular end-diastolic diameter was also noted from the preoperative echocardiogram. METHODS Arterial blood gas analysis was performed in supine, left and right lateral positions after keeping the patient in a given position for 15 min. During this period all patients received 35% oxygen supplementation. RESULTS Arterial oxygen tension and haemoglobin saturation were significantly higher in the right lateral position (PaO2 = 120.6 +/- 29.5 mmHg, SaO2 = 98.1 +/- 1.4%) than in supine (PaO2 = 111.0 +/- 30.6 mmHg, SaO2 = 97.6 +/- 2.2%) and left lateral positions (PaO2 = 109.7 +/- 32.0 mmHg, SaO2 = 97.6 +/- 1.7%; mean +/- SD; P 0.05). The change in PaO2 and SaO2 with change of posture from left to right was significantly related to left ventricular end-diastolic diameter (r = 0.50 and r = 0.63, respectively; Pearson correlation). Repeated measures of analysis of variance with left ventricular end-diastolic diameter as a covariate showed a significant change in arterial PaO2 with posture (P = 0.011). CONCLUSION Right lateral posture improves arterial oxygenation in the valvular heart disease patient with an enlarged left ventricle. In the preoperative period, these patients may benefit from a right lateral posture when lying in bed.
Collapse
Affiliation(s)
- G D Puri
- Post Graduate Institute of Medical Education and Research (PGIMER), Department of Anaesthesia and Intensive Care and Department of Cardiothoracic and Vascular Surgery, Chandigarh, India.
| | | | | | | | | | | |
Collapse
|
29
|
Álvarez-Rocha L, Alós J, Blanquer J, Álvarez-Lerma F, Garau J, Guerrero A, Torres A, Cobo J, Jordá R, Menéndez R, Olaechea P, Rodríguez de castro F. [Guidelines for the management of community pneumonia in adult who needs hospitalization]. Med Intensiva 2005; 29:21-62. [PMID: 38620135 PMCID: PMC7131443 DOI: 10.1016/s0210-5691(05)74199-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2004] [Indexed: 11/01/2022]
Abstract
Community acquired pneumonia is still an important health problem. In Spain the year incidence is 162 cases per 100,000 inhabitants with 53,000 hospital admission costing 115 millions of euros per year. In the last years there have been significant advances in the knowledge of: aetiology, diagnostic tools, treatment alternatives and antibiotic resistance. The Spanish Societies of Intensive and Critical Care (SEMICYUC), Infectious Diseases and Clinical Microbiology (SEIMC) and Pulmonology and Thoracic Surgery (SEPAR) have produced these evidence-based Guidelines for the management of community acquired pneumonia in Adults. The main objective is to help physicians to make decisions about this disease. The different points that have been developed are: aetiology, diagnosis, treatment and prevention.
Collapse
Affiliation(s)
- L. Álvarez-Rocha
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - J.I. Alós
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - J. Blanquer
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - F. Álvarez-Lerma
- Grupo de Estudio de la Infección en el Paciente Crítico. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIPC de la SEIMC)
| | - J. Garau
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - A. Guerrero
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - A. Torres
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - J. Cobo
- Grupo de Estudio de la Infección en Atención Primaria. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEIAP de la SEIMC)
| | - R. Jordá
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - R. Menéndez
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | - P. Olaechea
- Grupo de Trabajo de Enfermedades Infecciosas. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (GTEI de la SEMICYUC)
| | - F. Rodríguez de castro
- Área de Tuberculosis e Infección Respiratoria. Sociedad Española de Neumología y Cirugía Torácica (Area TIR de la SEPAR)
| | | |
Collapse
|
30
|
Abstract
During the past decade, the use of video-assisted thoracoscopic surgery (VATS) has dramatically increased in children as well as adults. Although VATS can be performed while both lungs are being ventilated, single-lung ventilation (SLV) is desirable during VATS. In addition, anaesthesiologists are performing (and paediatric surgeons are requesting) SLV more frequently for open thoracotomies in infants and children.
Collapse
Affiliation(s)
- Gregory B Hammer
- Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford University Medical Center, Stanford, CA 94305-5640, USA.
| |
Collapse
|
31
|
Fichele S, Woodhouse N, Swift AJ, Said Z, Paley MNJ, Kasuboski L, Mills GH, van Beek EJR, Wild JM. MRI of helium-3 gas in healthy lungs: Posture related variations of alveolar size. J Magn Reson Imaging 2004; 20:331-5. [PMID: 15269962 DOI: 10.1002/jmri.20104] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To probe the variation of alveolar size in healthy lung tissue as a function of posture using diffusion-weighted helium-3 hyperpolarized gas imaging. MATERIALS AND METHODS Measurements of the helium-3 apparent diffusion coefficient (ADC) were made on six healthy subjects. These were used to show the variation of alveolar size between the lowermost dependent regions of the lung compared to the uppermost regions of the lung in four postures: supine, prone, left-lateral decubitus, and right-lateral decubitus. RESULTS The distribution of acinar size in the lungs was found to be heterogeneous, and influenced by lung orientation. In nearly all postures, the ADC was significantly higher in the non-dependent uppermost regions of the lung compared to the dependent lowermost regions of the lung; the greatest variation was found in the left-lateral decubitus position. The difference in ADC between uppermost and lowermost regions was on average 0.012 cm(2)second(-1), which represents 20% of the average ADC value for the whole lung. A systematic decrease in ADC from the apex of the lung to the base was also found, which corresponds to an inherent gradient in alveolar size. CONCLUSION The posture dependent variations in ADC were attributed to compression of the parenchyma under its own weight and the mass of the heart.
Collapse
Affiliation(s)
- Stanislao Fichele
- Academic Unit of Radiology, The University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Fischer LG, Aken HV, Bürkle H. Management of pulmonary hypertension: physiological and pharmacological considerations for anesthesiologists. Anesth Analg 2003; 96:1603-1616. [PMID: 12760982 DOI: 10.1213/01.ane.0000062523.67426.0b] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lars G Fischer
- Department of Anesthesiology and Intensive Care, Universita[Combining Diaeresis]tsklinikum Mu[Combining Diaeresis]nster, Mu[Combining Diaeresis]nster, Germany
| | | | | |
Collapse
|
33
|
Nitz J, Burke B. A study of the facilitation of respiration in myotonic dystrophy. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2003; 7:228-38. [PMID: 12528578 DOI: 10.1002/pri.262] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Dystrophia myotonica or myotonic dystrophy is a progressive neuromuscular disorder in which patients demonstrate an irregular respiratory pattern and are particularly subject to cardiopulmonary compromise. The aim of the present study was to investigate the effects of both proprioceptive neuromuscular facilitation (PNF) and staged basal expansion (SBE) breathing exercises in subjects with myotonic dystrophy in two different positions: high support sitting and left side-lying. METHOD A randomized, double-blind study design was used. Seven non-congenital myotonic dystrophy subjects took part in the study. Six 'treatment' levels were applied to each subject: resting in high support sitting; resting in left side-lying; PNF of deep breathing in high support sitting; PNF of deep breathing in left side-lying; SBE in high support sitting and SBE in left side-lying. The outcome measures employed were arterial oxygen saturation (SpO2) and heart rate, as measured by oximetry and thoraco-abdominal motion (TAM), and respiratory rate, as measured by a pneumograph. RESULTS The PNF technique was found to be the main contributor to improvement in SpO2 for subjects with myotonic dystrophy, where a 2.2% increase was found in the high support sitting position and a 2.6% increase was found in the left side-lying position. There was an increase of between 377% and 556% in TAM during application of both treatment techniques, in either the high support sitting or left side-lying positions. Respiratory rate declined between 15% and 30% immediately after treatment application and heart rate dropped slightly by between 0.2% and 4.1%. CONCLUSION The present study provides objective evidence that application of these respiratory physiotherapy interventions elicits an improvement in respiratory function in subjects with myotonic dystrophy. Further research into the physiological effects of these techniques could explore the mechanisms responsible for improvement in respiratory indices.
Collapse
Affiliation(s)
- Jennifer Nitz
- Department of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Australia
| | | |
Collapse
|
34
|
Abstract
Mechanical ventilation is a supportive lifesaving therapy that can potentially cause lung injury if periodic alveolar overdistension, or cyclic collapse, and reopening occur. The use of a low tidal volume with moderate to high positive end-expiratory pressure improves the survival of patients with acute lung injury and acute respiratory distress syndrome. Positioning the patient with the "good lung down" and using differential ventilation with selective positive end-expiratory pressure are the two currently accepted ventilatory strategies to be applied in patients with severe unilateral lung injury. However, both have serious limitations in clinical practice. Lung injury may be rather inhomogeneous-confined to one lung or preferentially distributed toward the dependent lung areas. In unilateral lung injury, ventilatory strategies that allow recruitment of injured lung and that avoid overdistension of uninjured lung parenchyma should be applied. Experimental studies have shown that the use of selective tracheal gas insufflation and partial liquid ventilation facilitates low tidal volume with appropriate gas exchange while reducing cyclic lung stretch and shear stresses. Further studies are needed to determine future applications of these therapies in humans.
Collapse
Affiliation(s)
- Lluis Blanch
- MD Critical Care Center, Hospital de Sabadell, 08208 Sabadell, Spain.
| | | | | |
Collapse
|
35
|
Kim MJ, Hwang HJ, Song HH. A randomized trial on the effects of body positions on lung function with acute respiratory failure patients. Int J Nurs Stud 2002; 39:549-55. [PMID: 11996875 DOI: 10.1016/s0020-7489(01)00060-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In a randomized controlled trial, we compared the potential benefits of position changes on arterial oxygen pressure in 32 patients with acute respiratory failure, maintained on artificial ventilators, distinguishing prominently as left-sided, right-sided or bilateral lung disease. Our results indicate that randomly alternating supine, left-lateral, right-lateral and prone positions have influence on gas exchange and that improvement of arterial oxygen pressure is associated with various positions. Our results show, therefore, that nursing care of patients on artificial ventilators involving changes in body positions (a simple and noninvasive means of assistance) has important therapeutic consequences and warrants attention in clinical practice.
Collapse
Affiliation(s)
- Myung J Kim
- Department of Nursing, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | | | | |
Collapse
|
36
|
Abstract
The anesthesiologist caring for infants and children undergoing thoracic surgery faces many challenges. An understanding of the primary underlying lesion as well as associated anomalies that may impact perioperative management is paramount. A working knowledge of respiratory physiology and anatomy in infants and children is required for the planning and execution of appropriate intraoperative care. Familiarity with a variety of techniques for SLV suited to the patient's size will allow maximal surgical exposure while minimizing trauma to the lungs and airways. Finally, use of regional anesthetic techniques, including epidural anesthesia and analgesia, facilitates optimal postoperative pain control and pulmonary function.
Collapse
Affiliation(s)
- Gregory B Hammer
- Department of Anesthesia, Stanford University Medical Center, Palo Alto, California, USA
| |
Collapse
|
37
|
Blanch L, Murias G, Nahum A. Lung Recruitment in Localized Lung Injury. Intensive Care Med 2002. [DOI: 10.1007/978-1-4757-5551-0_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
38
|
Blanch L, Van der Kloot TE, Youngblood AM, Adams AB, Naveira A, Murias G, Romero PV, Nahum A. Selective tracheal gas insufflation during partial liquid ventilation improves lung function in an animal model of unilateral acute lung injury. Crit Care Med 2001; 29:2251-7. [PMID: 11801817 DOI: 10.1097/00003246-200112000-00003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE During unilateral lung injury, we hypothesized that we can improve global lung function by applying selective tracheal gas insufflation (TGI) and partial liquid ventilation (PLV) to the injured lung. DESIGN Prospective, interventional animal study. SETTING Animal laboratory in a university hospital. SUBJECTS Adult mixed-breed dogs. INTERVENTIONS In six anesthetized dogs, left saline lung lavage was performed until PaO(2)/FiO(2) fell below 100 torr (13.3 kPa). The dogs were then reintubated with a Univent single-lumen endotracheal tube, which incorporates an internal catheter to provide TGI. In a consecutive manner, we studied 1) the application of 10 cm H(2)O of positive end-expiratory pressure (PEEP); 2) instillation of 10 mL/kg of perflubron (Liquivent) to the left lung at a PEEP level of 10 cm H(2)O (PLV+PEEP 10 initial); 3) application of selective TGI (PLV+TGI) while maintaining end-expiratory lung volume (EELV) constant; 4) PLV+TGI at reduced tidal volume (VT); and 5) PLV+PEEP 10 final. MEASUREMENTS AND MAIN RESULTS Application of PLV+PEEP 10 initial did not change gas exchange, lung mechanics, or hemodynamics. PLV+TGI improved PaO(2)/FiO(2) from 189 +/- 13 torr (25.2 +/- 1.7 kPa) to 383 +/- 44 torr (51.1 +/- 5.9 kPa) (p <.01) and decreased PaCO(2) from 55 +/- 5 torr (7.3 +/- 0.7 kPa) to 30 +/- 2 torr (4.0 +/- 0.3 kPa) (p <.01). During ventilation with PLV+TGI, reducing VT from 15 mL/kg to 3.5 mL/kg while keeping EELV constant decreased PaO(2)/FiO(2) to 288 +/- 49 torr (38.4 +/- 6.5 kPa) (not significant) and normalized PaCO(2). At this stage, end-inspiratory plateau pressure decreased from 19.2 +/- 0.7 cm H(2)O to 13.6 +/- 0.7 cm H(2)O (p <.01). At PLV+PEEP 10 final, measurements returned to those observed at previous baseline stage (PLV+PEEP 10 initial). CONCLUSIONS During unilateral lung injury, PLV with a moderate PEEP did not improve oxygenation, TGI superimposed on PLV improved gas exchange, and combination of TGI and PLV allowed a 77% reduction in VT without any adverse effect on PaCO(2).
Collapse
Affiliation(s)
- L Blanch
- Servei de Medicina Intensiva, Hospital de Sabadell, Corporació Parc Tauli, Sabadell, Spain
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Blanch L, Van der Kloot TE, Youngblood AM, Murias G, Naveira A, Adams AB, Romero PV, Nahum A. Application of tracheal gas insufflation to acute unilateral lung injury in an experimental model. Am J Respir Crit Care Med 2001; 164:642-7. [PMID: 11520730 DOI: 10.1164/ajrccm.164.4.2005127] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In unilateral lung injury, application of global positive end-expiratory pressure (PEEP) may cause overdistension of normal alveoli and redistribution of blood flow to diseased lung areas, thereby worsening oxygenation. We hypothesized that selective application of tracheal gas insufflation (TGI) will recruit the injured lung without causing overdistension of the normal lung. In eight anesthetized dogs, left lung saline lavage was performed until Pa(O(2))/FI(O(2)) fell below 100 mm Hg. Then, the dogs were reintubated with a Univent single lumen endotracheal tube that incorporates an internal catheter to provide TGI. After injury, increasing PEEP from 3 to 10 cm H(2)O did not change gas exchange, hemodynamics, or lung compliance. Selective TGI, while keeping end-expiratory lung volume (EELV) constant, improved Pa(O(2))/FI(O(2)) from 212 +/- 43 to 301 +/- 38 mm Hg (p < 0.01) while Pa(CO(2)) and airway pressures decreased (p < 0.01). During selective TGI, reducing tidal volume to 5.2 ml/kg while keeping EELV constant, normalized Pa(CO(2)), did not affect Pa(O(2))/FI(O(2)), and decreased end-inspiratory plateau pressure from 16.6 +/- 1.0 to 11.9 +/- 0.5 cm H(2)O (p < 0.01). In unilateral lung injury, we conclude that selective TGI (1) improves oxygenation at a lower pressure cost as compared with conventional mechanical ventilation, (2) allows reduction in tidal volume without a change in alveolar ventilation, and (3) may be a useful adjunct to limit ventilator-associated lung injury.
Collapse
Affiliation(s)
- L Blanch
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Regions Hospital, St. Paul, Minnesota, USA.
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
OBJECTIVE The purpose of this study was to assess the effect of lateral positions on tissue oxygenation in critically ill patients. DESIGN The study design was prospective and quasi-experimental, and we used a convenience sample with random assignment. SETTING The study took place in the intensive care unit and the cardiac intensive care unit of a 450-bed medical center in the northwestern United States. PATIENTS The sample included 12 adult patients with indwelling pulmonary artery and radial arterial catheters who were receiving mechanical ventilation and who met the criteria of "critical illness" by having impaired arterial oxygenation (PaO2 < or = 70 mm Hg) and/or cardiac index < or = 2.0 L/min/m2. OUTCOME MEASURES The outcome measures were dependent variables reflecting oxygen delivery including heart rate, cardiac output, arterial oxygen content (CaO2) and oxygen consumption, and the adequacy of tissue oxygenation (serum lactate). INTERVENTION Each patient was passively turned to each of the three positions (right and left 45 degrees lateral and supine) according to a computer-generated, randomized positioning sequence. Dependent variables were measured 15 minutes after each position change. No changes in ventilator settings or vasoactive drugs occurred during data collection. RESULTS Analysis of variance for repeated measures was used in the data analysis. Post hoc analysis determined an effect size of 0.558 and power of 0.80 at an alpha level of.05. No statistically significant differences caused by position were found in mean CaO2, cardiac output, heart rate, respiratory rate, PaO2, SaO2, or lactate level. Pearson correlation analysis found no significant relationships between the primary variables reflecting oxygen delivery (cardiac output and CaO2) and serum lactate levels. CONCLUSIONS These findings suggest that lateral positioning of critically ill patients who are hypoxemic or have low cardiac output does not further endanger tissue oxygenation. Evaluation of individual patient responses to position changes in the clinical setting is encouraged until further studies using more heterogenous populations can provide more definitive guidance.
Collapse
Affiliation(s)
- J L Banasik
- Washington State University College of Nursing, USA
| | | |
Collapse
|
41
|
Affiliation(s)
- G B Hammer
- Department of Anesthesia, Stanford University Medical Center, Stanford, California 94305-5115, USA.
| |
Collapse
|
42
|
Choe KH, Kim YT, Shim TS, Lim CM, Lee SD, Koh Y, Kim WS, Kim DS, Ryu JS, Kim WD. Closing volume influences the postural effect on oxygenation in unilateral lung disease. Am J Respir Crit Care Med 2000; 161:1957-62. [PMID: 10852773 DOI: 10.1164/ajrccm.161.6.9909067] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In normal adults, both blood flow and ventilation are distributed preferentially to the dependent lung zones. In adults with unilateral lung disease, arterial oxygenation improves when they are positioned with their good lung down because of improved matching of ventilation and perfusion. When the closing volume is increased, dependent airways are closed during tidal breathing, so that reduced ventilation-perfusion ratio and hypoxia develops and ventilation is preferentially distributed to the upper lung zones. We undertook an observational study on the effects of lateral recumbency on arterial oxygenation in adult patients with unilateral lung disease and tested the hypothesis that oxygenation in lateral recumbency might be influenced by an increase in closing volume. Arterial blood gases were analyzed in the supine, right and left lateral decubitus positions and the AaPO(2) was calculated in 44 randomly selected patients 49.9 +/- 18.7 yr of age with unilateral pneumonia (23 cases) or pulmonary tuberculosis (21 cases). In 26 patients, individual Pa(O(2)) with the normal lung in the dependent position was higher than that with the diseased lung; the opposite was true for 18 patients. The difference in Pa(O(2)) and AaPO(2) between the two positions was statistically significant in both groups. In 16 patients (10 men and six women 49.2 +/- 18.2 yr of age), we measured closing volume and determined the fractional ventilation to each lung by (133)Xe lung scan in the three positions. In these 16 patients, the difference in Pa(O(2)) between the normal and the diseased lung in the dependent position was related significantly to the difference in the fractional ventilation going to the normal lung between the dependent and the supine position (r = 0.642, p = 0. 007). The latter was related significantly to the % predicted closing volume (CV/VC) (r = -0.597, p = 0.015). This study has shown that closing volume, as well as posture, might be involved in determining oxygenation in lateral recumbency in patients with unilateral lung disease.
Collapse
Affiliation(s)
- K H Choe
- Pulmonary and Critical Care Division, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Chatterton HJ, Pomeroy VM, Connolly MJ, Faragher EB, Clayton L, Tallis RC. The effect of body position on arterial oxygen saturation in acute stroke. J Gerontol A Biol Sci Med Sci 2000; 55:M239-44. [PMID: 10811154 DOI: 10.1093/gerona/55.4.m239] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Evidence suggests that respiratory function is impaired poststroke. Body position is known to influence respiratory function in normal subjects and those with respiratory pathologies. Its effect on respiratory function after stroke has received little attention. However, one study suggests that some positions used in clinical practice may adversely influence respiratory function. This study therefore aimed to identify resting positions that maintain arterial oxygen saturation (SaO2) at optimal levels, changes in SaO2 during time spent in the test position, and differences in SaO2 among the positions investigated. METHOD A within-subject, two-center clinical study was made. Patients in the first 72 hours following mild to moderately severe stroke were allocated a randomized sequence of four positions. One hour was spent in each position. SaO2 was recorded each minute by pulse oximetry with a finger probe. Mean values for the hour were calculated. RESULTS Mean arterial oxygen saturation values for all patients were >90% for the hour spent in each test position for all patients. There were no changes in arterial oxygen saturation across the hour spent in the test positions (repeated-measures analysis of variance). No differences in arterial oxygen saturation were identified among positions (analysis of covariance). DISCUSSION The saturation levels recorded corresponded to those observed in studies of normal elderly persons. The positions tested may be recommended for use in clinical practice to maintain arterial oxygen saturation in patients in the first 72 hours following mild to moderately severe stroke.
Collapse
Affiliation(s)
- H J Chatterton
- The Stroke Association's Therapy Research Unit, Hope Hospital, Salford, UK.
| | | | | | | | | | | |
Collapse
|
44
|
Yang IA, Bell SC, Fong KM, Aldons PM. Trepopnoea due to positional narrowing of the left main bronchus. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1999; 29:838-9. [PMID: 10677137 DOI: 10.1111/j.1445-5994.1999.tb00800.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
45
|
Abstract
Severe ULD presents a challenge in ventilator management because of the marked asymmetry in the mechanics of the two lungs. The asymmetry may result from significant decreases or increases in the compliance of the involved lung. Traditional ventilator support may fail to produce adequate gas exchange in these situations and has the potential to cause further deterioration. Fortunately, conventional techniques can be safely and effectively applied in the majority of cases without having to resort to less familiar and potentially hazardous forms of support. In those circumstances when conventional ventilation is unsuccessful in restoring adequate gas exchange, lateral positioning and ILV have proved effective at improving and maintaining gas exchange. Controlled trials to guide clinical decision making are lacking. In patients who have processes associated with decreased compliance in the involved lung, lateral positioning may be a simple method of improving gas exchange but is associated with many practical limitations. ILV in these patients is frequently successful when differential PEEP is applied with the higher pressure to the involved lung. In patients in whom the pathology results in distribution of ventilation favoring the involved lung, particularly BPF, ILV can be used to supply adequate support while minimizing flow through the fistula and allowing it to close. The application of these techniques should be undertaken with an understanding of the pathophysiology of the underlying process; the reported experience with these techniques, including indications and successfully applied methods; and the potential problems encountered with their use. Fortunately, these modalities are infrequently required, but they provide a critical means of support when conventional techniques fail.
Collapse
Affiliation(s)
- A R Thomas
- Department of Medicine, University of Arizona/Maricopa Medical Center, Phoenix, Arizona, USA
| | | |
Collapse
|
46
|
Gawlinski A, Dracup K. Effect of positioning on SvO2 in the critically ill patient with a low ejection fraction. Nurs Res 1998; 47:293-9. [PMID: 9766458 DOI: 10.1097/00006199-199809000-00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Critically ill patients with a low ejection fraction may be vulnerable to decreased mixed venous oxygen saturation (SvO2) resulting from position change. OBJECTIVES The objectives of this study were to describe the effects of changes in positioning on SvO2 in critically ill patients with a low ejection fraction (< or = 30%) and to describe the contribution of variables of oxygen delivery (DO2) and oxygen consumption (VO2) to the variance in SvO2. METHOD An experimental two-group repeated-measures design was used to study 42 critically ill patients with an ejection fraction of less than or equal to 30% (M= 19.5%). Patients were assigned randomly to one of two position sequences: supine, right lateral, left lateral; or supine, left lateral, right lateral. Data on SvO2 were collected at baseline, each minute after position change for 5 minutes, and at 15 and 25 minutes. RESULTS Repeated-measures multivariate analysis of variance showed a difference in SvO2 among the three positions across time (p< .0001), with the greatest differences occurring within the first 4 minutes and in the left lateral position. Stepwise multiple regression showed that VO2 accounted for a greater proportion of the variance in SvO2 with position change than did DO2 (54% [p = .001] vs. 31% [p= .001]). CONCLUSIONS Changes in SVO2 occur with positioning in critically ill patients with a low ejection fraction. These changes are transient and are the result of changes in VO2 rather than changes in DO2.
Collapse
Affiliation(s)
- A Gawlinski
- University of California, Los Angeles, Medical Center, USA
| | | |
Collapse
|
47
|
Fridrich P, Krafft P, Hochleuthner H, Mauritz W. The effects of long-term prone positioning in patients with trauma-induced adult respiratory distress syndrome. Anesth Analg 1996; 83:1206-11. [PMID: 8942587 DOI: 10.1097/00000539-199612000-00013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Prone positioning improves gas exchange in some patients with adult respiratory distress syndrome (ARDS), but the effects of repeated, long-term prone positioning (20 h duration) have never been evaluated systemically. We therefore investigated 20 patients with ARDS after multiple trauma (Injury Severity Score [ISS] 27.3 +/- 10, ARDS score 2.84 +/- 0.42). Patients who fulfilled the entry criteria (bilateral diffuse infiltrates, severe hypoxemia, pulmonary artery occlusion pressure [PAOP] < 18 mm Hg, and PaO2/fraction of inspired oxygen [FIO2] < 200 mm Hg at inverse ratio ventilation with positive end-expiratory pressure [PEEP] > 8 mm Hg for more than 24 h) were turned to the prone position at noon and were turned back to the supine position at 8:00 AM on the next day. Thus only two turns per day were necessary, and the risk of disconnecting airways or medical lines was minimized. Prone positioning was repeated for another 20 h if the patients fulfilled the entry criteria. Except for FIO2, the ventilator settings remained unchanged during the study period. All patients were sedated and, if needed paralyzed to minimize patient discomfort. One hour before and after each position change, ventilator settings and pulmonary and systemic hemodynamics were recorded and blood was obtained for blood gas analysis. Derived cardiopulmonary and ventilatory variables were calculated using standard formulas. Overall mortality was 10%. Oxygenation variables improved significantly each time the patients were placed prone. Immediately after the first turn from the supine to the prone position the following changes were observed: PaO2 increased from 97 +/- 4 to 152 +/- 15 mm Hg, intrapulmonary shunt (Qva/Qt) decreased from 30.3 +/- 2.3 to 25.5 +/- 1.8, and the alveolar-arterial oxygen difference decreased from 424 +/- 24 to 339 +/- 25 mm Hg. All these changes were statistically significant. Most of these improvements were lost when the patients were turned supine, but could be reproduced when prone positioning was repeated after a short period (4 h) in the supine position. Short periods in the supine position were necessary to allow for nursing care, medical evaluation, and interventions such as placement of central lines. No position-dependent changes of systemic hemodynamic variables were observed. We conclude that, in trauma patients with ARDS undergoing long-term positioning treatment, lung function improves significantly during prone position compared to short phases of conventional supine position during which the beneficial effects are partly lost.
Collapse
Affiliation(s)
- P Fridrich
- Department of Anesthesia and General Intensive Care Medicine, Vienna General Hospital, University of Vienna, Austria
| | | | | | | |
Collapse
|
48
|
The Effects of Long-Term Prone Positioning in Patients with Trauma-Induced Adult Respiratory Distress Syndrome. Anesth Analg 1996. [DOI: 10.1213/00000539-199612000-00013] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
49
|
Abstract
A quasi-experimental, repeated-measures cross-over design study on the effect of body position on oxygenation (SaO2) blood pressure, respiration and pulse in patients with unilateral lung pathology was conducted. Previous research strongly suggests that positioning with the healthy (unaffected) lung in the dependent lateral (down) position is related to improved oxygenation, but knowledge about whether this effect is maintained over time is lacking. The purpose of this investigation was to determine: (1) Is positioning with the unaffected lung in the dependent lateral position related to increased arterial blood saturation levels and decreased blood pressure, pulse and respiration? (2) What is the relationship between the dependent variables--oxygenation saturation levels, blood pressure, pulse and respiration--and the independent variables--body position and time in the position? Thirty-nine patients with unilateral lung pathology were positioned on their sides with the unaffected lung down, on their sides with the affected lung down, and also in semi-Fowler's position. Arterial (SaO2) blood saturation and vital signs were measured at baseline 0, 15 and 30 minutes. There was no statistically significant relationship between oxygenation level or systolic blood pressure. Diastolic blood pressure, respiration and pulse did vary significantly with position.
Collapse
Affiliation(s)
- E M Yeaw
- College of Nursing, University of Rhode Island, Kingston 02881-0814, USA
| |
Collapse
|
50
|
Romero S, Martín C, Hernández L, Arriero JM, Benito N, Gil J. Effect of body position on gas exchange in patients with unilateral pleural effusion: influence of effusion volume. Respir Med 1995; 89:297-301. [PMID: 7597270 DOI: 10.1016/0954-6111(95)90091-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The objective of this study was to evaluate the effect of lateral body position on gas exchange in patients with unilateral pleural effusion, with special reference to the influence of effusion volume. Thirty consecutive patients with unilateral pleural effusion, without evidence of parenchymal pulmonary involvement, were entered into the study. Arterial blood gas tensions (PaO2, PaCO2) were randomly measured in both right and left lateral decubitus body positions, while breathing room air. To assess the influence of the effusion volume, roentgenographic and functional parameters were used. Among the latter, FVC, FEV1, TLC and RV were determined. The influence of the presence or absence of pleuritic pain on gas exchange was also assessed. There was no significant difference in PaCO2 between right and left lateral decubitus body positions (31.1 +/- 4.2 vs. 31.0 +/- 4.5 mmHg). The differences in PaO2 between the two body positions ranged from 0.5-25 mmHg (mean 9.3 +/- 6.6 mmHg). Mean PaO2 with the normal-side (control) down (PaO2-N) (81.4 +/- 8.5 mmHg) was higher, but without significant statistical difference, than mean PaO2 with the effusion-side down (PaO2-E) (78.0 +/- 12.5 mmHg). PaO2-N was higher than PaO2-E in 22 of 30 patients (conventional), and lower in eight patients (paradoxical). No consistent relationship was found for alterations in PaO2 in different positions with the volume of effusion, either when estimated by a roentgenographic method or when using spirometric or plethysmographic values.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- S Romero
- Hospital General Universitario S.V.S. de Alicante, Spain
| | | | | | | | | | | |
Collapse
|