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Mekontso Dessap A, Bagate F, Repesse X, Blayau C, Fartoukh M, Canoui-Poitrine F, de Prost N, Vieillard-Baron A. Low-flow ECCO 2R conjoined with renal replacement therapy platform to manage pulmonary vascular dysfunction with refractory hypercapnia in ARDS. Heliyon 2024; 10:e23878. [PMID: 38226285 PMCID: PMC10788508 DOI: 10.1016/j.heliyon.2023.e23878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/17/2024] Open
Abstract
Background Hypercapnia worsens lung vascular dysfunction during acute respiratory distress syndrome (ARDS). We tested whether an extracorporeal carbon dioxide removal (ECCO2R) device based on a renal replacement therapy platform (Prismalung®) may reduce PaCO2 and alleviate lung vascular dysfunction in ARDS patients with refractory hypercapnia. Methods We planned to prospectively include 20 patients with moderate-to-severe ARDS, pulmonary vascular dysfunction on echocardiography, and PaCO2 ≥ 48 mmHg despite instrumental dead space reduction and the increase in respiratory rate. Hemodynamics, echocardiography, respiratory mechanics, and arterial blood gases were recorded at 2 (H2), 6 (H6) and 24 (H24) hours as ECCO2R treatment was continued for at least 24 h. Results Only eight patients were included, and the study was stopped due to worldwide shortage of ECCO2R membranes and the pandemic. Only one patient fulfilled the primary endpoint criterion (decrease in PaCO2 of more than 20 %) at H2, but this objective was achieved in half of patients (n = 4) at H6. The percentage of patients with a PaCO2 value < 48 mmHg increased with time, from 0/8 (0 %) at H0, to 3/8 (37.5 %) at H2 and 4/8 (50 %) at H6 (p = 0.04). There was no major change in hemodynamic and echocardiographic variables with ECCO2R, except for a significant decrease in heart rate. ECCO2R was prematurely discontinued before H24 in five (62.5 %) patients, due to membrane clotting in all cases. Conclusions This pilot study testing showed a narrow efficacy and high rate of membrane thrombosis with the first version of the system. Improved versions should be tested in future trials. Trial registration Registered at clinicaltrials.gov, identifier: NCT03303807, Registered: October 6, 2017, https://clinicaltrials.gov/ct2/show/NCT03303807.
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Affiliation(s)
- Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - François Bagate
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - Xavier Repesse
- AP-HP, Hôpital Ambroise Paré, Service de Médecine Intensive Réanimation, Boulogne Billancourt, Créteil, France
| | - Clarisse Blayau
- AP-HP, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France
| | - Muriel Fartoukh
- AP-HP, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France
| | - Florence Canoui-Poitrine
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Santé Publique, F-94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - Antoine Vieillard-Baron
- AP-HP, Hôpital Ambroise Paré, Service de Médecine Intensive Réanimation, Boulogne Billancourt, Créteil, France
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Burrell A, Kim J, Alliegro P, Romero L, Serpa Neto A, Mariajoseph F, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev 2023; 9:CD010381. [PMID: 37750499 PMCID: PMC10521169 DOI: 10.1002/14651858.cd010381.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) may provide benefit in certain populations of adults, including those with severe cardiac failure, severe respiratory failure, and cardiac arrest. However, it is also associated with serious short- and long-term complications, and there remains a lack of high-quality evidence to guide practice. Recently several large randomized controlled trials (RCTs) have been published, therefore, we undertook an update of our previous systematic review published in 2014. OBJECTIVES To evaluate whether venovenous (VV), venoarterial (VA), or ECMO cardiopulmonary resuscitation (ECPR) improve mortality compared to conventional cardiopulmonary support in critically ill adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was March 2022. The search was limited to English language only. SELECTION CRITERIA We included RCTs, quasi-RCTs, and cluster-RCTs that compared VV ECMO, VA ECMO or ECPR to conventional support in critically ill adults. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was 1. all-cause mortality at day 90 to one year. Our secondary outcomes were 2. length of hospital stay, 3. survival to discharge, 4. disability, 5. adverse outcomes/safety events, 6. health-related quality of life, 7. longer-term health status, and 8. cost-effectiveness. We used GRADE to assess certainty of evidence. MAIN RESULTS Five RCTs met our inclusion criteria, with four new studies being added to the original review (total 757 participants). Two studies were of VV ECMO (429 participants), one VA ECMO (41 participants), and two ECPR (285 participants). Four RCTs had a low risk of bias and one was unclear, and the overall certainty of the results (GRADE score) was moderate, reduced primarily due to indirectness of the study populations and interventions. ECMO was associated with a reduction in 90-day to one-year mortality compared to conventional treatment (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.70 to 0.92; P = 0.002, I2 = 11%). This finding remained stable after performing a sensitivity analysis by removing the single trial with an uncertain risk of bias. Subgroup analyses did not reveal a significant subgroup effect across VV, VA, or ECPR modes (P = 0.73). Four studies reported an increased risk of major hemorrhage with ECMO (RR 3.32, 95% CI 1.90 to 5.82; P < 0.001), while two studies reported no difference in favorable neurologic outcome (RR 2.83, 95% CI 0.36 to 22.42; P = 0.32). Other secondary outcomes were not consistently reported across the studies. AUTHORS' CONCLUSIONS In this updated systematic review, which included four additional RCTs, we found that ECMO was associated with a reduction in day-90 to one-year all-cause mortality, as well as three times increased risk of bleeding. However, the certainty of this result was only low to moderate, limited by a low number of small trials, clinical heterogeneity, and indirectness across studies.
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Affiliation(s)
- Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Jiwon Kim
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Patricia Alliegro
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care, Austin Hospital, Melbourne, Australia
| | - Frederick Mariajoseph
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Australia
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3
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Abstract
The pathophysiology of acute respiratory distress syndrome (ARDS) is marked by inflammation-mediated disruptions in alveolar-capillary permeability, edema formation, reduced alveolar clearance and collapse/derecruitment, reduced compliance, increased pulmonary vascular resistance, and resulting gas exchange abnormalities due to shunting and ventilation-perfusion mismatch. Mechanical ventilation, especially in the setting of regional disease heterogeneity, can propagate ventilator-associated injury patterns including barotrauma/volutrauma and atelectrauma. Lung injury due to the novel coronavirus SARS-CoV-2 resembles other causes of ARDS, though its initial clinical characteristics may include more profound hypoxemia and loss of dyspnea perception with less radiologically-evident lung injury, a pattern not described previously in ARDS.
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Affiliation(s)
- Kai Erik Swenson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, BUL 148, Boston, MA 02114, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Erik Richard Swenson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA; Medical Service, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Campus Box 358280 (S-111 Pulm), Seattle, WA 98108, USA
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4
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Heuts S, Makhoul M, Mansouri AN, Taccone FS, Obeid A, Belliato M, Broman LM, Malfertheiner M, Meani P, Raffa GM, Delnoij T, Maessen J, Bolotin G, Lorusso R. Defining and understanding the "extra-corporeal membrane oxygenation gap" in the veno-venous configuration: Timing and causes of death. Artif Organs 2021; 46:349-361. [PMID: 34494291 PMCID: PMC9293076 DOI: 10.1111/aor.14058] [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] [Received: 06/14/2021] [Revised: 07/27/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
In‐hospital mortality of adult veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) patients remains invariably high. However, little is known regarding timing and causes of in‐hospital death, either on‐ECMO or after weaning. The current review aims to investigate the timing and causes of death of adult patients during hospital admittance for V‐V ECMO, and to define the V‐V ECMO gap, which is represented by the patients that are successfully weaned of ECMO but still die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V‐V ECMO patients from January 2006 to December 2020 were screened. Studies that did not report on at least on‐ECMO mortality and discharge rate were excluded from analysis as they could not provide the required information regarding the proposed V‐V ECMO‐gap. Mortality rates on‐ECMO and after weaning, as well as weaning and discharge rates, were analyzed as primary outcomes. Secondary outcomes were the causes of death and complications. Initially, 35 studies were finally included in this review. Merely 24 of these studies (comprising 975 patients) reported on prespecified V‐V ECMO outcomes (on‐ECMO mortality and discharge rate). Mortality on V‐V ECMO support was 27.8% (95% confidence interval (CI) 22.5%‐33.2%), whereas mortality after successful weaning was 12.7% (95% CI 8.8%‐16.6%, defining the V‐V ECMO gap). 72.2% of patients (95% CI 66.8%‐77.5%) were weaned successfully from support and 56.8% (95% CI 49.9%‐63.8%) of patients were discharged from hospital. The most common causes of death on ECMO were multiple organ failure, bleeding, and sepsis. Most common causes of death after weaning were multiorgan failure and sepsis. Although the majority of patients are weaned successfully from V‐V ECMO support, a significant proportion of subjects still die during hospital stay, defining the V‐V ECMO gap. Overall, timing and causes of death are poorly reported in current literature. Future studies on V‐V ECMO should describe morbidity and mortality outcomes in more detail in relation to the timing of the events, to improve patient management, due to enhanced understanding of the clinical course.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Maged Makhoul
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Abdulrahman N Mansouri
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Clinique Universitaire de Bruxelles (CUB) Erasme, Brussels, Belgium
| | - Amir Obeid
- Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | | | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | | | - Paolo Meani
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, ISMETT-IRCCS, Palermo, Italy
| | - Thijs Delnoij
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Intensive Care Department, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Gil Bolotin
- Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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5
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Serrano R, Corbella X, Rello J. Management of hypoxemia in SARS-CoV-2 infection: Lessons learned from one year of experience, with a special focus on silent hypoxemia. JOURNAL OF INTENSIVE MEDICINE 2021; 1:26-30. [PMID: 36943810 PMCID: PMC7939974 DOI: 10.1016/j.jointm.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/29/2021] [Accepted: 02/18/2021] [Indexed: 12/21/2022]
Abstract
Silent hypoxemia is common in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this article, the possible pathophysiological mechanisms underlying respiratory symptoms have been reviewed, and the presence of hypoxemia without hypoxia is also discussed. The experience we have gained since the start of the Coronavirus disease 19 (COVID-19) pandemic has changed our point of view about which patients with respiratory involvement should be admitted to the intensive care unit/high-dependency unit for mechanical ventilation and monitoring. In patients with clinically well-tolerated mild to moderate hypoxemia (silent hypoxemia), regardless of the extent of pulmonary opacities found in radiological studies, the administration of supplemental oxygen therapy may increase the risk of endothelial damage. The risk of sudden respiratory arrest during emergency intubation, which could expose healthcare workers to infection, should be considered along with the risks of premature intubation. Criteria for intubation need to be revisited based on updated evidence showing that many patients with severe hypoxemia do not show increased work of breathing. This has implications in patient management and may explain in part reports of broad differences in outcomes among intubated patients.
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Affiliation(s)
- Ricardo Serrano
- Critical Care Department. Hospital de Hellín. Gerencia Atención Integrada de Hellín, Albacete 02400, Spain
| | - Xavier Corbella
- Interna Medicine Department, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona 08907, Spain
- School of Medicine, Universitat Internacional de Catalunya, Barcelona 08017, Spain
| | - Jordi Rello
- Vall d'Hebron Institute of Research, Barcelona 08035, Spain
- Research in Critical Care, CHU Caremeau, Nîmes 30900, France
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid 28029, Spain
- Corresponding author: Jordi Rello, Vall d'Hebron Institute of Research, P. Vall d'Hebron 129. AMI-14, Barcelona 08035, Spain.
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6
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Swenson KE, Ruoss SJ, Swenson ER. The Pathophysiology and Dangers of Silent Hypoxemia in COVID-19 Lung Injury. Ann Am Thorac Soc 2021; 18:1098-1105. [PMID: 33621159 PMCID: PMC8328372 DOI: 10.1513/annalsats.202011-1376cme] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/23/2021] [Indexed: 01/08/2023] Open
Abstract
The ongoing coronavirus disease (COVID-19) pandemic has been unprecedented on many levels, not least of which are the challenges in understanding the pathophysiology of these new critically ill patients. One widely reported phenomenon is that of a profoundly hypoxemic patient with minimal to no dyspnea out of proportion to the extent of radiographic abnormality and change in lung compliance. This apparently unique presentation, sometimes called "happy hypoxemia or hypoxia" but better described as "silent hypoxemia," has led to the speculation of underlying pathophysiological differences between COVID-19 lung injury and acute respiratory distress syndrome (ARDS) from other causes. We explore three proposed distinctive features of COVID-19 that likely bear on the genesis of silent hypoxemia, including differences in lung compliance, pulmonary vascular responses to hypoxia, and nervous system sensing and response to hypoxemia. In the context of known principles of respiratory physiology and neurobiology, we discuss whether these particular findings are due to direct viral effects or, equally plausible, are within the spectrum of typical ARDS pathophysiology and the wide range of hypoxic ventilatory and pulmonary vascular responses and dyspnea perception in healthy people. Comparisons between lung injury patterns in COVID-19 and other causes of ARDS are clouded by the extent and severity of this pandemic, which may underlie the description of "new" phenotypes, although our ability to confirm these phenotypes by more invasive and longitudinal studies is limited. However, given the uncertainty about anything unique in the pathophysiology of COVID-19 lung injury, there are no compelling pathophysiological reasons at present to support a therapeutic approach for these patients that is different from the proven standards of care in ARDS.
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Affiliation(s)
- Kai E. Swenson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Stephen J. Ruoss
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Erik R. Swenson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington; and
- Medical Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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7
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Spinelli E, Kircher M, Stender B, Ottaviani I, Basile MC, Marongiu I, Colussi G, Grasselli G, Pesenti A, Mauri T. Unmatched ventilation and perfusion measured by electrical impedance tomography predicts the outcome of ARDS. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:192. [PMID: 34082795 PMCID: PMC8173510 DOI: 10.1186/s13054-021-03615-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/21/2021] [Indexed: 12/30/2022]
Abstract
Background In acute respiratory distress syndrome (ARDS), non-ventilated perfused regions coexist with non-perfused ventilated regions within lungs. The number of unmatched regions might reflect ARDS severity and affect the risk of ventilation-induced lung injury. Despite pathophysiological relevance, unmatched ventilation and perfusion are not routinely assessed at the bedside. The aims of this study were to quantify unmatched ventilation and perfusion at the bedside by electrical impedance tomography (EIT) investigating their association with mortality in patients with ARDS and to explore the effects of positive end-expiratory pressure (PEEP) on unmatched ventilation and perfusion in subgroups of patients with different ARDS severity based on PaO2/FiO2 and compliance. Methods Prospective observational study in 50 patients with mild (36%), moderate (46%), and severe (18%) ARDS under clinical ventilation settings. EIT was applied to measure the regional distribution of ventilation and perfusion using central venous bolus of saline 5% during end-inspiratory pause. We defined unmatched units as the percentage of only ventilated units plus the percentage of only perfused units. Results Percentage of unmatched units was significantly higher in non-survivors compared to survivors (32[27–47]% vs. 21[17–27]%, p < 0.001). Percentage of unmatched units was an independent predictor of mortality (OR 1.22, 95% CI 1.07–1.39, p = 0.004) with an area under the ROC curve of 0.88 (95% CI 0.79–0.97, p < 0.001). The percentage of ventilation to the ventral region of the lung was higher than the percentage of ventilation to the dorsal region (32 [27–38]% vs. 18 [13–21]%, p < 0.001), while the opposite was true for perfusion (28 [22–38]% vs. 36 [32–44]%, p < 0.001). Higher percentage of only perfused units was correlated with lower dorsal ventilation (r = − 0.486, p < 0.001) and with lower PaO2/FiO2 ratio (r = − 0.293, p = 0.039). Conclusions EIT allows bedside assessment of unmatched ventilation and perfusion in mechanically ventilated patients with ARDS. Measurement of unmatched units could identify patients at higher risk of death and could guide personalized treatment.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Michael Kircher
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | | | - Irene Ottaviani
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Maria C Basile
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Ines Marongiu
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Colussi
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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8
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Time-Course of Physiologic Variables During Extracorporeal Membrane Oxygenation and Outcome of Severe Acute Respiratory Distress Syndrome. ASAIO J 2021; 66:663-670. [PMID: 31335371 DOI: 10.1097/mat.0000000000001048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In patients undergoing extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS), it is unknown which clinical physiologic variables should be monitored to follow the evolution of lung injury and extrapulmonary organ dysfunction and to differentiate patients according to their course. We analyzed the time-course of prospectively collected clinical physiologic variables in 83 consecutive ARDS patients undergoing ECMO at a single referral center. Selected variables-including ventilator settings, respiratory system compliance, intrapulmonary shunt, arterial blood gases, central hemodynamics, and sequential organ failure assessment (SOFA) score-were compared according to outcome at time-points corresponding to 0%, 25%, 50%, 75%, and 100% of the entire ECMO duration and daily during the first 7 days. A logistic regression analysis was performed to identify changes between ECMO start and end that independently predicted hospital mortality. Tidal volume, intrapulmonary shunt, arterial lactate, and SOFA score differentiated survivors and nonsurvivors early during the first 7 days and over the entire ECMO duration. Respiratory system compliance, PaO2/FiO2 ratio, arterial pH, and mean pulmonary arterial pressure showed distinct temporal course according to outcome over the entire ECMO duration. Lack of improvement of SOFA score independently predicted hospital mortality. In ARDS patients on ECMO, temporal trends of specific physiologic parameters differentiate survivors from non-survivors and could be used to monitor the evolution of lung injury. Progressive worsening of extrapulmonary organ dysfunction is associated with worse outcome.
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9
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Diagnosis and Management of Acute Respiratory Distress Syndrome in a Time of COVID-19. Diagnostics (Basel) 2020; 10:diagnostics10121053. [PMID: 33291238 PMCID: PMC7762111 DOI: 10.3390/diagnostics10121053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) remains a serious illness with significant morbidity and mortality, characterized by hypoxemic respiratory failure most commonly due to pneumonia, sepsis, and aspiration. Early and accurate diagnosis of ARDS depends upon clinical suspicion and chest imaging. Coronavirus disease 2019 (COVID-19) is an important novel cause of ARDS with a distinct time course, imaging and laboratory features from the time of SARS-CoV-2 infection to hypoxemic respiratory failure, which may allow diagnosis and management prior to or at earlier stages of ARDS. Treatment of ARDS remains largely supportive, and consists of incremental respiratory support (high flow nasal oxygen, non-invasive respiratory support, and invasive mechanical ventilation), and avoidance of iatrogenic complications, all of which improve clinical outcomes. COVID-19-associated ARDS is largely similar to other causes of ARDS with respect to pathology and respiratory physiology, and as such, COVID-19 patients with hypoxemic respiratory failure should typically be managed as other patients with ARDS. Non-invasive respiratory support may be beneficial in avoiding intubation in COVID-19 respiratory failure including mild ARDS, especially under conditions of resource constraints or to avoid overwhelming critical care resources. Compared to other causes of ARDS, medical therapies may improve outcomes in COVID-19-associated ARDS, such as dexamethasone and remdesivir. Future improved clinical outcomes in ARDS of all causes depends upon individual patient physiological and biological endotyping in order to improve accuracy and timeliness of diagnosis as well as optimal targeting of future therapies in the right patient at the right time in their disease.
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10
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Esnault P, Hraiech S, Bordes J, Forel JM, Adda M, Rambaud R, Lehingue S, Roch A, Papazian L, Guervilly C. Evaluation of Almitrine Infusion During Veno-Venous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome in Adults. Anesth Analg 2020; 129:e48-e51. [PMID: 29337729 DOI: 10.1213/ane.0000000000002786] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This single-center case series investigated the effect of almitrine infusion on PaO2/fraction of inspired oxygen (FIO2) in 25 patients on veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. A positive trial was defined as an increase of PaO2/FIO2 ratio ≥20%. Thirty-two trials were performed. Twenty (62.5%, 95% confidence interval, 37.5%-75%) trials in 18 patients were positive, with a median PaO2/FIO2 ratio increase of 35% (25%-43%). A focal acute respiratory distress syndrome and inhaled nitric oxide therapy were more frequent in patients with a positive response to almitrine. We observed no complications of almitrine use.
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Affiliation(s)
- Pierre Esnault
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France.,Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France
| | - Sami Hraiech
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Julien Bordes
- Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France
| | - Jean-Marie Forel
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Mélanie Adda
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Romain Rambaud
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Samuel Lehingue
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Antoine Roch
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France.,Department of Emergency, Nord Hospital, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Laurent Papazian
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Christophe Guervilly
- From the Medical Intensive Care Unit, Respiratory Distress and Severe Infections, Nord Hospital, URMITE CNRS-UMR 6236, Aix-Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
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Crotti S, Bottino N, Spinelli E. Spontaneous breathing during veno-venous extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S661-S669. [PMID: 29732184 DOI: 10.21037/jtd.2017.10.27] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Veno-venous extracorporeal membrane oxygenation (VV ECMO) has started to be applied in awake spontaneously breathing patients as an alternative to invasive mechanical ventilation. As the physiologic cardiorespiratory variability is increased in this condition, the dynamic interaction between patient respiratory activity and extracorporeal system function affects the clinical management. The effect of extracorporeal CO2 removal on patient respiratory drive is variable and not always predictable, with some patients responding to CO2 removal with a decrease in respiratory rate and effort and other patients demonstrating a persistently high work of breathing independent on CO2 unload. While the pathophysiological mechanisms of this different interactions are still to be clarified, improved monitoring ability is needed both to titrate the support in responders and to avoid the risk of ventilation injury in non-responders. Acute changes in patient respiratory patterns may also occur during spontaneous breathing, making it difficult to maintain constant levels of extracorporeal respiratory support, also because changes in the distribution of venous blood volume due to lung-heart interactions affect extracorporeal blood flow. Assessment of native lung function and of its evolution over time is challenging while respiratory gas exchanges are provided by the extracorporeal system, since both oxygenation and decarboxylation capabilities can be fully evaluated only when alveolar ventilation is restored reducing extracorporeal CO2 removal. The rationale for using "awake ECMO" varies across different types of acute respiratory failure: the pathophysiological mechanisms of the underlying disease affect the patient-ECMO interaction and the goal of support. In this review we discuss the pathophysiology, technical challenges and monitoring issues of the use of ECMO in awake spontaneously breathing patients with acute respiratory failure of different etiologies.
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Affiliation(s)
- Stefania Crotti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Bottino
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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12
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Langer T, Santini A, Bottino N, Crotti S, Batchinsky AI, Pesenti A, Gattinoni L. "Awake" extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:150. [PMID: 27357690 PMCID: PMC4928342 DOI: 10.1186/s13054-016-1329-y] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/27/2016] [Indexed: 12/14/2022]
Abstract
Venovenous extracorporeal membrane oxygenation (vv-ECMO) has been classically employed as a rescue therapy for patients with respiratory failure not treatable with conventional mechanical ventilation alone. In recent years, however, the timing of ECMO initiation has been readdressed and ECMO is often started earlier in the time course of respiratory failure. Furthermore, some centers are starting to use ECMO as a first line of treatment, i.e., as an alternative to invasive mechanical ventilation in awake, non-intubated, spontaneously breathing patients with respiratory failure ("awake" ECMO). There is a strong rationale for this type of respiratory support as it avoids several side effects related to sedation, intubation, and mechanical ventilation. However, the complexity of the patient-ECMO interactions, the difficulties related to respiratory monitoring, and the management of an awake patient on extracorporeal support together pose a major challenge for the intensive care unit staff. Here, we review the use of vv-ECMO in awake, spontaneously breathing patients with respiratory failure, highlighting the pros and cons of this approach, analyzing the pathophysiology of patient-ECMO interactions, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.
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Affiliation(s)
- Thomas Langer
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
| | - Alessandro Santini
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Nicola Bottino
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Stefania Crotti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Andriy I Batchinsky
- The Geneva Foundation, Tacoma, WA, USA.,Multi Organ Support and Preservation Task Area, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas, USA
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.,Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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13
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Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. Intensive Care Med 2015; 42:862-870. [PMID: 26650055 DOI: 10.1007/s00134-015-4141-2] [Citation(s) in RCA: 292] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 11/04/2015] [Indexed: 02/07/2023]
Abstract
RATIONALE Increased right ventricle (RV) afterload during acute respiratory distress syndrome (ARDS) may induce acute cor pulmonale (ACP). OBJECTIVES To determine the prevalence and prognosis of ACP and build a clinical risk score for the early detection of ACP. METHODS This was a prospective study in which 752 patients with moderate-to-severe ARDS receiving protective ventilation were assessed using transesophageal echocardiography in 11 intensive care units. The study cohort was randomly split in a derivation (n = 502) and a validation (n = 250) cohort. MEASUREMENTS AND MAIN RESULTS ACP was defined as septal dyskinesia with a dilated RV [end-diastolic RV/left ventricle (LV) area ratio >0.6 (≥1 for severe dilatation)]. ACP was found in 164 of the 752 patients (prevalence of 22 %; 95 % confidence interval 19-25 %). In the derivation cohort, the ACP risk score included four variables [pneumonia as a cause of ARDS, driving pressure ≥18 cm H2O, arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio <150 mmHg, and arterial carbon dioxide partial pressure ≥48 mmHg]. The ACP risk score had a reasonable discrimination and a good calibration. Hospital mortality did not differ between patients with or without ACP, but it was significantly higher in patients with severe ACP than in the other patients [31/54 (57 %) vs. 291/698 (42 %); p = 0.03]. Independent risk factors for hospital mortality included severe ACP along with male gender, age, SAPS II, shock, PaO2/FiO2 ratio, respiratory rate, and driving pressure, while prone position was protective. CONCLUSIONS We report a 22 % prevalence of ACP and a poor outcome of severe ACP. We propose a simple clinical risk score for early identification of ACP that could trigger specific therapeutic strategies to reduce RV afterload.
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14
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Nieman GF, Gatto LA, Habashi NM. Reducing acute respiratory distress syndrome occurrence using mechanical ventilation. World J Respirol 2015; 5:188-198. [DOI: 10.5320/wjr.v5.i3.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023] Open
Abstract
The standard treatment for acute respiratory distress syndrome (ARDS) is supportive in the form of low tidal volume ventilation applied after significant lung injury has already developed. Nevertheless, ARDS mortality remains unacceptably high (> 40%). Indeed, once ARDS is established it becomes refractory to treatment, and therefore avoidance is key. However, preventive techniques and therapeutics to reduce the incidence of ARDS in patients at high-risk have not been validated clinically. This review discusses the current data suggesting that preemptive application of the properly adjusted mechanical breath can block progressive acute lung injury and significantly reduce the occurrence of ARDS.
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15
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Nieman GF, Gatto LA, Habashi NM. Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury. J Appl Physiol (1985) 2015; 119:1245-61. [PMID: 26472873 DOI: 10.1152/japplphysiol.00659.2015] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/01/2015] [Indexed: 02/08/2023] Open
Abstract
The earliest description of what is now known as the acute respiratory distress syndrome (ARDS) was a highly lethal double pneumonia. Ashbaugh and colleagues (Ashbaugh DG, Bigelow DB, Petty TL, Levine BE Lancet 2: 319-323, 1967) correctly identified the disease as ARDS in 1967. Their initial study showing the positive effect of mechanical ventilation with positive end-expiratory pressure (PEEP) on ARDS mortality was dampened when it was discovered that improperly used mechanical ventilation can cause a secondary ventilator-induced lung injury (VILI), thereby greatly exacerbating ARDS mortality. This Synthesis Report will review the pathophysiology of ARDS and VILI from a mechanical stress-strain perspective. Although inflammation is also an important component of VILI pathology, it is secondary to the mechanical damage caused by excessive strain. The mechanical breath will be deconstructed to show that multiple parameters that comprise the breath-airway pressure, flows, volumes, and the duration during which they are applied to each breath-are critical to lung injury and protection. Specifically, the mechanisms by which a properly set mechanical breath can reduce the development of excessive fluid flux and pulmonary edema, which are a hallmark of ARDS pathology, are reviewed. Using our knowledge of how multiple parameters in the mechanical breath affect lung physiology, the optimal combination of pressures, volumes, flows, and durations that should offer maximum lung protection are postulated.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York;
| | - Louis A Gatto
- Biological Sciences Department, State University of New York, Cortland, New York; and
| | - Nader M Habashi
- R Adams Cowley Shock/Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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16
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Tramm R, Ilic D, Davies AR, Pellegrino VA, Romero L, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev 2015; 1:CD010381. [PMID: 25608845 PMCID: PMC6353247 DOI: 10.1002/14651858.cd010381.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and returns blood from the venous system and provides non-pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump-driven and pump-free systems are in use. Use of ECMO is associated with several risks. Patient-related adverse events include haemorrhage or extremity ischaemia; circuit-related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain. OBJECTIVES The primary objective of this systematic review was to determine whether use of veno-venous (VV) or venous-arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting abstracts, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs and cluster-RCTs that compared adult ECMO versus conventional support. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of all retrieved citations against the inclusion criteria. We independently reviewed full-text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias. MAIN RESULTS We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all-cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health-related quality of life.In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non-brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.Clinical heterogeneity between studies prevented meta-analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest). AUTHORS' CONCLUSIONS Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta-analysis.We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.
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Affiliation(s)
- Ralph Tramm
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineLevel 6 The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Dragan Ilic
- Monash UniversityDepartment of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine553 St Kilda RoadMelbourneVictoriaAustralia3004
| | - Andrew R Davies
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineLevel 6 The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Vincent A Pellegrino
- The Alfred HospitalDepartment of Intensive CareCommercial RoadMelbourneAustralia3181
| | - Lorena Romero
- The Alfred HospitalThe Ian Potter Library55 Commercial RoadMelbourneVictoriaAustralia3000
| | - Carol Hodgson
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineLevel 6 The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
- The Alfred HospitalDepartment of PhysiotherapyMelbourneAustralia
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17
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Abstract
Acute respiratory distress syndrome (ARDS) is characterised by diffuse alveolar damage and is frequently complicated by pulmonary hypertension (PH). Multiple factors may contribute to the development of PH in this setting. In this review, we report the results of a systematic search of the available peer-reviewed literature for papers that measured indices of pulmonary haemodynamics in patients with ARDS and reported on mortality in the period 1977 to 2010. There were marked differences between studies, with some reporting strong associations between elevated pulmonary arterial pressure or elevated pulmonary vascular resistance and mortality, whereas others found no such association. In order to discuss the potential reasons for these discrepancies, we review the physiological concepts underlying the measurement of pulmonary haemodynamics and highlight key differences between the concepts of resistance in the pulmonary and systemic circulations. We consider the factors that influence pulmonary arterial pressure, both in normal lungs and in the presence of ARDS, including the important effects of mechanical ventilation. Pulmonary arterial pressure, pulmonary vascular resistance and transpulmonary gradient (TPG) depend not alone on the intrinsic properties of the pulmonary vascular bed but are also strongly influenced by cardiac output, airway pressures and lung volumes. The great variability in management strategies within and between studies means that no unified analysis of these papers was possible. Uniquely, Bull et al. (Am J Respir Crit Care Med 182:1123-1128, 2010) have recently reported that elevated pulmonary vascular resistance (PVR) and TPG were independently associated with increased mortality in ARDS, in a large trial with protocol-defined management strategies and using lung-protective ventilation. We then considered the existing literature to determine whether the relationship between PVR/TPG and outcome might be causal. Although we could identify potential mechanisms for such a link, the existing evidence does not allow firm conclusions to be drawn. Nonetheless, abnormally elevated PVR/TPG may provide a useful index of disease severity and progression. Further studies are required to understand the role and importance of pulmonary vascular dysfunction in ARDS in the era of lung-protective ventilation.
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18
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VIMLÁTI L, LARSSON A, HEDENSTIERNA G, LICHTWARCK-ASCHOFF M. Haemodynamic stability and pulmonary shunt during spontaneous breathing and mechanical ventilation in porcine lung collapse. Acta Anaesthesiol Scand 2012; 56:748-54. [PMID: 22524589 DOI: 10.1111/j.1399-6576.2012.02700.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND We investigated the haemodynamic stability of a novel porcine model of lung collapse induced by negative pressure application (NPA). A secondary aim was to study whether pulmonary shunt correlates with cardiac output (CO). METHODS In 12 anaesthetized and relaxed supine piglets, lung collapse was induced by NPA (-50 kPa). Six animals resumed spontaneous breathing (SB) after 15 min; the other six animals were kept on mechanical ventilation (MV) at respiratory rate and tidal volume (V(T) ) that corresponded to SB. All animals were followed for 135 min with blood gas analysis and detailed haemodynamic monitoring. RESULTS Haemodynamics and gas exchange were stable in both groups during the experiment with arterial oxygen tension (PaO(2) )/inspired fraction of oxygen (FiO(2) ) and pulmonary artery occlusion pressure being higher, venous admixture (Q(va) /Q(t) ) and pulmonary perfusion pressure being lower in the SB group. CO was similar in both groups, showing slight decrease over time in the SB group. During MV, Q(va) /Q(t) increased with CO (slope: 4.3 %min/l; P < 0.001), but not so during SB (slope: 0.55 %min/l; P = 0.16). CONCLUSIONS This porcine lung collapse model is reasonably stable in terms of haemodynamics for at least 2 h irrespective of the mode of ventilation. SB achieves higher PaO(2) /FiO(2) and lower Q(va) /Q(t) compared with MV. During SB, Q(va) /Q(t) seems to be less, if at all, affected by CO compared with MV.
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Affiliation(s)
- L. VIMLÁTI
- Department of Surgical Sciences; Anaesthesiology and Critical Care Medicine; Uppsala University; Uppsala; Sweden
| | - A. LARSSON
- Department of Surgical Sciences; Anaesthesiology and Critical Care Medicine; Uppsala University; Uppsala; Sweden
| | - G. HEDENSTIERNA
- Department of Medical Sciences; Clinical Physiology; Uppsala University; Uppsala; Sweden
| | - M. LICHTWARCK-ASCHOFF
- Department of Surgical Sciences; Anaesthesiology and Critical Care Medicine; Uppsala University; Uppsala; Sweden
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19
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Abstract
It has been known for more than 60 years, and suspected for over 100, that alveolar hypoxia causes pulmonary vasoconstriction by means of mechanisms local to the lung. For the last 20 years, it has been clear that the essential sensor, transduction, and effector mechanisms responsible for hypoxic pulmonary vasoconstriction (HPV) reside in the pulmonary arterial smooth muscle cell. The main focus of this review is the cellular and molecular work performed to clarify these intrinsic mechanisms and to determine how they are facilitated and inhibited by the extrinsic influences of other cells. Because the interaction of intrinsic and extrinsic mechanisms is likely to shape expression of HPV in vivo, we relate results obtained in cells to HPV in more intact preparations, such as intact and isolated lungs and isolated pulmonary vessels. Finally, we evaluate evidence regarding the contribution of HPV to the physiological and pathophysiological processes involved in the transition from fetal to neonatal life, pulmonary gas exchange, high-altitude pulmonary edema, and pulmonary hypertension. Although understanding of HPV has advanced significantly, major areas of ignorance and uncertainty await resolution.
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Affiliation(s)
- J. T. Sylvester
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
| | - Larissa A. Shimoda
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
| | - Philip I. Aaronson
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
| | - Jeremy P. T. Ward
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Division of Asthma, Allergy and Lung Biology, School of Medicine, King's College, London, United Kingdom
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20
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Strang CM, Freden F, Maripuu E, Ebmeyer U, Hachenberg T, Hedenstierna G. Improved ventilation-perfusion matching with increasing abdominal pressure during CO(2) -pneumoperitoneum in pigs. Acta Anaesthesiol Scand 2011; 55:887-96. [PMID: 21689075 DOI: 10.1111/j.1399-6576.2011.02464.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND CO(2) -pneumoperitoneum (PP) is performed at varying abdominal pressures. We studied in an animal preparation the effect of increasing abdominal pressures on gas exchange during PP. METHODS Eighteen anaesthetized pigs were studied. Three abdominal pressures (8, 12 and 16 mmHg) were randomly selected in each animal. In six pigs, single-photon emission computed tomography (SPECT) was used for the analysis of V/Q distributions; in another six pigs, multiple inert gas elimination technique (MIGET) was used for assessing V/Q matching. In further six pigs, computed tomography (CT) was performed for the analysis of regional aeration. MIGET, CT and central haemodynamics and pulmonary gas exchange were recorded during anaesthesia and after 60 min on each of the three abdominal pressures. SPECT was performed three times, corresponding to each PP level. RESULTS Atelectasis, as assessed by CT, increased during PP and in proportion to abdominal pressure [from 9 ± 2% (mean ± standard deviation) at 8 mmHg to 15 ± 2% at 16 mmHg, P<0.05]. SPECT during increasing abdominal CO(2) pressures showed a shift of blood flow towards better ventilated areas. V/Q analysis by MIGET showed no change in shunt during 8 mmHg PP (9 ± 1.9% compared with baseline 9 ± 1.2%) but a decrease during 12 mmHg PP (7 ± 0.9%, P<0.05) and 16 mmHg PP (5 ± 1%, P<0.01). PaO(2) increased from 39 ± 10 to 52 ± 9 kPa (baseline to 16 mmHg PP, P<0.01). Arterial carbon dioxide (PCO(2) ) increased during PP and increased further with increasing abdominal pressures. CONCLUSION With increasing abdominal pressure during PP perfusion was redistributed more than ventilation away from dorsal, collapsed lung regions. This resulted in a better V/Q match. A possible mechanism is enhanced hypoxic pulmonary vasoconstriction mediated by increasing PCO(2) .
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Affiliation(s)
- C M Strang
- Department of Medical Sciences, Clinical Physiology, University of Uppsala, Uppsala, Sweden
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21
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Strang CM, Fredén F, Maripuu E, Hachenberg T, Hedenstierna G. Ventilation-perfusion distributions and gas exchange during carbon dioxide-pneumoperitoneum in a porcine model. Br J Anaesth 2010; 105:691-7. [PMID: 20693177 DOI: 10.1093/bja/aeq211] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Carbon dioxide (CO₂)-pneumoperitoneum (PP) of 12 mm Hg increases arterial oxygenation, but it also promotes collapse of dependent lung regions. This seeming paradox prompted the present animal study on the effects of PP on ventilation-perfusion distribution (V/Q) and gas exchange. METHODS Fourteen anaesthetized pigs were studied. In seven pigs, single photon emission computed tomography (SPECT) was used for spatial analysis of ventilation and perfusion distributions, and in another seven pigs, multiple inert gas elimination technique (MIGET) was used for detailed analysis of V/Q matching. SPECT/MIGET and central haemodynamics and pulmonary gas exchange were recorded during anaesthesia before and 60 min after induction of PP. RESULTS SPECT during PP showed no or only poorly ventilated regions in the dependent lung compared with the ventilation distribution during anaesthesia before PP. PP was accompanied by redistribution of blood flow away from the non- or poorly ventilated regions. V/Q analysis by MIGET showed decreased shunt from 9 (sd 2) to 7 (2)% after induction of PP (P<0.05). No regions of low V/Q were seen either before or during PP. Almost no regions of high V/Q developed during PP (1% of total ventilation). Pa(o₂) increased from 33 (1.2) to 35.7 (3.2) kPa (P<0.01) and arterial to end-tidal Pco₂ gradient (Pae'(co₂) increased from 0.3 (0.1) to 0.6 (0.2) kPa (P<0.05). CONCLUSIONS Perfusion was redistributed away from dorsal, collapsed lung regions when PP was established. This resulted in a better V/Q match. A possible mechanism is enhanced hypoxic pulmonary vasoconstriction.
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Affiliation(s)
- C M Strang
- Department of Medical Sciences and Clinical Physiology, Uppsala University, Sweden
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Falcucci OA, Kasirajan V, Green JA. Transesophageal echocardiographic and oxymetric evidence of intraoperative reversal of flow through a patent foramen ovale during an off-pump coronary artery bypass grafting. J Clin Anesth 2005; 17:617-20. [PMID: 16427533 DOI: 10.1016/j.jclinane.2005.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Accepted: 01/17/2005] [Indexed: 11/23/2022]
Abstract
Mechanical stabilization of target coronary arteries in the beating heart has facilitated the practice of "off-pump" coronary artery bypass grafting. Exposing the target coronary artery for stabilization involves maneuvers that frequently cause hemodynamic alterations including decreased cardiac output and increased pulmonary artery and/or central venous pressures (CVP). The presence of a patent foramen ovale (PFO) in the setting of increased CVP may produce a right-to-left shunt through the PFO. We report a case of a patient undergoing off-pump coronary artery bypass grafting with a PFO with a left to right atrium shunt flow of 307 mL/min. During manipulation and elevation of the heart to expose the target vessel, the CVP increased from 15 to 30 mm Hg and the shunt through the PFO reversed direction, going from right to left atrium with a flow of 161 mL/min. Mixed venous oxygen saturation and the calculated shunt fraction decreased from 84% to 78% and 14% to 10%, respectively. All parameters returned to normal after the heart was lowered back inside the chest.
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Affiliation(s)
- Octavio A Falcucci
- Department of Anesthesiology, Virginia Commonwealth University, Box 980695, Richmond, VA 23298, USA.
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Kerbaul F, Rondelet B, Collart F, Naeije R, Gouin F. Hypertension artérielle pulmonaire en anesthésie–réanimation. ACTA ACUST UNITED AC 2005; 24:528-40. [PMID: 15904732 DOI: 10.1016/j.annfar.2005.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2004] [Accepted: 02/22/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review the perioperative anaesthetic management of pulmonary arterial hypertension. DATA SOURCES Extraction from Pubmed database of French and English articles on the perioperative anaesthetic management of pulmonary hypertension for 9 years. DATA SELECTION The collected articles were reviewed and selected according their quality and originality. The more recent data were selected. DATA SYNTHESIS Pulmonary arterial hypertension is classically divided in primary and secondary. Primary pulmonary hypertension (familial and sporadic) is relatively severe and rare. Muscularization of the terminal portion of the pulmonary vascular arterial tree, caused by smooth muscle cell hyperplasia is the first change. Pulmonary arterial hypertension linked with disorders of the respiratory system and hypoxemia or pulmonary venous hypertension including mitral valve disease and chronic left ventricular dysfunction are often associated with high morbidity and mortality. The main consequence of pulmonary hypertension development is the occurrence of right-sided circulatory failure. A better understanding of disease pathophysiology will contribute to the development of new therapies increasing then the prognosis of these patients. The management of primary pulmonary hypertension or secondary pulmonary arterial hypertension is a challenge for the anaesthesiologist because the risk of right ventricular failure is markedly increased.
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MESH Headings
- Anesthesia/methods
- Anesthetics/pharmacology
- Case Management
- Critical Care/methods
- Echocardiography, Doppler
- Heart Failure/etiology
- Humans
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/therapy
- Intraoperative Complications/prevention & control
- Intraoperative Complications/therapy
- Middle Aged
- Mitral Valve Insufficiency/complications
- Mitral Valve Insufficiency/physiopathology
- Nitric Oxide/physiology
- Oxygen/administration & dosage
- Oxygen/therapeutic use
- Preanesthetic Medication
- Pulmonary Circulation/drug effects
- Pulmonary Disease, Chronic Obstructive/complications
- Respiration, Artificial/methods
- Vascular Resistance
- Vasodilator Agents/pharmacology
- Vasodilator Agents/therapeutic use
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Right/etiology
- Ventricular Function, Left/drug effects
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Affiliation(s)
- F Kerbaul
- Département d'anesthésie-réanimation adultes, CHU de La Timone, 126 rue saint-Pierre, 13385 Marseille cedex 5, France.
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Heinonen E, Hedenstierna G, Meriläinen P, Högman M, Nyman G. Pulsed delivery of nitric oxide counteracts hypoxaemia in the anaesthetized horse. Vet Anaesth Analg 2001; 28:3-11. [DOI: 10.1046/j.1467-2987.2000.00035.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2000] [Accepted: 06/19/2000] [Indexed: 11/20/2022]
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Mols G, Loop T, Geiger K, Farthmann E, Benzing A. Extracorporeal membrane oxygenation: a ten-year experience. Am J Surg 2000; 180:144-54. [PMID: 11044532 DOI: 10.1016/s0002-9610(00)00432-3] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a supportive therapy used for severe acute respiratory distress syndrome (ARDS). We present outcome, clinical parameters, and complications in a cohort of 245 ARDS patients of whom 62 were treated with ECMO. METHODS Data of all ARDS patients were prospectively collected between 1991 and 1999. Outcome and clinical parameters of patients treated with and without ECMO were evaluated. RESULTS One hundred thirty-eight patients were referred from other hospitals, 107 were primarily located in our hospital. About one fourth of these patients were treated with ECMO. The survival rate was 55% in ECMO patients and 61% in non-ECMO patients. CONCLUSIONS ECMO is a therapeutic option for patients with severe ARDS, likely to increase survival. However, a randomized controlled study proving its benefit is still awaited. Until the development of a causal or otherwise superior therapy ECMO should be used in selected patients.
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Affiliation(s)
- G Mols
- Department of Anesthesiology and Critical Care Medicine, University of Freiburg, Freiburg, Germany
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Meyer J, Booke M. Inhaled vasodilator therapy for treatment of acute lung injury. Curr Opin Anaesthesiol 1999; 12:143-7. [PMID: 17013305 DOI: 10.1097/00001503-199904000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In randomized controlled trials, inhaled nitric oxide failed to provide significant clinical benefit in patients with acute lung injury. Despite temporary improvement in oxygenation, inhaled nitric oxide neither improved survival, nor decreased length of mechanical ventilation. Thus, with the exception of severe hypoxaemia refractory to conventional therapy, inhaled nitric oxide is not indicated in patients with acute lung injury. Inhalation of prostacyclin and prostaglandin E1, respectively, has been associated with an improvement in oxygenation and a decrease in pulmonary artery pressure. Prospective randomized trials are warranted to assess the impact of inhaled prostaglandins on the outcome of patients with acute lung injury.
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Affiliation(s)
- J Meyer
- Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Westfälische Wilhelms-Universität Münster, Münster, Germany.
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Abstract
Hypoxic pulmonary vasoconstriction is a local reflex in the lung that diverts blood away from poorly oxygenated regions. Improvements in understanding of modulators of this response have led to pharmacologic methods whereby V/Q matching may potentially be improved in certain types of pulmonary pathology and during anesthesia for thoracic surgical procedures.
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Affiliation(s)
- J B Eisenkraft
- Department of Anesthesiology, The Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1010, New York, NY 10029-6574, USA.
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Gallart L, Lu Q, Puybasset L, Umamaheswara Rao GS, Coriat P, Rouby JJ. Intravenous almitrine combined with inhaled nitric oxide for acute respiratory distress syndrome. The NO Almitrine Study Group. Am J Respir Crit Care Med 1998; 158:1770-7. [PMID: 9847266 DOI: 10.1164/ajrccm.158.6.9804066] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Inhaled nitric oxide (iNO), a selective pulmonary vasodilator and intravenously administered almitrine, a selective pulmonary vasoconstrictor, have been shown to increase PaO2 in patients with acute respiratory distress syndrome (ARDS). This prospective study was undertaken to assess the cardiopulmonary effects of combining both drugs. In 48 consecutive patients with early ARDS, cardiorespiratory parameters were measured at control, after iNO 5 ppm, after almitrine 4 micrograms. kg-1. min-1, and after the combination of both drugs. In 30 patients, dose response to 2, 4, and 16 micrograms. kg-1. min-1 of almitrine with and without NO was determined. Almitrine and lactate plasma concentrations were measured in 17 patients. Using pure O2, PaO2 increased by 75 +/- 8 mm Hg after iNO, by 101 +/- 12 mm Hg after almitrine 4 micrograms. kg-1. min-1, and by 175 +/- 18 mm Hg after almitrine combined with iNO (p < 0.001). In 63% of the patients, PaO2 increased by more than 100% with the combination of both drugs. Mean pulmonary artery pressure (Ppa) increased by 1.4 +/- 0.2 mm Hg with almitrine 4 micrograms/kg/ min (p < 0.001) and decreased by 3.4 +/- 0.4 mm Hg with iNO and by 1.5 +/- 0.3 mm Hg with the combination (p < 0.001). The maximum increase in PaO2 was obtained at almitrine concentrations <= 4 micrograms. kg-1. min-1, whereas almitrine increased Ppa dose-dependently. Almitrine plasma concentrations also increased dose-dependently and returned to values close to zero after 12 h. In many patients with early ARDS, the combination of iNO 5 ppm and almitrine 4 micrograms. kg-1. min-1 dramatically increases PaO2 without apparent deleterious effect allowing a rapid reduction in inspired fraction of O2. The long-term consequences of this immediate beneficial effect remain to be determined.
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Affiliation(s)
- L Gallart
- Unité de Réanimation Chirurgicale (Department of Anesthesiology), Hôpital de la Pitié-Salpétrière, University of Paris VI, France
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Ozaki M, Marshall C, Amaki Y, Marshall BE. Role of wall tension in hypoxic responses of isolated rat pulmonary arteries. THE AMERICAN JOURNAL OF PHYSIOLOGY 1998; 275:L1069-77. [PMID: 9843843 DOI: 10.1152/ajplung.1998.275.6.l1069] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The changes in force developed during 40-min exposures to hypoxia (37 +/- 1 mmHg) were recorded in large (0.84 +/- 0.02-mm-diameter) and small (0.39 +/- 0.01-mm-diameter) intrapulmonary arteries during combinations of mechanical wall stretch tensions (passive + active myogenic components), equivalent to transmural vascular pressures of 5, 15, 30, 50, and 100 mmHg, and active (vasoconstriction) tensions, stimulated by PGF2alpha in doses of 0, 25, 50, and 75% effective concentrations. Constriction was observed in all arteries during the first minute; however, at any active tension, the pattern of the subsequent response was a function of the stretch tension. At 5, 15, and 30 mmHg, the constriction decreased slightly at 5 min and then increased again to remain constrictor throughout. At 50 and 100 mmHg, the initial constriction was followed by persistent dilation. Hypoxic constrictor responses, most resembling those observed in lungs in vivo and in vitro, were observed when the mechanical stretch wall tension was equivalent to 15 or 30 mmHg and the dose of PGF2alpha was 25 or 50% effective concentration. These observations reconcile many apparently contradictory results reported previously.
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Affiliation(s)
- M Ozaki
- Department of Anesthesia, Jikei University School of Medicine, Tokyo 105-8461, Japan
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Abstract
Vasodilators that affect the pulmonary vasculature are appealing adjuncts in many cardiopulmonary conditions that require mechanical ventilation such as ARDS, COPD, PPHN, and cardiothoracic surgery. The adverse systemic effects of parenteral PGE1 and parenteral prostacyclin limit their usefulness in critically ill patients. Liposomal PGE1 has few systemic effects, but thus far has not resulted in a significant clinical benefit in patients with ARDS. Inhaled NO and aerosolized prostacyclin offer the advantage of selective pulmonary vasodilation with minimal systemic effects. Both agents decrease PAP and in many clinical situations improve oxygenation; however, the physiologic effects of inhaled NO and aerosolized prostacyclin have not convincingly led to improved clinical outcomes. Currently, use of vasodilators in mechanically ventilated patients remains investigational.
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