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Rostamzadeh S, Allafasghari A, Allafasghari A, Abouhossein A. Handgrip strength as a prognostic factor for COVID-19 mortality among older adult patients admitted to the intensive care unit (ICU): a comparison Alpha (B.1.1.7) and Delta (B.1.617.2) variants. Sci Rep 2024; 14:19927. [PMID: 39198687 PMCID: PMC11358457 DOI: 10.1038/s41598-024-71034-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 08/23/2024] [Indexed: 09/01/2024] Open
Abstract
Handgrip strength (HGS) is a non-invasive and reliable biomarker of overall health, physical function, mobility, and mortality. This study aimed to investigate the possible relationship between HGS and mortality in older adult patients hospitalized with COVID-19 in the intensive care unit (ICU) by Alpha (B.1.1.7) and Delta (B.1.617.2) variants. This retrospective cohort study was conducted on 472 COVID-19 patients (222 female and 250 male) aged 60-85 years admitted to the ICU. Demographic data, underlying comorbidities, COVID-19-related symptoms, as well as laboratory and computed tomography (CT) findings were obtained from the patient's medical records. Using a JAMAR® hydraulic dynamometer, the average grip strength value (kg) after three measurements on the dominant side was recorded for subsequent analysis. Low grip strength (LGS) was defined as an arbitrary cut-off of two standard deviations below the gender-specific peak mean value of normative HGS in Iranian healthy population, i.e. < 26 kg in males and < 14 kg in females. The findings showed lower mean grip strength and high frequency of LGS in the non-survivors patients versus survivors group and in the Delta (B.1.617.2) variant vs. Alpha (B.1.1.7) variant, respectively (both p < 0.01). The binary logistic regression analysis showed that chronic obstructive pulmonary disease (COPD) (adjusted odds ratio [OR] 5.125, 95% CI 1.425-25.330), LGS (OR 4.805, 95% CI 1.624-10.776), SaO2 (OR - 3.501, 95% CI 2.452-1.268), C-reactive protein (CRP) level (OR 2.625, 95% CI 1.256-7.356), and age (OR 1.118, 95% CI 1.045-1.092) were found to be independent predictors for mortality of patients with Alpha (B.1.1.7) variant (all p < 0.05). However, only four independent predictors including COPD (OR 6.728, 95% CI 1.683-28.635), LGS (OR 5.405, 95% CI 1.461-11.768), SaO2 (OR - 4.120, 95% CI 2.924-1.428), and CRP level (OR 1.893, 95% CI 1.127-8.692) can be predicted the mortality of patients with Delta (B.1.617.2) variant (p < 0.05). Along with the well-known and common risk factors (i.e. COPD, CRP, and SaO2), handgrip strength can be a quick and low-cost prognostic tool in predicting chances of mortality in older adults who are afflicted with COVID-19 variants.
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Affiliation(s)
- Sajjad Rostamzadeh
- Department of Ergonomics, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atabak Allafasghari
- Department of Health, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Amin Allafasghari
- Department of Health, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Alireza Abouhossein
- Department of Ergonomics, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Boesing C, Krebs J, Conrad AM, Otto M, Beck G, Thiel M, Rocco PRM, Luecke T, Schaefer L. Effects of prone positioning on lung mechanical power components in patients with acute respiratory distress syndrome: a physiologic study. Crit Care 2024; 28:82. [PMID: 38491457 PMCID: PMC10941550 DOI: 10.1186/s13054-024-04867-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Prone positioning (PP) homogenizes ventilation distribution and may limit ventilator-induced lung injury (VILI) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The static and dynamic components of ventilation that may cause VILI have been aggregated in mechanical power, considered a unifying driver of VILI. PP may affect mechanical power components differently due to changes in respiratory mechanics; however, the effects of PP on lung mechanical power components are unclear. This study aimed to compare the following parameters during supine positioning (SP) and PP: lung total elastic power and its components (elastic static power and elastic dynamic power) and these variables normalized to end-expiratory lung volume (EELV). METHODS This prospective physiologic study included 55 patients with moderate to severe ARDS. Lung total elastic power and its static and dynamic components were compared during SP and PP using an esophageal pressure-guided ventilation strategy. In SP, the esophageal pressure-guided ventilation strategy was further compared with an oxygenation-guided ventilation strategy defined as baseline SP. The primary endpoint was the effect of PP on lung total elastic power non-normalized and normalized to EELV. Secondary endpoints were the effects of PP and ventilation strategies on lung elastic static and dynamic power components non-normalized and normalized to EELV, respiratory mechanics, gas exchange, and hemodynamic parameters. RESULTS Lung total elastic power (median [interquartile range]) was lower during PP compared with SP (6.7 [4.9-10.6] versus 11.0 [6.6-14.8] J/min; P < 0.001) non-normalized and normalized to EELV (3.2 [2.1-5.0] versus 5.3 [3.3-7.5] J/min/L; P < 0.001). Comparing PP with SP, transpulmonary pressures and EELV did not significantly differ despite lower positive end-expiratory pressure and plateau airway pressure, thereby reducing non-normalized and normalized lung elastic static power in PP. PP improved gas exchange, cardiac output, and increased oxygen delivery compared with SP. CONCLUSIONS In patients with moderate to severe ARDS, PP reduced lung total elastic and elastic static power compared with SP regardless of EELV normalization because comparable transpulmonary pressures and EELV were achieved at lower airway pressures. This resulted in improved gas exchange, hemodynamics, and oxygen delivery. TRIAL REGISTRATION German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://drks.de/search/en/trial/DRKS00017449.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Alice Marguerite Conrad
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Matthias Otto
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Grietje Beck
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Liu Y, Cai X, Fang R, Peng S, Luo W, Du X. Future directions in ventilator-induced lung injury associated cognitive impairment: a new sight. Front Physiol 2023; 14:1308252. [PMID: 38164198 PMCID: PMC10757930 DOI: 10.3389/fphys.2023.1308252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024] Open
Abstract
Mechanical ventilation is a widely used short-term life support technique, but an accompanying adverse consequence can be pulmonary damage which is called ventilator-induced lung injury (VILI). Mechanical ventilation can potentially affect the central nervous system and lead to long-term cognitive impairment. In recent years, many studies revealed that VILI, as a common lung injury, may be involved in the central pathogenesis of cognitive impairment by inducing hypoxia, inflammation, and changes in neural pathways. In addition, VILI has received attention in affecting the treatment of cognitive impairment and provides new insights into individualized therapy. The combination of lung protective ventilation and drug therapy can overcome the inevitable problems of poor prognosis from a new perspective. In this review, we summarized VILI and non-VILI factors as risk factors for cognitive impairment and concluded the latest mechanisms. Moreover, we retrospectively explored the role of improving VILI in cognitive impairment treatment. This work contributes to a better understanding of the pathogenesis of VILI-induced cognitive impairment and may provide future direction for the treatment and prognosis of cognitive impairment.
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Affiliation(s)
- Yinuo Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Xintong Cai
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Ruiying Fang
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Shengliang Peng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wei Luo
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Du
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Souza ABF, Diedrich Y, Machado-Junior PA, Castro TDF, Lopes LSE, Cardoso JMDO, Roatt BM, Cangussú SD, de Menezes RCA, Bezerra FS. Exogenous surfactant reduces inflammation and redox imbalance in rats under prone or supine mechanical ventilation. Exp Biol Med (Maywood) 2023; 248:1074-1084. [PMID: 37092748 PMCID: PMC10581162 DOI: 10.1177/15353702231160352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/12/2023] [Indexed: 04/25/2023] Open
Abstract
Mechanical ventilation (MV) is a lifesaving therapy for patients with acute or chronic respiratory failure. Despite, it can also cause lung injury by inducing or worsening inflammatory responses and oxidative stress. Several clinical approaches have protective effects on the lungs, including the prone position and exogenous surfactant; however, few studies have evaluated the association between the two strategies, especially in individuals without previous lung injury. We tested the hypothesis that the effects of the homogenization in lung aeration caused by the prone position in association with the anti-inflammatory properties of exogenous surfactant pre-treatment could have a cumulative protective effect against ventilator-induced lung injury. Therefore, Wistar rats were divided into four experimental groups: Mechanical Ventilation in Supine Position (MVSP), Mechanical Ventilation in Prone position (MVPP), Mechanical Ventilation in Supine Position + surfactant (MVSPS), and Mechanical Ventilation in Prone Position + Surfactant (MVPPS). The intranasal instillation of a porcine surfactant (Curosurf®) was performed in the animals of MVSPS and MVPPS 1 h before the MV, all the rats were subjected to MV for 1 h. The prone position in association with surfactant decreased mRNA expression levels of pro-inflammatory cytokines in ventilated animals compared to the supine position; in addition, the NfκB was lower in MVPP, MVSPS and MVPPS when compared to MVSP. However, it had no effects on oxidative stress caused by MV. Pre-treatment with exogenous surfactant was more efficient in promoting lung protection than the prone position, as it also reduced oxidative damage in the lung parenchyma. Nevertheless, the surfactant did not cause additional improvements in most parameters that were also improved by the prone position. Our results indicate that the pre-treatment with exogenous surfactant, regardless of the position adopted in mechanical ventilation, preserves the original lung histoarchitecture, reduces redox imbalance, and reduces acute inflammatory responses caused by mechanical ventilation in healthy adult Wistar rats.
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Affiliation(s)
- Ana Beatriz Farias Souza
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI) and Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto, MG 35400-000, Brazil
| | - Yannick Diedrich
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI) and Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto, MG 35400-000, Brazil
- HZ University of Applied Sciences, 4382 Vlissingen, The Netherlands
| | - Pedro Alves Machado-Junior
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI) and Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto, MG 35400-000, Brazil
| | - Thalles de Freitas Castro
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI) and Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto, MG 35400-000, Brazil
| | - Leonardo Spinelli Estevão Lopes
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI) and Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto, MG 35400-000, Brazil
| | - Jamille Mirelle de Oliveira Cardoso
- Immunopathology Laboratory (LIMP), Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto 35400-000, Brazil
| | - Bruno Mendes Roatt
- Immunopathology Laboratory (LIMP), Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto 35400-000, Brazil
| | - Sílvia Dantas Cangussú
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI) and Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto, MG 35400-000, Brazil
| | - Rodrigo Cunha Alvim de Menezes
- Laboratory of Cardiovascular Physiology, Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto 35400-000, Brazil
| | - Frank Silva Bezerra
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI) and Center of Research in Biological Sciences (NUPEB), Federal University of Ouro Preto (UFOP), Ouro Preto, MG 35400-000, Brazil
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Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2023; 11:197-212. [PMID: 36566767 PMCID: PMC10880453 DOI: 10.1016/s2213-2600(22)00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous clinical syndrome that is associated with high rates of mortality and long-term morbidity. Factors that distinguish PARDS from adult acute respiratory distress syndrome (ARDS) include changes in developmental stage and lung maturation with age, precipitating factors, and comorbidities. No specific treatment is available for PARDS and management is largely supportive, but methods to identify patients who would benefit from specific ventilation strategies or ancillary treatments, such as prone positioning, are needed. Understanding of the clinical and biological heterogeneity of PARDS, and of differences in clinical features and clinical course, pathobiology, response to treatment, and outcomes between PARDS and adult ARDS, will be key to the development of novel preventive and therapeutic strategies and a precision medicine approach to care. Studies in which clinical, biomarker, and transcriptomic data, as well as informatics, are used to unpack the biological and phenotypic heterogeneity of PARDS, and implementation of methods to better identify patients with PARDS, including methods to rapidly identify subphenotypes and endotypes at the point of care, will drive progress on the path to precision medicine.
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Affiliation(s)
- Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Critical Care, Anaesthesiology, Peri-operative and Emergency Medicine, University of Groningen, Groningen, Netherlands.
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert G T Blokpoel
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Mary K Dahmer
- Department of Pediatrics, Division of Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte Justine, Université de Montréal, Montreal, QC, Canada
| | - Jocelyn Grunwell
- Department of Pediatrics, Division of Critical Care, Emory University, Atlanta, GA, USA
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Bhushan H Katira
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Yolanda M Lopez-Fernandez
- Pediatric Intensive Care Unit, Department of Pediatrics, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute, Bizkaia, Spain
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics (Critical Care), Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Northwestern University Feinberg School of Medicine and Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
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Gattinoni L, Brusatori S, D’Albo R, Maj R, Velati M, Zinnato C, Gattarello S, Lombardo F, Fratti I, Romitti F, Saager L, Camporota L, Busana M. Prone position: how understanding and clinical application of a technique progress with time. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:3. [PMCID: PMC9995262 DOI: 10.1007/s44254-022-00002-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Historical background The prone position was first proposed on theoretical background in 1974 (more advantageous distribution of mechanical ventilation). The first clinical report on 5 ARDS patients in 1976 showed remarkable improvement of oxygenation after pronation. Pathophysiology The findings in CT scans enhanced the use of prone position in ARDS patients. The main mechanism of the improved gas exchange seen in the prone position is nowadays attributed to a dorsal ventilatory recruitment, with a substantially unchanged distribution of perfusion. Regardless of the gas exchange, the primary effect of the prone position is a more homogenous distribution of ventilation, stress and strain, with similar size of pulmonary units in dorsal and ventral regions. In contrast, in the supine position the ventral regions are more expanded compared with the dorsal regions, which leads to greater ventral stress and strain, induced by mechanical ventilation. Outcome in ARDS The number of clinical studies paralleled the evolution of the pathophysiological understanding. The first two clinical trials in 2001 and 2004 were based on the hypothesis that better oxygenation would lead to a better survival and the studies were more focused on gas exchange than on lung mechanics. The equations better oxygenation = better survival was disproved by these and other larger trials (ARMA trial). However, the first studies provided signals that some survival advantages were possible in a more severe ARDS, where both oxygenation and lung mechanics were impaired. The PROSEVA trial finally showed the benefits of prone position on mortality supporting the thesis that the clinical advantages of prone position, instead of improved gas exchange, were mainly due to a less harmful mechanical ventilation and better distribution of stress and strain. In less severe ARDS, in spite of a better gas exchange, reduced mechanical stress and strain, and improved oxygenation, prone position was ineffective on outcome. Prone position and COVID-19 The mechanisms of oxygenation impairment in early COVID-19 are different than in typical ARDS and relate more on perfusion alteration than on alveolar consolidation/collapse, which are minimal in the early phase. Bronchial shunt may also contribute to the early COVID-19 hypoxemia. Therefore, in this phase, the oxygenation improvement in prone position is due to a better matching of local ventilation and perfusion, primarily caused by the perfusion component. Unfortunately, the conditions for improved outcomes, i.e. a better distribution of stress and strain, are almost absent in this phase of COVID-19 disease, as the lung parenchyma is nearly fully inflated. Due to some contradictory results, further studies are needed to better investigate the effect of prone position on outcome in COVID-19 patients. Graphical Abstract ![]()
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | | | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
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Protti A, Santini A, Pennati F, Chiurazzi C, Ferrari M, Iapichino GE, Carenzo L, Dalla Corte F, Lanza E, Martinetti N, Aliverti A, Cecconi M. Lung response to prone positioning in mechanically-ventilated patients with COVID-19. Crit Care 2022; 26:127. [PMID: 35526009 PMCID: PMC9076814 DOI: 10.1186/s13054-022-03996-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/23/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Prone positioning improves survival in moderate-to-severe acute respiratory distress syndrome (ARDS) unrelated to the novel coronavirus disease (COVID-19). This benefit is probably mediated by a decrease in alveolar collapse and hyperinflation and a more homogeneous distribution of lung aeration, with fewer harms from mechanical ventilation. In this preliminary physiological study we aimed to verify whether prone positioning causes analogue changes in lung aeration in COVID-19. A positive result would support prone positioning even in this other population. METHODS Fifteen mechanically-ventilated patients with COVID-19 underwent a lung computed tomography in the supine and prone position with a constant positive end-expiratory pressure (PEEP) within three days of endotracheal intubation. Using quantitative analysis, we measured the volume of the non-aerated, poorly-aerated, well-aerated, and over-aerated compartments and the gas-to-tissue ratio of the ten vertical levels of the lung. In addition, we expressed the heterogeneity of lung aeration with the standardized median absolute deviation of the ten vertical gas-to-tissue ratios, with lower values indicating less heterogeneity. RESULTS By the time of the study, PEEP was 12 (10-14) cmH2O and the PaO2:FiO2 107 (84-173) mmHg in the supine position. With prone positioning, the volume of the non-aerated compartment decreased by 82 (26-147) ml, of the poorly-aerated compartment increased by 82 (53-174) ml, of the normally-aerated compartment did not significantly change, and of the over-aerated compartment decreased by 28 (11-186) ml. In eight (53%) patients, the volume of the over-aerated compartment decreased more than the volume of the non-aerated compartment. The gas-to-tissue ratio of the ten vertical levels of the lung decreased by 0.34 (0.25-0.49) ml/g per level in the supine position and by 0.03 (- 0.11 to 0.14) ml/g in the prone position (p < 0.001). The standardized median absolute deviation of the gas-to-tissue ratios of those ten levels decreased in all patients, from 0.55 (0.50-0.71) to 0.20 (0.14-0.27) (p < 0.001). CONCLUSIONS In fifteen patients with COVID-19, prone positioning decreased alveolar collapse, hyperinflation, and homogenized lung aeration. A similar response has been observed in other ARDS, where prone positioning improves outcome. Therefore, our data provide a pathophysiological rationale to support prone positioning even in COVID-19.
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Affiliation(s)
- Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Chiara Chiurazzi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Michele Ferrari
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giacomo E Iapichino
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Dalla Corte
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ezio Lanza
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Boesing C, Graf PT, Schmitt F, Thiel M, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study. Crit Care 2022; 26:82. [PMID: 35346325 PMCID: PMC8962042 DOI: 10.1186/s13054-022-03956-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/19/2022] [Indexed: 01/01/2023] Open
Abstract
Background Prone positioning in combination with the application of low tidal volume and adequate positive end-expiratory pressure (PEEP) improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the effects of PEEP on end-expiratory transpulmonary pressure (Ptpexp) during prone positioning require clarification. For this purpose, the effects of three different PEEP titration strategies on Ptpexp, respiratory mechanics, mechanical power, gas exchange, and hemodynamics were evaluated comparing supine and prone positioning. Methods In forty consecutive patients with moderate to severe ARDS protective ventilation with PEEP titrated according to three different titration strategies was evaluated during supine and prone positioning: (A) ARDS Network recommendations (PEEPARDSNetwork), (B) the lowest static elastance of the respiratory system (PEEPEstat,RS), and (C) targeting a positive Ptpexp (PEEPPtpexp). The primary endpoint was to analyze whether Ptpexp differed significantly according to PEEP titration strategy during supine and prone positioning. Results Ptpexp increased progressively with prone positioning compared with supine positioning as well as with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork (positioning effect p < 0.001, PEEP strategy effect p < 0.001). PEEP was lower during prone positioning with PEEPEstat,RS and PEEPPtpexp (positioning effect p < 0.001, PEEP strategy effect p < 0.001). During supine positioning, mechanical power increased progressively with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork, and prone positioning attenuated this effect (positioning effect p < 0.001, PEEP strategy effect p < 0.001). Prone compared with supine positioning significantly improved oxygenation (positioning effect p < 0.001, PEEP strategy effect p < 0.001) while hemodynamics remained stable in both positions. Conclusions Prone positioning increased transpulmonary pressures while improving oxygenation and hemodynamics in patients with moderate to severe ARDS when PEEP was titrated according to the ARDS Network lower PEEP table. This PEEP titration strategy minimized parameters associated with ventilator-induced lung injury induction, such as transpulmonary driving pressure and mechanical power. We propose that a lower PEEP strategy (PEEPARDSNetwork) in combination with prone positioning may be part of a lung protective ventilation strategy in patients with moderate to severe ARDS. Trial registration German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03956-8.
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9
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Yildirim M, Halacli B, Pektezel MY, Er B, Geldigitti IT, Tok G, Ersoy EO, Topeli A. Comparison of critically ill COVID-19 and influenza patients with acute respiratory failure. Acute Crit Care 2022; 37:168-176. [PMID: 35280038 PMCID: PMC9184989 DOI: 10.4266/acc.2021.00920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/27/2021] [Indexed: 01/08/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) is one of the biggest pandemic causing acute respiratory failure (ARF) in the last century. Seasonal influenza carries high mortality, as well. The aim of this study was to compare features and outcomes of critically-ill COVID-19 and influenza patients with ARF. Methods Patients with COVID-19 and influenza admitted to intensive care unit with ARF were retrospectively analyzed. Results Fifty-four COVID-19 and 55 influenza patients with ARF were studied. Patients with COVID-19 had 32% of hospital mortality, while those with influenza had 47% (P=0.09). Patients with influenza had higher Eastern Cooperative Oncology Group, Clinical Frailty Scale, Acute Physiology and Chronic Health Evaluation II and admission Sequential Organ Failure Assessment (SOFA) scores than COVID-19 patients (P<0.01). Secondary bacterial infection, admission acute kidney injury, procalcitonin level above 0.2 ng/ml were the independent factors distinguishing influenza from COVID-19 while prone positioning differentiated COVID-19 from influenza. Invasive mechanical ventilation (odds ratio [OR], 42.16; 95% confidence interval [CI], 9.45–187.97), admission SOFA score more than 4 (OR, 5.92; 95% CI, 1.85–18.92), malignancy (OR, 4.95; 95% CI, 1.13–21.60), and age more than 65 years (OR, 3.31; 95% CI, 0.99–11.03) were found to be independent risk factors for hospital mortality. Conclusions There were few differences in clinical features of critically-ill COVID-19 and influenza patients. Influenza cases had worse performance status and disease severity. There was no significant difference in hospital mortality rates between COVID-19 and influenza patients.
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Affiliation(s)
- Mehmet Yildirim
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Burcin Halacli
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Yasir Pektezel
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Berrin Er
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ismail Tuna Geldigitti
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gulay Tok
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Ortac Ersoy
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Arzu Topeli
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
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10
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Katira BH, Osada K, Engelberts D, Bastia L, Damiani LF, Li X, Chan H, Yoshida T, Amato MBP, Ferguson ND, Post M, Kavanagh BP, Brochard LJ. Positive End-Expiratory Pressure, Pleural Pressure, and Regional Compliance during Pronation: An Experimental Study. Am J Respir Crit Care Med 2021; 203:1266-1274. [PMID: 33406012 DOI: 10.1164/rccm.202007-2957oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: The physiological basis of lung protection and the impact of positive end-expiratory pressure (PEEP) during pronation in acute respiratory distress syndrome are not fully elucidated. Objectives: To compare pleural pressure (Ppl) gradient, ventilation distribution, and regional compliance between dependent and nondependent lungs, and investigate the effect of PEEP during supination and pronation. Methods: We used a two-hit model of lung injury (saline lavage and high-volume ventilation) in 14 mechanically ventilated pigs and studied supine and prone positions. Global and regional lung mechanics including Ppl and distribution of ventilation (electrical impedance tomography) were analyzed across PEEP steps from 20 to 3 cm H2O. Two pigs underwent computed tomography scans: tidal recruitment and hyperinflation were calculated. Measurements and Main Results: Pronation improved oxygenation, increased Ppl, thus decreasing transpulmonary pressure for any PEEP, and reduced the dorsal-ventral pleural pressure gradient at PEEP < 10 cm H2O. The distribution of ventilation was homogenized between dependent and nondependent while prone and was less dependent on the PEEP level than while supine. The highest regional compliance was achieved at different PEEP levels in dependent and nondependent regions in supine position (15 and 8 cm H2O), but for similar values in prone position (13 and 12 cm H2O). Tidal recruitment was more evenly distributed (dependent and nondependent), hyperinflation lower, and lungs cephalocaudally longer in the prone position. Conclusions: In this lung injury model, pronation reduces the vertical pleural pressure gradient and homogenizes regional ventilation and compliance between the dependent and nondependent regions. Homogenization is much less dependent on the PEEP level in prone than in supine positon.
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Affiliation(s)
- Bhushan H Katira
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,The Institute of Medical Science.,Department of Physiology.,The Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Kohei Osada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine
| | - Doreen Engelberts
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luca Bastia
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - L Felipe Damiani
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Xuehan Li
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Anesthesiology and.,Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Han Chan
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Surgical Intensive Care Unit, Fujian Provincial Hospital, Fuzhou, China
| | - Takeshi Yoshida
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,The Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine.,Department of Physiology.,Department of Medicine.,Department of Physiology.,Institute for Health Policy, Management, and Evaluation.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Martin Post
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,The Institute of Medical Science.,Department of Physiology
| | - Brian P Kavanagh
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,The Institute of Medical Science.,Department of Physiology.,Department of Critical Care Medicine, Hospital for Sick Children, and.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada; and
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine.,Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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11
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Safety and Outcomes of Prolonged Usual Care Prone Position Mechanical Ventilation to Treat Acute Coronavirus Disease 2019 Hypoxemic Respiratory Failure. Crit Care Med 2021; 49:490-502. [PMID: 33405409 DOI: 10.1097/ccm.0000000000004818] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Prone position ventilation is a potentially life-saving ancillary intervention but is not widely adopted for coronavirus disease 2019 or acute respiratory distress syndrome from other causes. Implementation of lung-protective ventilation including prone positioning for coronavirus disease 2019 acute respiratory distress syndrome is limited by isolation precautions and personal protective equipment scarcity. We sought to determine the safety and associated clinical outcomes for coronavirus disease 2019 acute respiratory distress syndrome treated with prolonged prone position ventilation without daily repositioning. DESIGN Retrospective single-center study. SETTING Community academic medical ICU. PATIENTS Sequential mechanically ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome. INTERVENTIONS Lung-protective ventilation and prolonged protocolized prone position ventilation without daily supine repositioning. Supine repositioning was performed only when Fio2 less than 60% with positive end-expiratory pressure less than 10 cm H2O for greater than or equal to 4 hours. MEASUREMENTS AND MAIN RESULTS Primary safety outcome: proportion with pressure wounds by Grades (0-4). Secondary outcomes: hospital survival, length of stay, rates of facial and limb edema, hospital-acquired infections, device displacement, and measures of lung mechanics and oxygenation. Eighty-seven coronavirus disease 2019 patients were mechanically ventilated. Sixty-one were treated with prone position ventilation, whereas 26 did not meet criteria. Forty-two survived (68.9%). Median (interquartile range) time from intubation to prone position ventilation was 0.28 d (0.11-0.80 d). Total prone position ventilation duration was 4.87 d (2.08-9.97 d). Prone position ventilation was applied for 30.3% (18.2-42.2%) of the first 28 days. Pao2:Fio2 diverged significantly by day 3 between survivors 147 (108-164) and nonsurvivors 107 (85-146), mean difference -9.632 (95% CI, -48.3 to 0.0; p = 0·05). Age, driving pressure, day 1, and day 3 Pao2:Fio2 were predictive of time to death. Thirty-eight (71.7%) developed ventral pressure wounds that were associated with prone position ventilation duration and day 3 Sequential Organ Failure Assessment. Limb weakness occurred in 58 (95.1%) with brachial plexus palsies in five (8.2%). Hospital-acquired infections other than central line-associated blood stream infections were infrequent. CONCLUSIONS Prolonged prone position ventilation was feasible and relatively safe with implications for wider adoption in treating critically ill coronavirus disease 2019 patients and acute respiratory distress syndrome of other etiologies.
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12
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Prone Ventilation for Patients with Mild or Moderate Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2021; 17:24-29. [PMID: 31532692 DOI: 10.1513/annalsats.201906-456ip] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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13
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Shin KM, Choi J, Chae KJ, Jin GY, Eskandari A, Hoffman EA, Hall C, Castro M, Lee CH. Quantitative CT-based image registration metrics provide different ventilation and lung motion patterns in prone and supine positions in healthy subjects. Respir Res 2020; 21:254. [PMID: 33008396 PMCID: PMC7531138 DOI: 10.1186/s12931-020-01519-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/22/2020] [Indexed: 12/22/2022] Open
Abstract
Background Previous studies suggested that the prone position (PP) improves oxygenation and reduces mortality among patients with acute respiratory distress syndrome (ARDS). However, the mechanism of this clinical benefit of PP is not completely understood. The aim of the present study was to quantitatively compare regional characteristics of lung functions in the PP with those in the supine position (SP) using inspiratory and expiratory computed tomography (CT) scans. Methods Ninety subjects with normal pulmonary function and inspiration and expiration CT images were included in the study. Thirty-four subjects were scanned in PP, and 56 subjects were scanned in SP. Non-rigid image registration-based inspiratory-expiratory image matching assessment was used for regional lung function analysis. Tissue fractions (TF) were computed based on the CT density and compared on a lobar basis. Three registration-derived functional variables, relative regional air volume change (RRAVC), volumetric expansion ratio (J), and three-dimensional relative regional displacement (s*) were used to evaluate regional ventilation and deformation characteristics. Results J was greater in PP than in SP in the right middle lobe (P = 0 .025), and RRAVC was increased in the upper and right middle lobes (P < 0.001). The ratio of the TF on inspiratory and expiratory scans, J, and RRAVC at the upper lobes to those at the middle and lower lobes and that ratio at the upper and middle lobes to those at the lower lobes of were all near unity in PP, and significantly higher than those in SP (0.98–1.06 vs 0.61–0.94, P < 0.001). Conclusion We visually and quantitatively observed that PP not only induced more uniform contributions of regional lung ventilation along the ventral-dorsal axis but also minimized the lobar differences of lung functions in comparison with SP. This may help in the clinician’s search for an understanding of the benefits of the application of PP to the patients with ARDS or other gravitationally dependent pathologic lung diseases. Trial registration Retrospectively registered.
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Affiliation(s)
- Kyung Min Shin
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Jiwoong Choi
- Department of Internal Medicine, School of Medicine, The University of Kansas, Kansas City, Kansas, USA.,Department of Bioengineering, The University of Kansas, Lawrence, Kansas, USA
| | - Kum Ju Chae
- Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Gong Yong Jin
- Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Ali Eskandari
- Department of Radiology, University of Iowa, Iowa City, USA
| | - Eric A Hoffman
- Department of Radiology, University of Iowa, Iowa City, USA.,Internal Medicine, University of Iowa, Iowa City, USA.,Biomedical Engineering, University of Iowa, Iowa City, USA
| | - Chase Hall
- Department of Internal Medicine, School of Medicine, The University of Kansas, Kansas City, Kansas, USA
| | - Mario Castro
- Department of Internal Medicine, School of Medicine, The University of Kansas, Kansas City, Kansas, USA
| | - Chang Hyun Lee
- Department of Radiology, University of Iowa, Iowa City, USA. .,Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongnogu, Seoul, 03080, South Korea.
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14
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Coppo A, Bellani G, Winterton D, Di Pierro M, Soria A, Faverio P, Cairo M, Mori S, Messinesi G, Contro E, Bonfanti P, Benini A, Valsecchi MG, Antolini L, Foti G. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. THE LANCET. RESPIRATORY MEDICINE 2020; 8:765-774. [PMID: 32569585 PMCID: PMC7304954 DOI: 10.1016/s2213-2600(20)30268-x] [Citation(s) in RCA: 339] [Impact Index Per Article: 67.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic is challenging advanced health systems, which are dealing with an overwhelming number of patients in need of intensive care for respiratory failure, often requiring intubation. Prone positioning in intubated patients is known to reduce mortality in moderate-to-severe acute respiratory distress syndrome. We aimed to investigate feasibility and effect on gas exchange of prone positioning in awake, non-intubated patients with COVID-19-related pneumonia. METHODS In this prospective, feasibility, cohort study, patients aged 18-75 years with a confirmed diagnosis of COVID-19-related pneumonia receiving supplemental oxygen or non-invasive continuous positive airway pressure were recruited from San Gerardo Hospital, Monza, Italy. We collected baseline data on demographics, anthropometrics, arterial blood gas, and ventilation parameters. After baseline data collection, patients were helped into the prone position, which was maintained for a minimum duration of 3 h. Clinical data were re-collected 10 min after prone positioning and 1 h after returning to the supine position. The main study outcome was the variation in oxygenation (partial pressure of oxygen [PaO2]/fractional concentration of oxygen in inspired air [FiO2]) between baseline and resupination, as an index of pulmonary recruitment. This study is registered on ClinicalTrials.gov, NCT04365959, and is now complete. FINDINGS Between March 20 and April 9, 2020, we enrolled 56 patients, of whom 44 (79%) were male; the mean age was 57·4 years (SD 7·4) and the mean BMI was 27·5 kg/m2 (3·7). Prone positioning was feasible (ie, maintained for at least 3 h) in 47 patients (83·9% [95% CI 71·7 to 92·4]). Oxygenation substantially improved from supine to prone positioning (PaO2/FiO2 ratio 180·5 mm Hg [SD 76·6] in supine position vs 285·5 mm Hg [112·9] in prone position; p<0·0001). After resupination, improved oxygenation was maintained in 23 patients (50·0% [95% CI 34·9-65·1]; ie, responders); however, this improvement was on average not significant compared with before prone positioning (PaO2/FiO2 ratio 192·9 mm Hg [100·9] 1 h after resupination; p=0·29). Patients who maintained increased oxygenation had increased levels of inflammatory markers (C-reactive protein: 12·7 mg/L [SD 6·9] in responders vs 8·4 mg/L [6·2] in non-responders; and platelets: 241·1 × 103/μL [101·9] vs 319·8 × 103/μL [120·6]) and shorter time between admission to hospital and prone positioning (2·7 days [SD 2·1] in responders vs 4·6 days [3·7] in non-responders) than did those for whom improved oxygenation was not maintained. 13 (28%) of 46 patients were eventually intubated, seven (30%) of 23 responders and six (26%) of 23 non-responders (p=0·74). Five patients died during follow-up due to underlying disease, unrelated to study procedure. INTERPRETATION Prone positioning was feasible and effective in rapidly ameliorating blood oxygenation in awake patients with COVID-19-related pneumonia requiring oxygen supplementation. The effect was maintained after resupination in half of the patients. Further studies are warranted to ascertain the potential benefit of this technique in improving final respiratory and global outcomes. FUNDING University of Milan-Bicocca.
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Affiliation(s)
- Anna Coppo
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy
| | - Giacomo Bellani
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
| | - Dario Winterton
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Michela Di Pierro
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alessandro Soria
- Clinic of Infectious Diseases, San Gerardo Hospital, Monza, Italy
| | - Paola Faverio
- Respiratory Unit, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Matteo Cairo
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy
| | - Silvia Mori
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | | | - Ernesto Contro
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy
| | - Paolo Bonfanti
- Clinic of Infectious Diseases, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Annalisa Benini
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy
| | | | - Laura Antolini
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Giuseppe Foti
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
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15
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Marini JJ, Rocco PRM, Gattinoni L. Static and Dynamic Contributors to Ventilator-induced Lung Injury in Clinical Practice. Pressure, Energy, and Power. Am J Respir Crit Care Med 2020; 201:767-774. [PMID: 31665612 PMCID: PMC7124710 DOI: 10.1164/rccm.201908-1545ci] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Ventilation is inherently a dynamic process. The present-day clinical practice of concentrating on the static inflation characteristics of the individual tidal cycle (plateau pressure, positive end-expiratory pressure, and their difference [driving pressure, the ratio of Vt to compliance]) does not take into account key factors shown experimentally to influence ventilator-induced lung injury (VILI). These include rate of airway pressure change (influenced by flow amplitude, inspiratory time fraction, and inspiratory inflation contour) and cycling frequency. Energy must be expended to cause injury, and the product of applied stress and resulting strain determines the energy delivered to the lungs per breathing cycle. Understanding the principles of VILI energetics may provide valuable insights and guidance to intensivists for safer clinical practice. In this interpretive review, we highlight that the injuring potential of the inflation pattern depends upon tissue vulnerability, the number of intolerable high-energy cycles applied in unit time (mechanical power), and the duration of that exposure. Yet, as attractive as this energy/power hypothesis for encapsulating the drivers of VILI may be for clinical applications, we acknowledge that even these all-inclusive and measurable ergonomic parameters (energy per cycle and power) are still too bluntly defined to pinpoint the precise biophysical link between ventilation strategy and tissue injury.
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Affiliation(s)
- John J Marini
- University of Minnesota and Regions Hospital, Minneapolis/St. Paul, Minnesota
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; and
| | - Luciano Gattinoni
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
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16
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What have we learned from animal models of ventilator-induced lung injury? Intensive Care Med 2020; 46:2377-2380. [PMID: 32500178 PMCID: PMC7270159 DOI: 10.1007/s00134-020-06143-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/26/2020] [Indexed: 11/25/2022]
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17
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Jochmans S, Mazerand S, Chelly J, Pourcine F, Sy O, Thieulot-Rolin N, Ellrodt O, Mercier Des Rochettes E, Michaud G, Serbource-Goguel J, Vinsonneau C, Vong LVP, Monchi M. Duration of prone position sessions: a prospective cohort study. Ann Intensive Care 2020; 10:66. [PMID: 32449068 PMCID: PMC7245995 DOI: 10.1186/s13613-020-00683-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 05/16/2020] [Indexed: 12/16/2022] Open
Abstract
Background Prone position (PP) is highly recommended in moderate-to-severe ARDS. However, the optimal duration of PP sessions remains unclear. We searched to evaluate the time required to obtain the maximum physiological effect, and to search for parameters related to patient survival in PP. Methods and results It was a prospective, monocentric, physiological study. We included in the study all prone-positioned patients in our ICU between June 2016 and January 2018. Pulmonary mechanics, data from volumetric capnography and arterial blood gas were recorded before prone positioning, 2 h after proning, before return to a supine position (SP) and 2 h after return to SP. Dynamic parameters were recorded before proning and every 30 min during the session until 24 h. 103 patients (ARDS 95%) were included performing 231 PP sessions with a mean length of 21.5 ± 5 h per session. They presented a significant increase in pH, static compliance and PaO2/FiO2 with a significant decrease in PaCO2, Pplat, phase 3 slope of the volumetric capnography, PetCO2, VD/VT-phy and ΔP. The beneficial physiological effects continued after 16 h of PP and at least up to 24 h in some patients. The evolution of the respiratory parameters during the first session and also during the pooled sessions did not find any predictor of response to PP, whether before, during or 2 h after the return in SP. Conclusions PP sessions should be prolonged at least 24 h and be extended in the event that the PaO2/FiO2 ratio at 24 h remains below 150, especially since no criteria can predict which patient will benefit or not from it. Trial registration The trial has been registered on 28 June 2016 in ClinicalTrials.gov (NCT 02816190) (https://clinicaltrials.gov/ct2/show/NCT02816190?term=propocap&rank=1).
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Affiliation(s)
- Sebastien Jochmans
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France. .,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.
| | - Sandie Mazerand
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Jonathan Chelly
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Franck Pourcine
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Oumar Sy
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Nathalie Thieulot-Rolin
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Olivier Ellrodt
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Emmanuelle Mercier Des Rochettes
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Service de Réanimation Médicale, AP-HP, Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Gaël Michaud
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Jean Serbource-Goguel
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Christophe Vinsonneau
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Service de Réanimation, Hôpital de Béthune, 27 rue Delbecque, 62660, Beuvry, France
| | - Ly Van Phach Vong
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
| | - Mehran Monchi
- Département de Médecine Intensive-Réanimation, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France.,Unité de Recherche Clinique, GH Sud Ile-de-France, Hôpital de Melun, 270 avenue Marc Jacquet, 77000, Melun, France
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18
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Inata Y, Sofue T, Hatachi T, Kyogoku M, Takeuchi M. Prone positioning without neuromuscular blockade during extracorporeal membrane oxygenation in children. Pediatr Int 2020; 62:649-651. [PMID: 32383291 DOI: 10.1111/ped.14151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 12/16/2019] [Accepted: 01/15/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Toshiki Sofue
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Miyako Kyogoku
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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19
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Abstract
BACKGROUND This study hypothesized that, in experimental mild acute respiratory distress syndrome, lung damage caused by high tidal volume (VT) could be attenuated if VT increased slowly enough to progressively reduce mechanical heterogeneity and to allow the epithelial and endothelial cells, as well as the extracellular matrix of the lung to adapt. For this purpose, different strategies of approaching maximal VT were tested. METHODS Sixty-four Wistar rats received Escherichia coli lipopolysaccharide intratracheally. After 24 h, animals were randomly assigned to receive mechanical ventilation with VT = 6 ml/kg for 2 h (control); VT = 6 ml/kg during hour 1 followed by an abrupt increase to VT = 22 ml/kg during hour 2 (no adaptation time); VT = 6 ml/kg during the first 30 min followed by a gradual VT increase up to 22 ml/kg for 30 min, then constant VT = 22 ml/kg during hour 2 (shorter adaptation time); and a more gradual VT increase, from 6 to 22 ml/kg during hour 1 followed by VT = 22 ml/kg during hour 2 (longer adaptation time). All animals were ventilated with positive end-expiratory pressure of 3 cm H2O. Nonventilated animals were used for molecular biology analysis. RESULTS At 2 h, diffuse alveolar damage score and heterogeneity index were greater in the longer adaptation time group than in the control and shorter adaptation time animals. Gene expression of interleukin-6 favored the shorter (median [interquartile range], 12.4 [9.1-17.8]) adaptation time compared with longer (76.7 [20.8 to 95.4]; P = 0.02) and no adaptation (65.5 [18.1 to 129.4]) time (P = 0.02) strategies. Amphiregulin, metalloproteinase-9, club cell secretory protein-16, and syndecan showed similar behavior. CONCLUSIONS In experimental mild acute respiratory distress syndrome, lung damage in the shorter adaptation time group compared with the no adaptation time group was attenuated in a time-dependent fashion by preemptive adaptation of the alveolar epithelial cells and extracellular matrix. Extending the adaptation period increased cumulative power and did not prevent lung damage, because it may have exposed animals to injurious strain earlier and for a longer time, thereby negating any adaptive benefit.
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20
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Zebialowicz Ahlström J, Massaro F, Mikolka P, Feinstein R, Perchiazzi G, Basabe-Burgos O, Curstedt T, Larsson A, Johansson J, Rising A. Synthetic surfactant with a recombinant surfactant protein C analogue improves lung function and attenuates inflammation in a model of acute respiratory distress syndrome in adult rabbits. Respir Res 2019; 20:245. [PMID: 31694668 PMCID: PMC6836435 DOI: 10.1186/s12931-019-1220-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 10/17/2019] [Indexed: 02/06/2023] Open
Abstract
AIM In acute respiratory distress syndrome (ARDS) damaged alveolar epithelium, leakage of plasma proteins into the alveolar space and inactivation of pulmonary surfactant lead to respiratory dysfunction. Lung function could potentially be restored with exogenous surfactant therapy, but clinical trials have so far been disappointing. These negative results may be explained by inactivation and/or too low doses of the administered surfactant. Surfactant based on a recombinant surfactant protein C analogue (rSP-C33Leu) is easy to produce and in this study we compared its effects on lung function and inflammation with a commercial surfactant preparation in an adult rabbit model of ARDS. METHODS ARDS was induced in adult New Zealand rabbits by mild lung-lavages followed by injurious ventilation (VT 20 m/kg body weight) until P/F ratio < 26.7 kPa. The animals were treated with two intratracheal boluses of 2.5 mL/kg of 2% rSP-C33Leu in DPPC/egg PC/POPG, 50:40:10 or poractant alfa (Curosurf®), both surfactants containing 80 mg phospholipids/mL, or air as control. The animals were subsequently ventilated (VT 8-9 m/kg body weight) for an additional 3 h and lung function parameters were recorded. Histological appearance of the lungs, degree of lung oedema and levels of the cytokines TNFα IL-6 and IL-8 in lung homogenates were evaluated. RESULTS Both surfactant preparations improved lung function vs. the control group and also reduced inflammation scores, production of pro-inflammatory cytokines, and formation of lung oedema to similar degrees. Poractant alfa improved compliance at 1 h, P/F ratio and PaO2 at 1.5 h compared to rSP-C33Leu surfactant. CONCLUSION This study indicates that treatment of experimental ARDS with synthetic lung surfactant based on rSP-C33Leu improves lung function and attenuates inflammation.
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Affiliation(s)
- J Zebialowicz Ahlström
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - F Massaro
- Anesthesia and Intesive Care, Villa Anthea Hospital, Bari, Italy
| | - P Mikolka
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Biomedical Center Martin and Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - R Feinstein
- Department of Pathology, The Swedish National Veterinary Institute, Uppsala, Sweden
| | - G Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - O Basabe-Burgos
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - T Curstedt
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - J Johansson
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - A Rising
- Division for Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden. .,Department of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Uppsala, Sweden.
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21
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Motta-Ribeiro GC, Hashimoto S, Winkler T, Baron RM, Grogg K, Paula LFSC, Santos A, Zeng C, Hibbert K, Harris RS, Bajwa E, Vidal Melo MF. Deterioration of Regional Lung Strain and Inflammation during Early Lung Injury. Am J Respir Crit Care Med 2019; 198:891-902. [PMID: 29787304 DOI: 10.1164/rccm.201710-2038oc] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE The contribution of aeration heterogeneity to lung injury during early mechanical ventilation of uninjured lungs is unknown. OBJECTIVES To test the hypotheses that a strategy consistent with clinical practice does not protect from worsening in lung strains during the first 24 hours of ventilation of initially normal lungs exposed to mild systemic endotoxemia in supine versus prone position, and that local neutrophilic inflammation is associated with local strain and blood volume at global strains below a proposed injurious threshold. METHODS Voxel-level aeration and tidal strain were assessed by computed tomography in sheep ventilated with low Vt and positive end-expiratory pressure while receiving intravenous endotoxin. Regional inflammation and blood volume were estimated from 2-deoxy-2-[(18)F]fluoro-d-glucose (18F-FDG) positron emission tomography. MEASUREMENTS AND MAIN RESULTS Spatial heterogeneity of aeration and strain increased only in supine lungs (P < 0.001), with higher strains and atelectasis than prone at 24 hours. Absolute strains were lower than those considered globally injurious. Strains redistributed to higher aeration areas as lung injury progressed in supine lungs. At 24 hours, tissue-normalized 18F-FDG uptake increased more in atelectatic and moderately high-aeration regions (>70%) than in normally aerated regions (P < 0.01), with differential mechanistically relevant regional gene expression. 18F-FDG phosphorylation rate was associated with strain and blood volume. Imaging findings were confirmed in ventilated patients with sepsis. CONCLUSIONS Mechanical ventilation consistent with clinical practice did not generate excessive regional strain in heterogeneously aerated supine lungs. However, it allowed worsening of spatial strain distribution in these lungs, associated with increased inflammation. Our results support the implementation of early aeration homogenization in normal lungs.
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Affiliation(s)
- Gabriel C Motta-Ribeiro
- 1 Department of Anesthesia, Critical Care and Pain Medicine.,2 Biomedical Engineering Program, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Soshi Hashimoto
- 1 Department of Anesthesia, Critical Care and Pain Medicine.,3 Department of Anesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, Japan; and
| | - Tilo Winkler
- 1 Department of Anesthesia, Critical Care and Pain Medicine
| | - Rebecca M Baron
- 4 Department of Medicine (Pulmonary and Critical Care), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Arnoldo Santos
- 1 Department of Anesthesia, Critical Care and Pain Medicine.,6 CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Congli Zeng
- 1 Department of Anesthesia, Critical Care and Pain Medicine
| | - Kathryn Hibbert
- 7 Department of Medicine (Pulmonary and Critical Care), Massachusetts General Hospital, and
| | - Robert S Harris
- 7 Department of Medicine (Pulmonary and Critical Care), Massachusetts General Hospital, and
| | - Ednan Bajwa
- 7 Department of Medicine (Pulmonary and Critical Care), Massachusetts General Hospital, and
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22
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23
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Yajnik V, Breslin KM, Riley C. Acute Respiratory Distress in the Operating Room and Prone Ventilation: A Case Report. A A Pract 2019; 12:19-21. [PMID: 30004910 DOI: 10.1213/xaa.0000000000000832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There have been many advances in the management of acute respiratory distress syndrome, a condition which Bellani et al, in the LUNG SAFE trial (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure), found represents up to 10.4% of intensive care unit admissions and 23.4% of patients requiring mechanical ventilation, with an unadjusted intensive care unit and hospital mortality of 35.3% and 40%, respectively. Studies have shown that prone positioning can improve oxygenation in patients who are mechanically ventilated for acute respiratory distress syndrome. This case report describes an example in which intraoperative prone positioning improved oxygenation in a patient after aspiration of gastric contents on induction of general anesthesia.
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Affiliation(s)
- Vishal Yajnik
- From the Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, Virginia
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24
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Fang M, Fan S, Yao X, Liu N, Gao J, Wang Z, Xu T, Xian X, Li W. Transfection of Sox11 plasmid alleviates ventilator-induced lung injury via Sox11 and FAK. Biochem Biophys Res Commun 2019; 512:182-188. [PMID: 30879763 DOI: 10.1016/j.bbrc.2019.03.041] [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: 02/22/2019] [Accepted: 03/08/2019] [Indexed: 12/15/2022]
Abstract
Background Ventilator-induced lung injury (VILI) is the most common complication in the mechanical ventilation in clinic. The pathogenesis of VILI has not been well understood. The SRY related High Mobility Group box group-F family member 11(Sox11) is a protein associated with lung development. The focal adhesion kinase(FAK) is a cytoplasmic tyrosine kinase and is regulated by Sox11. The present study, therefore, was undertaken to explore the potential role of Sox11 and FAK in VILI. Methods High volume mechanical ventilation(HMV) was used to establish mouse VILI model under anesthesia. The lung injury was evaluated by analyzing the lung weight, bronchoalveolar lavage fluid, histopathological changes and apoptosis of the lung. The Sox11 and FAK expressions in the lung were investigated by real-time qPCR, western blot and immunohistochemistry analysis. Results HMV induced VILI simultaneously companied with decreased expressions of Sox11 and FAK in alveolar epithelial and interstitial cells either in gene and protein levels. Transfection of Sox11 plasmid significantly upregulated expressions of Sox11 and FAK in gene and protein levels in the lung and particularly effectively alleviated VILI. Furthermore, FAK antagonism by PF562271(FAK antagonist) blocked the alleviating effect of Sox11 plasmid transfection on the VILI. Conclusion The dysregulation in the Sox11 and FAK after HMV play an important role in the pathogenesis of VILI, and facilitating the activity of Sox11and FAK might be an effective target and potential option in the prevention and treatment of VILI in clinic.
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Affiliation(s)
- Mingxing Fang
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China; Department of Intensive Care Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shujuan Fan
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Xiaoguang Yao
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China; College of Integrative Medicine, Hebei University of Chinese Medicine, Shijiazhuang, China
| | - Na Liu
- Department of Emergency, The Forth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junxia Gao
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Zhiyong Wang
- Department of Intensive Care Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Tieling Xu
- Department of Emergency, Hebei General Hospital, Shijiazhuang, China
| | - Xiaohui Xian
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China
| | - Wenbin Li
- Department of Pathophysiology, Neuroscience Research Center, Hebei Medical University, Shijiazhuang, China.
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Dissipation of energy during the respiratory cycle: conditional importance of ergotrauma to structural lung damage. Curr Opin Crit Care 2018; 24:16-22. [PMID: 29176330 DOI: 10.1097/mcc.0000000000000470] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To describe and put into context recent conceptual advances regarding the relationship of energy load and power to ventilator-induced lung injury (VILI). RECENT FINDINGS Investigative emphasis regarding VILI has almost exclusively centered on the static characteristics of the individual tidal cycle - tidal volume, plateau pressure, positive end-expiratory pressure, and driving pressure. Although those static characteristics of the tidal cycle are undeniably important, the 'dynamic' characteristics of ventilation must not be ignored. To inflict the nonrupturing damage we identify as VILI, work must be performed and energy expended by high stress cycles applied at rates that exceed the capacity of endogenous repair. Machine power, the pace at which the work performing energy load is applied by the ventilator, has received increasing scrutiny as a candidate for the proximate and integrative cause of VILI. SUMMARY Although the unmodified values of machine-delivered energy or power (which are based on airway pressures and tidal volumes) cannot serve unconditionally as a rigid and quantitative guide to ventilator adjustment for lung protection, bedside consideration of the dynamics of ventilation and potential for ergotrauma represents a clear conceptual advance that complements the static parameters of the individual tidal cycle that with few exceptions have held our scientific attention.
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26
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Xin Y, Cereda M, Hamedani H, Pourfathi M, Siddiqui S, Meeder N, Kadlecek S, Duncan I, Profka H, Rajaei J, Tustison NJ, Gee JC, Kavanagh BP, Rizi RR. Unstable Inflation Causing Injury. Insight from Prone Position and Paired Computed Tomography Scans. Am J Respir Crit Care Med 2018; 198:197-207. [PMID: 29420904 PMCID: PMC6058981 DOI: 10.1164/rccm.201708-1728oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 01/16/2023] Open
Abstract
RATIONALE It remains unclear how prone positioning improves survival in acute respiratory distress syndrome. Using serial computed tomography (CT), we previously reported that "unstable" inflation (i.e., partial aeration with large tidal density swings, indicating increased local strain) is associated with injury progression. OBJECTIVES We prospectively tested whether prone position contains the early propagation of experimental lung injury by stabilizing inflation. METHODS Injury was induced by tracheal hydrochloric acid in rats; after randomization to supine or prone position, injurious ventilation was commenced using high tidal volume and low positive end-expiratory pressure. Paired end-inspiratory (EI) and end-expiratory (EE) CT scans were acquired at baseline and hourly up to 3 hours. Each sequential pair (EI, EE) of CT images was superimposed in parametric response maps to analyze inflation. Unstable inflation was then measured in each voxel in both dependent and nondependent lung. In addition, five pigs were imaged (EI and EE) prone versus supine, before and (1 hour) after hydrochloric acid aspiration. MEASUREMENTS AND MAIN RESULTS In rats, prone position limited lung injury propagation and increased survival (11/12 vs. 7/12 supine; P = 0.01). EI-EE densities, respiratory mechanics, and blood gases deteriorated more in supine versus prone rats. At baseline, more voxels with unstable inflation occurred in dependent versus nondependent regions when supine (41 ± 6% vs. 18 ± 7%; P < 0.01) but not when prone. In supine pigs, unstable inflation predominated in dorsal regions and was attenuated by prone positioning. CONCLUSIONS Prone position limits the radiologic progression of early lung injury. Minimizing unstable inflation in this setting may alleviate the burden of acute respiratory distress syndrome.
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Affiliation(s)
- Yi Xin
- Department of Radiology and
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Nicholas J. Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia; and
| | | | - Brian P. Kavanagh
- Department of Critical Care Medicine and
- Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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27
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Mechanical Ventilation in Adults with Acute Respiratory Distress Syndrome. Summary of the Experimental Evidence for the Clinical Practice Guideline. Ann Am Thorac Soc 2018; 14:S261-S270. [PMID: 28985479 DOI: 10.1513/annalsats.201704-345ot] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE The American Thoracic Society/European Society for Intensive Care Medicine/Society of Critical Care Medicine guidelines on mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS) provide treatment recommendations derived from a thorough analysis of the clinical evidence on six clinical interventions. However, each of the recommendations contains areas of uncertainty and controversy, which may affect their appropriate clinical application. OBJECTIVES To provide a critical review of the experimental evidence surrounding the pathophysiology of ventilator-induced lung injury and to help clinicians apply the clinical recommendations to individual patients. METHODS We conducted a literature search and narrative review. RESULTS A large number of experimental studies have been performed with the aim of improving understanding of the pathophysiological effects of mechanical ventilation. These studies have formed the basis for the design of many clinical trials. Translational research has fundamentally advanced understanding of the mechanisms of ventilator-induced lung injury, thus informing the design of interventions that improve survival in patients with ARDS. CONCLUSIONS Because daily management of patients with ARDS presents the challenge of competing considerations, clinicians should consider the mechanism of ventilator-induced lung injury, as well as the rationale for interventions designed to mitigate it, when applying evidence-based recommendations at the bedside.
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28
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Hepokoski ML, Odish M, Malhotra A. Prone positioning in acute respiratory distress syndrome: why aren't we using it more? J Thorac Dis 2018; 10:S1020-S1024. [PMID: 29849212 PMCID: PMC5949405 DOI: 10.21037/jtd.2018.04.60] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/26/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Mark L Hepokoski
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA
| | - Mazen Odish
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA, USA
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Lung volumes and lung volume recruitment in ARDS: a comparison between supine and prone position. Ann Intensive Care 2018; 8:25. [PMID: 29445887 PMCID: PMC5812959 DOI: 10.1186/s13613-018-0371-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/08/2018] [Indexed: 12/26/2022] Open
Abstract
Background The use of positive end-expiratory pressure (PEEP) and prone position (PP) is common in the management of severe acute respiratory distress syndrome patients (ARDS). We conducted this study to analyze the variation in lung volumes and PEEP-induced lung volume recruitment with the change from supine position (SP) to PP in ARDS patients. Methods The investigation was conducted in a multidisciplinary intensive care unit. Patients who met the clinical criteria of the Berlin definition for ARDS were included. The responsible physician set basal PEEP. To avoid hypoxemia, FiO2 was increased to 0.8 1 h before starting the protocol. End-expiratory lung volume (EELV) and functional residual capacity (FRC) were measured using the nitrogen washout/washin technique. After the procedures in SP, the patients were turned to PP and 1 h later the same procedures were made in PP. Results Twenty-three patients were included in the study, and twenty were analyzed. The change from SP to PP significantly increased FRC (from 965 ± 397 to 1140 ± 490 ml, p = 0.008) and EELV (from 1566 ± 476 to 1832 ± 719 ml, p = 0.008), but PEEP-induced lung volume recruitment did not significantly change (269 ± 186 ml in SP to 324 ± 188 ml in PP, p = 0.263). Dynamic strain at PEEP decreased with the change from SP to PP (0.38 ± 0.14 to 0.33 ± 0.13, p = 0.040). Conclusions As compared to supine, prone position increases resting lung volumes and decreases dynamic lung strain. Electronic supplementary material The online version of this article (10.1186/s13613-018-0371-0) contains supplementary material, which is available to authorized users.
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30
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Mauri T, Lazzeri M, Bellani G, Zanella A, Grasselli G. Respiratory mechanics to understand ARDS and guide mechanical ventilation. Physiol Meas 2017; 38:R280-H303. [PMID: 28967868 DOI: 10.1088/1361-6579/aa9052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE As precision medicine is becoming a standard of care in selecting tailored rather than average treatments, physiological measurements might represent the first step in applying personalized therapy in the intensive care unit (ICU). A systematic assessment of respiratory mechanics in patients with the acute respiratory distress syndrome (ARDS) could represent a step in this direction, for two main reasons. Approach and Main results: On the one hand, respiratory mechanics are a powerful physiological method to understand the severity of this syndrome in each single patient. Decreased respiratory system compliance, for example, is associated with low end expiratory lung volume and more severe lung injury. On the other hand, respiratory mechanics might guide protective mechanical ventilation settings. Improved gravitationally dependent regional lung compliance could support the selection of positive end-expiratory pressure and maximize alveolar recruitment. Moreover, the association between driving airway pressure and mortality in ARDS patients potentially underlines the importance of sizing tidal volume on respiratory system compliance rather than on predicted body weight. SIGNIFICANCE The present review article aims to describe the main alterations of respiratory mechanics in ARDS as a potent bedside tool to understand severity and guide mechanical ventilation settings, thus representing a readily available clinical resource for ICU physicians.
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Affiliation(s)
- Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy. Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
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31
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Radermacher P, Maggiore SM, Mercat A. FiftyYears ofResearch inARDS.Gas Exchange in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:964-984. [DOI: 10.1164/rccm.201610-2156so] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Peter Radermacher
- Institute of Anaesthesiological Pathophysiology and Process Engineering, University Medical School, Ulm, Germany
| | - Salvatore Maurizio Maggiore
- Section of Anesthesia, Analgesia, Perioperative, and Intensive Care, Department of Medical, Oral, and Biotechnological Sciences, School of Medicine and Health Sciences, “SS. Annunziata” Hospital, “Gabriele d’Annunzio” University of Chieti-Pescara, Chieti, Italy; and
| | - Alain Mercat
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France
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Guérin C. Prone positioning acute respiratory distress syndrome patients. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:289. [PMID: 28828364 DOI: 10.21037/atm.2017.06.63] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Prone position has been used in acute respiratory distress syndrome (ARDS) patients for more than 40 years in ICU. After having demonstrated its capability to significantly improve oxygenation in a large number of patients, sometimes dramatically, this procedure has been found to prevent ventilator-induced lung injury, the primary concern for the intensivists managing ARDS patients. Over the time, several trials have been done, which regularly improved and refined from each other. At the end, significant improvement in survival has been demonstrated in the most severe ARDS patients, at a threshold of 100-150 mmHg PaO2/FiO2 ratio. The effect of proning on survival cannot be predicted and seems unrelated with both severity of oxygenation impairment and oxygenation response to proning. The rate of complication is declining with the increase in centers expertise. The pressure sores are more frequent in prone and require a special attention. Prone position is a key component of lung protective mechanical ventilation and should be used as a first line therapy in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS.
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Affiliation(s)
- Claude Guérin
- Medical ICU, Croix Rousse Hospital, Lyon, France.,University of Lyon, Lyon, France.,INSERM 955, Créteil, France
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Gaudry S, Tuffet S, Lukaszewicz AC, Laplace C, Zucman N, Pocard M, Costaglioli B, Msika S, Duranteau J, Payen D, Dreyfuss D, Hajage D, Ricard JD. Prone positioning in acute respiratory distress syndrome after abdominal surgery: a multicenter retrospective study : SAPRONADONF (Study of Ards and PRONe position After abDOmiNal surgery in France). Ann Intensive Care 2017; 7:21. [PMID: 28236174 PMCID: PMC5325801 DOI: 10.1186/s13613-017-0235-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/09/2017] [Indexed: 01/28/2023] Open
Abstract
Background The recent demonstration of prone position’s strong benefit on patient survival has rendered proning a major therapeutic intervention in severe ARDS. Uncertainties remain as to whether or not ARDS patients in the postoperative period of abdominal surgery should be turned prone because of the risk of abdominal complications. Our aim was to investigate the prevalence of surgical complications between patients with and without prone position after abdominal surgery. Methods This study was a multicenter retrospective cohort of patients with ARDS in a context of recent abdominal surgery. Primary outcome was the number of patients who had at least one surgical complication that could be induced or worsened by prone position. Secondary outcomes included effects of prone position on oxygenation. Data from the prone group were compared with those from the supine group (not having undergone at least a prone position session). Results Among 98 patients included, 36 (37%) had at least one prone position session. The rate of surgical complications induced or worsened by prone position did not differ between prone and supine groups [respectively, 14 (39%) vs 27 (44%); p = 0.65]. After propensity score application, there was no significant difference between the two groups (OR 0.72 [0.26–2.02], p = 0.54). Revision surgery did not differ between the groups. The first prone session significantly increased PaO2/FiO2 ratio from 95 ± 47 to 189 ± 92 mmHg, p < 0.0001. Conclusion Prone position of ARDS patients after abdominal surgery was not associated with an increased rate of surgical complication. Intensivists should not refrain from proning these patients. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0235-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stéphane Gaudry
- Medico-Surgical Intensive Care Unit, Hôpital Louis Mourier, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,Sorbonne Paris Cité, ECEVE UMR 1123, Univ Paris Diderot, 75018, Paris, France
| | - Samuel Tuffet
- Medico-Surgical Intensive Care Unit, Hôpital Louis Mourier, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,Département d'Anesthésie Réanimation, Hôpital Lariboisière, AP-HP, 75010, Paris, France.,UMR U 1160, Université Paris-Diderot Paris 7, 75010, Paris, France
| | - Anne-Claire Lukaszewicz
- Département d'Anesthésie Réanimation, Hôpital Lariboisière, AP-HP, 75010, Paris, France.,UMR U 1160, Université Paris-Diderot Paris 7, 75010, Paris, France
| | - Christian Laplace
- Département d'Anesthésie Réanimation, Hôpital Bicêtre, AP-HP, 94270, Le Kremlin-Bicêtre, France
| | - Noémie Zucman
- Medico-Surgical Intensive Care Unit, Hôpital Louis Mourier, AP-HP, 178 rue des Renouillers, 92700, Colombes, France
| | - Marc Pocard
- Hôpital Lariboisière, Chirurgie digestive et cancérologique, AP-HP, 75010, Paris, France.,UMR U 965, Université Paris-Diderot Paris 7, 75010, Paris, France
| | - Bruno Costaglioli
- Hôpital Bicêtre, Chirurgie générale et digestive, AP-HP, 94270, Le Kremlin-Bicêtre, France
| | - Simon Msika
- Hôpital Louis Mourier, Chirurgie digestive, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,UMR 1149, Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France
| | - Jacques Duranteau
- Département d'Anesthésie Réanimation, Hôpital Bicêtre, AP-HP, 94270, Le Kremlin-Bicêtre, France
| | - Didier Payen
- Département d'Anesthésie Réanimation, Hôpital Lariboisière, AP-HP, 75010, Paris, France.,UMR U 1160, Université Paris-Diderot Paris 7, 75010, Paris, France
| | - Didier Dreyfuss
- Medico-Surgical Intensive Care Unit, Hôpital Louis Mourier, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,IAME,UMR 1137, INSERM, 75018, Paris, France.,IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France
| | - David Hajage
- Sorbonne Paris Cité, ECEVE UMR 1123, Univ Paris Diderot, 75018, Paris, France.,Epidemiology and Clinical Research Department, Hôpital Louis Mourier, AP-HP, 178 rue des Renouillers, 92700, Colombes, France
| | - Jean-Damien Ricard
- Medico-Surgical Intensive Care Unit, Hôpital Louis Mourier, AP-HP, 178 rue des Renouillers, 92700, Colombes, France. .,IAME,UMR 1137, INSERM, 75018, Paris, France. .,IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France. .,Service de Réanimation Médicale, 178 rue des Renouillers, 92701, Colombes Cedex, France.
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Wu J, Zhai J, Jiang H, Sun Y, Jin B, Zhang Y, Zhou B. Effect of Change of Mechanical Ventilation Position on the Treatment of Neonatal Respiratory Failure. Cell Biochem Biophys 2017; 72:845-9. [PMID: 25647746 DOI: 10.1007/s12013-015-0547-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The aim of the study was to evaluate the effect of different ventilation positions in newborn infants with respiratory failure. A total of 67 newborn infant cases with respiratory failure were treated in neonatal intensive care unit of Xuzhou Central Hospital from February 2012 to August 2013. These infants were randomly divided into supine group (n = 33) and different position group (n = 34). Supine position for 4 h and prone position for 4 h were alternated in different position group. The results for 8 and 16 h ventilator parameters: oxygenation index OI (OI = PaO2/FiO2), the lung mechanics parameters, ventilator weaning time, arterial carbon dioxide partial pressure (PaCO2), and arterial oxygen tension (PaO2) after 1 h of ventilator weaning were recorded and compared. PaO2 in the different position ventilation groups for 8 h (65.29 ± 7.62 mm Hg) and 16 h (67.52 ± 9.31 mm Hg) were correspondingly higher than PaO2 at 8 h (60.13 ± 8.95 mm Hg) and 16 h (62.22 ± 10.83 mm Hg) in the supine position ventilation group, and the difference was statistically significant (P < 0.05), whereas OI at 8 h (166.95 ± 25.27 mm Hg) and 16 h (169.59 ± 20.28 mm Hg) in the former group was correspondingly higher than the OI at 8 h (150.16 ± 20.51 mm Hg) and 16 h (152.23 ± 22.45 mm Hg) in the latter group, and the difference was statistically significant (P < 0.05). The ventilator weaning time of the two groups and the change in the PaCO2 and PaO2, an hour after ventilator weaning was very similar and the difference was not statistically significant (P > 0.05). The symptoms of respiratory failure and oxygenation can be effectively improved in the newborn infants with different ventilation positions compared to traditional supine position.
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Affiliation(s)
- Jiebin Wu
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Jingfang Zhai
- Obstetrical Department, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Hongxia Jiang
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Yingjun Sun
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Bao Jin
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Yanyan Zhang
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China
| | - Bin Zhou
- Department of Pediatrics, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, China.
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Biotrauma and Ventilator-Induced Lung Injury: Clinical Implications. Chest 2016; 150:1109-1117. [PMID: 27477213 DOI: 10.1016/j.chest.2016.07.019] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 11/22/2022] Open
Abstract
The pathophysiological mechanisms by which mechanical ventilation can contribute to lung injury, termed "ventilator-induced lung injury" (VILI), is increasingly well understood. "Biotrauma" describes the release of mediators by injurious ventilatory strategies, which can lead to lung and distal organ injury. Insights from preclinical models demonstrating that traditional high tidal volumes drove the inflammatory response helped lead to clinical trials demonstrating lower mortality in patients who underwent ventilation with a lower-tidal-volume strategy. Other approaches that minimize VILI, such as higher positive end-expiratory pressure, prone positioning, and neuromuscular blockade have each been demonstrated to decrease indices of activation of the inflammatory response. This review examines the evolution of our understanding of the mechanisms underlying VILI, particularly regarding biotrauma. We will assess evidence that ventilatory and other "adjunctive" strategies that decrease biotrauma offer great potential to minimize the adverse consequences of VILI and to improve the outcomes of patients with respiratory failure.
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Scholten EL, Beitler JR, Prisk GK, Malhotra A. Treatment of ARDS With Prone Positioning. Chest 2016; 151:215-224. [PMID: 27400909 DOI: 10.1016/j.chest.2016.06.032] [Citation(s) in RCA: 241] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/11/2016] [Accepted: 06/29/2016] [Indexed: 12/15/2022] Open
Abstract
Prone positioning was first proposed in the 1970s as a method to improve gas exchange in ARDS. Subsequent observations of dramatic improvement in oxygenation with simple patient rotation motivated the next several decades of research. This work elucidated the physiological mechanisms underlying changes in gas exchange and respiratory mechanics with prone ventilation. However, translating physiological improvements into a clinical benefit has proved challenging; several contemporary trials showed no major clinical benefits with prone positioning. By optimizing patient selection and treatment protocols, the recent Proning Severe ARDS Patients (PROSEVA) trial demonstrated a significant mortality benefit with prone ventilation. This trial, and subsequent meta-analyses, support the role of prone positioning as an effective therapy to reduce mortality in severe ARDS, particularly when applied early with other lung-protective strategies. This review discusses the physiological principles, clinical evidence, and practical application of prone ventilation in ARDS.
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Affiliation(s)
- Eric L Scholten
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, CA.
| | - Jeremy R Beitler
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, CA
| | - G Kim Prisk
- Departments of Medicine and Radiology, University of California, San Diego, La Jolla, CA
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, La Jolla, CA
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Koulouras V, Papathanakos G, Papathanasiou A, Nakos G. Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review. World J Crit Care Med 2016; 5:121-36. [PMID: 27152255 PMCID: PMC4848155 DOI: 10.5492/wjccm.v5.i2.121] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome with heterogeneous underlying pathological processes. It represents a common clinical problem in intensive care unit patients and it is characterized by high mortality. The mainstay of treatment for ARDS is lung protective ventilation with low tidal volumes and positive end-expiratory pressure sufficient for alveolar recruitment. Prone positioning is a supplementary strategy available in managing patients with ARDS. It was first described 40 years ago and it proves to be in alignment with two major ARDS pathophysiological lung models; the "sponge lung" - and the "shape matching" -model. Current evidence strongly supports that prone positioning has beneficial effects on gas exchange, respiratory mechanics, lung protection and hemodynamics as it redistributes transpulmonary pressure, stress and strain throughout the lung and unloads the right ventricle. The factors that individually influence the time course of alveolar recruitment and the improvement in oxygenation during prone positioning have not been well characterized. Although patients' response to prone positioning is quite variable and hard to predict, large randomized trials and recent meta-analyses show that prone position in conjunction with a lung-protective strategy, when performed early and in sufficient duration, may improve survival in patients with ARDS. This pathophysiology-based review and recent clinical evidence strongly support the use of prone positioning in the early management of severe ARDS systematically and not as a rescue maneuver or a last-ditch effort.
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The Effects of Prone Position Ventilation on Experimental Mild Acute Lung Injury Induced by Intraperitoneal Lipopolysaccharide Injection in Rats. Lung 2016; 194:193-9. [PMID: 26912235 DOI: 10.1007/s00408-016-9853-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/05/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The benefits of prone position ventilation are well demonstrated in the severe forms of acute respiratory distress syndrome, but not in the milder forms. We investigated the effects of prone position on arterial blood gases, lung inflammation, and histology in an experimental mild acute lung injury (ALI) model. METHODS ALI was induced in Wistar rats by intraperitoneal Escherichia coli lipopolysaccharide (LPS, 5 mg/kg). After 24 h, the animals with PaO2/FIO2 between 200 and 300 mmHg were randomized into 2 groups: prone position (n = 6) and supine position (n = 6). Both groups were compared with a control group (n = 5) that was ventilated in the supine position. All of the groups were ventilated for 1 h with volume-controlled ventilation mode (tidal volume = 6 ml/kg, respiratory rate = 80 breaths/min, positive end-expiratory pressure = 5 cmH2O, inspired oxygen fraction = 1) RESULTS: Significantly higher lung injury scores were observed in the LPS-supine group compared to the LPS-prone and control groups (0.32 ± 0.03; 0.17 ± 0.03 and 0.13 ± 0.04, respectively) (p < 0.001), mainly due to a higher neutrophil infiltration level in the interstitial space and more proteinaceous debris that filled the airspaces. Similar differences were observed when the gravity-dependent lung regions and non-dependent lung regions were analyzed separately (p < 0.05). The BAL neutrophil content was also higher in the LPS-supine group compared to the LPS-prone and control groups (p < 0.05). There were no significant differences in the wet/dry ratio and gas exchange levels. CONCLUSIONS In this experimental extrapulmonary mild ALI model, prone position ventilation for 1 h, when compared with supine position ventilation, was associated with lower lung inflammation and injury.
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Santini A, Protti A, Langer T, Comini B, Monti M, Sparacino CC, Dondossola D, Gattinoni L. Prone position ameliorates lung elastance and increases functional residual capacity independently from lung recruitment. Intensive Care Med Exp 2015; 3:55. [PMID: 26215819 PMCID: PMC4480350 DOI: 10.1186/s40635-015-0055-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prone position is used to recruit collapsed dependent lung regions during severe acute respiratory distress syndrome, improving lung elastance and lung gas content. We hypothesised that, in the absence of recruitment, prone position would not result in any improvement in lung mechanical properties or gas content compared to supine position. METHODS Ten healthy pigs under general anaesthesia and paralysis underwent a pressure-volume curve of the respiratory system, chest wall and lung in supine and prone positions; the respective elastances were measured. A lung computed tomography (CT) scan was performed in the two positions to compute gas content (i.e. functional residual capacity (FRC)) and the distribution of aeration. Recruitment was defined as a percentage change in non-aerated lung tissue compared to the total lung weight. RESULTS Non-aerated (recruitable) lung tissue was a small percentage of the total lung tissue weight in both positions (4 ± 3 vs 1 ± 1 %, supine vs prone, p = 0.004). Lung elastance decreased (20.5 ± 1.8 vs 15.5 ± 1.6 cmH2O/l, supine vs prone, p < 0.001) and functional residual capacity increased (380 ± 82 vs 459 ± 60 ml, supine vs prone, p = 0.025) in prone position; specific lung elastance did not change (7.0 ± 0.5 vs 6.5 ± 0.5 cmH2O, supine vs prone, p = 0.24). Lung recruitment was low (3 ± 2 %) and was not correlated to increases in functional residual capacity (R (2) 0.2, p = 0.19). A higher amount of well-aerated and a lower amount of poorly aerated lung tissue were found in prone position. CONCLUSIONS In healthy pigs, prone position ameliorates lung mechanical properties and increases functional residual capacity independently from lung recruitment, through a redistribution of lung aeration.
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Affiliation(s)
- Alessandro Santini
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Alessandro Protti
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Thomas Langer
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Beatrice Comini
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Massimo Monti
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Cristina Carin Sparacino
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Daniele Dondossola
- />Centro di Ricerche Chirurgiche Precliniche, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luciano Gattinoni
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
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Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M, Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H. S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). Anaesthesist 2015; 64 Suppl 1:1-26. [PMID: 26335630 PMCID: PMC4712230 DOI: 10.1007/s00101-015-0071-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.
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Affiliation(s)
- Th Bein
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany.
| | - M Bischoff
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - U Brückner
- Physiotherapy Department, Clinic Donaustauf, Centre for Pneumology, 93093, Donaustauf, Germany
| | - K Gebhardt
- Clinic for Anaesthesiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - D Henzler
- Clinic for Anaesthesiology, Surgical Intensive Care Medicine, Emergency Care Medicine, Pain Management, Klinikum Herford, 32049, Herford, Germany
| | - C Hermes
- HELIOS Clinic Siegburg, 53721, Siegburg, Germany
| | - K Lewandowski
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Elisabeth Hospital Essen, 45138, Essen, Germany
| | - M Max
- Centre Hospitalier, Soins Intensifs Polyvalents, 1210, Luxembourg, Luxemburg
| | - M Nothacker
- Association of Scientific Medical Societies (AWMF), 35043, Marburg, Germany
| | - Th Staudinger
- University Hospital for Internal Medicine I, Medical University of Wien, General Hospital of Vienna, 1090, Vienna, Austria
| | - M Tryba
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Management, Klinikum Kassel, 34125, Kassel, Germany
| | - S Weber-Carstens
- Clinic for Anaesthesiology and Surgical Intensive Care Medicine, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, 13353, Berlin, Germany
| | - H Wrigge
- Clinic and Policlinic for Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103, Leipzig, Germany
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Vendettuoli V, Veneroni C, Zannin E, Mercadante D, Matassa P, Pedotti A, Colnaghi M, Dellacà RL, Mosca F. Positional effects on lung mechanics of ventilated preterm infants with acute and chronic lung disease. Pediatr Pulmonol 2015; 50:798-804. [PMID: 24706414 DOI: 10.1002/ppul.23049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 03/07/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The role of prone position in preterm infants has not been completely clarified. We investigated prone versus supine posture-related changes in respiratory system resistance (Rrs) and reactance (Xrs) measured by the Forced Oscillation Technique (FOT) in mechanically ventilated preterm newborns. METHODS Patients were studied in the supine versus prone positions in random order. Oxygen saturation, transcutaneous partial pressure of oxygen (ptcO2 ), carbon dioxide (ptcCO2 ), Rrs and Xrs were measured in each position. RESULTS Nine patients with respiratory distress syndrome (RDS) and nine with evolving broncho-pulmonary dysplasia (BPD) were studied. Rrs was, on average, 9.8 (1.3, 18.3 as 95%CI) cmH2 O*s/l lower in the prone compared to the supine position (P = 0.02), while no differences in Xrs, ptcO2 , ptcCO2 , and breathing pattern were observed between postures. Only patients with evolving BPD showed a significant reduction of Rrs from 69.0 ± 27.4 to 53.0 ± 16.7 cmH2 O*s/l, P = 0.01. No significant correlations were found between changes in lung mechanics and ptcO2 , ptcCO2 , or breathing pattern. CONCLUSIONS On short-term basis, prone positioning does not offer significant advantages in lung mechanics in mechanically ventilated infants with RDS, while it is associated with lower Rrs values in patients with evolving BPD.
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Affiliation(s)
- V Vendettuoli
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - C Veneroni
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - E Zannin
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - D Mercadante
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - P Matassa
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - A Pedotti
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - M Colnaghi
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - R L Dellacà
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - F Mosca
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
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Marcozzi C, Moriondo A, Solari E, Reguzzoni M, Severgnini P, Protasoni M, Passi A, Pelosi P, Negrini D. Regional lung tissue changes with mechanical ventilation and fluid load. Exp Lung Res 2015; 41:228-40. [DOI: 10.3109/01902148.2014.1003436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Pfurtscheller K, Ring S, Beran E, Sorantin E, Zobel J, Ganster D, Avian A, Zobel G. Effect of body position on ventilation distribution during PEEP titration in a porcine model of acute lung injury using advanced respiratory monitoring and electrical impedance tomography. Intensive Care Med Exp 2015. [PMID: 26215805 PMCID: PMC4513029 DOI: 10.1186/s40635-014-0038-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Lung failure after acute lung injury remains a challenge in different clinical settings. Various interventions for restoration of gas exchange have been investigated. Recruitment of collapsed alveoli by positive end expiratory pressure (PEEP) titration and optimization of ventilation-perfusion ratio by prone positioning have been extensively described in animal and clinical trials. This animal study was conducted to investigate the effects of PEEP and positioning by means of advanced respiratory monitoring including gas exchange, respiratory mechanics, volumetric capnography and electrical impedance tomography. Methods After induction of acute lung injury by oleic acid and lung lavage, 12 domestic pigs were studied in randomly assigned supine or prone position during a PEEP titration trial with maximal PEEP of 30 mbar. Results Induction of lung injury resulted in significant deterioration of oxygenation [partial pressure of arterial oxygen/inspiratory fraction of oxygen (PaO2/FiO2): p = 0.002] and ventilation [partial pressure of arterial carbon dioxide (PaCO2): p = 0.002] and elevated alveolar dead-space ratios (Valv/Vte: p = 0.003) in both groups. Differences in the prone and the supine group were significant for PaCO2 at incremental PEEP 10 and 20 and at decremental PEEP 20 (20d) and 10 (10d), for PaO2/FiO2 at PEEP 10 and 10d and for alveolar dead space at PEEP 10d. Electrical impedance tomography revealed homogenous ventilation distribution in prone position during PEEP 20, 30 and 20d. Conclusions Prone position leads to improved oxygenation and ventilation parameters in a lung injury model. Respiratory monitoring with measurement of alveolar dead space and electrical impedance tomography may visualize optimized ventilation in a PEEP titration trial.
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Affiliation(s)
- Klaus Pfurtscheller
- Pediatric Intensive Care Unit, University Children's Hospital and Medical University Graz, Auenbruggerplatz 34, 8036, Graz, Austria,
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Guerin C, Baboi L, Richard JC. Mechanisms of the effects of prone positioning in acute respiratory distress syndrome. Intensive Care Med 2014; 40:1634-42. [PMID: 25266133 DOI: 10.1007/s00134-014-3500-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/17/2014] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Prone positioning has been used for many years in patients with acute respiratory distress syndrome (ARDS). The initial reason for prone positioning in ARDS patients was improvement in oxygenation. It was later shown that mechanical ventilation in the prone position can be less injurious to the lung and hence the primary reason to use prone positioning is prevention of ventilator-induced lung injury (VILI). MATERIAL AND METHODS A large body of physiologic benefits of prone positioning in ARDS patients accumulated but these failed to translate into clinical benefits. More recently, meta-analyses and randomized controlled trial in a specific subgroup of ARDS patients demonstrated that prone positioning can improve survival. This review covers the effects of prone positioning on oxygenation, respiratory mechanics, and VILI. CONCLUSIONS We conclude with the effects of prone positioning on patient outcome, in particular on survival.
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Affiliation(s)
- C Guerin
- Service de Réanimation Médicale, Hôpital de la croix-rousse, CHU de Lyon, Bâtiment R, 2ème étage, 103 Grande rue de la croix-rousse, 69004, Lyon, France,
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Abstract
Multiple animal and human studies have shown that prone positioning improves oxygenation and reduces ventilator-induced lung injury (VILI) in the setting of acute lung injury or acute respiratory distress syndrome (ARDS). In this article, the physiologic changes explaining the improvement in oxygenation are reviewed, how prone positioning reduces VILI is described, randomized controlled trials of prone ventilation in patients with ARDS are evaluated, the complications associated with prone ventilation are summarized, suggestions are made as to how these might be reduced or avoided, and when prone ventilation should start and stop and for what duration it should be used are discussed.
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Affiliation(s)
- Alexander B Benson
- University of Colorado, 12605 E, 16th avenue, Aurora, CO 80045, USA; Department of Medicine, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204-4507, USA
| | - Richard K Albert
- University of Colorado, 12605 E, 16th avenue, Aurora, CO 80045, USA; Department of Medicine, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204-4507, USA.
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Wu XY, Huang YZ, Liu HG, Huang DY, Tang R, Qiu HB. Effects of pulmonary stretch reflex on lung injury in rabbits with acute respiratory distress syndrome. World J Emerg Med 2014; 2:296-301. [PMID: 25215027 DOI: 10.5847/wjem.j.1920-8642.2011.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Accepted: 08/20/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary stretch reflex plays an important role in regulation of respiratory movement. This study aimed to evaluate the effect of pulmonary stretch reflex on lung injury in rabbits with acute respiratory distress syndrome (ARDS). METHODS ARDS rabbits were given intratracheal infusion of hydrochloric acid and ventilated with neurally adjusted ventilatory assistance (NAVA) with a tidal volume (VT) of 6 mL/kg and the electrical activity of diaphragm (EAdi)-determined positive end expiratory pressure. After isolation of the bilateral vagus nerve trunk, the rabbits were randomized into two groups: sham operation (SHAM) group (n=5) and bilateral vagotomy (VAG) group (n=5). Gas exchange and respiratory mechanics were detected at baseline, after lung injury and 1, 2, and 3 hours after ventilation respectively. Pulmonary permeability index, pathological changes and inflammatory response were also measured. RESULTS Compared with the SHAM group, PaO2/FiO2 in the VAG group decreased significantly 2 and 3 hours after ventilation (P<0.05). There was no significant difference in PaCO2 between the SHAM and VAG groups (P>0.05), and the VAG group had a high VT, peak pressure (Ppeak), and mean pressure (Pm) compared with the SHAM group 1, 2, 3 hours after ventilation (P<0.05). Compared to the SHAM group, dead space fraction (VD/VT) and respiratory system elastance (Ers) in the VAG group increased (P<0.05) and static pulmonary compliance (Cst) decreased markedly (P<0.05) after ventilation for 3 hours. Lung wet/dry weight ratio (W/D) (8.4±1.2 vs. 6.6±1.0), lung injury score (6.3±1.8 vs. 3.8±1.3), tumor necrosis factor-α (TNF-α) (779±372 pg/mL vs. 355±130 pg/mL) and interleukin-8 (IL-8) (169±21 pg/mL vs. 118±17 pg/mL) increased significantly in the VAG group compared with the SHAM group (P<0.05). CONCLUSION Lung injury is aggravated after bilateral vagotomy, demonstrating that pulmonary stretch reflex may have protective effect on the lung.
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Affiliation(s)
- Xiao-Yan Wu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Clinical Medicine, Nanjing 210009, China (Wu XY, Huang YZ, Liu HG, Huang DA, Tang R, Qiu HB); Subei People's Hospital & Clinical Medical School, Yangzhou University ,Yangzhou 225001, China (Wu XY)
| | - Ying-Zi Huang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Clinical Medicine, Nanjing 210009, China (Wu XY, Huang YZ, Liu HG, Huang DA, Tang R, Qiu HB); Subei People's Hospital & Clinical Medical School, Yangzhou University ,Yangzhou 225001, China (Wu XY)
| | - Huo-Gen Liu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Clinical Medicine, Nanjing 210009, China (Wu XY, Huang YZ, Liu HG, Huang DA, Tang R, Qiu HB); Subei People's Hospital & Clinical Medical School, Yangzhou University ,Yangzhou 225001, China (Wu XY)
| | - Dong-Ya Huang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Clinical Medicine, Nanjing 210009, China (Wu XY, Huang YZ, Liu HG, Huang DA, Tang R, Qiu HB); Subei People's Hospital & Clinical Medical School, Yangzhou University ,Yangzhou 225001, China (Wu XY)
| | - Rui Tang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Clinical Medicine, Nanjing 210009, China (Wu XY, Huang YZ, Liu HG, Huang DA, Tang R, Qiu HB); Subei People's Hospital & Clinical Medical School, Yangzhou University ,Yangzhou 225001, China (Wu XY)
| | - Hai-Bo Qiu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University School of Clinical Medicine, Nanjing 210009, China (Wu XY, Huang YZ, Liu HG, Huang DA, Tang R, Qiu HB); Subei People's Hospital & Clinical Medical School, Yangzhou University ,Yangzhou 225001, China (Wu XY)
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Stress et strain : application au cours du syndrome de détresse respiratoire aiguë. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0906-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wellman TJ, Winkler T, Costa EL, Musch G, Harris RS, Zheng H, Venegas JG, Vidal Melo MF. Effect of local tidal lung strain on inflammation in normal and lipopolysaccharide-exposed sheep*. Crit Care Med 2014; 42:e491-500. [PMID: 24758890 PMCID: PMC4123638 DOI: 10.1097/ccm.0000000000000346] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Regional tidal lung strain may trigger local inflammation during mechanical ventilation, particularly when additional inflammatory stimuli are present. However, it is unclear whether inflammation develops proportionally to tidal strain or only above a threshold. We aimed to 1) assess the relationship between regional tidal strain and local inflammation in vivo during the early stages of lung injury in lungs with regional aeration heterogeneity comparable to that of humans and 2) determine how this strain-inflammation relationship is affected by endotoxemia. DESIGN Interventional animal study. SETTING Experimental laboratory and PET facility. SUBJECTS Eighteen 2- to 4-month-old sheep. INTERVENTIONS Three groups of sheep (n = 6) were mechanically ventilated to the same plateau pressure (30-32 cm H2O) with high-strain (VT = 18.2 ± 6.5 mL/kg, positive end-expiratory pressure = 0), high-strain plus IV lipopolysaccharide (VT = 18.4 ± 4.2 mL/kg, positive end-expiratory pressure = 0), or low-strain plus lipopolysaccharide (VT = 8.1 ± 0.2 mL/kg, positive end-expiratory pressure = 17 ± 3 cm H2O). At baseline, we acquired respiratory-gated PET scans of inhaled NN to measure tidal strain from end-expiratory and end-inspiratory images in six regions of interest. After 3 hours of mechanical ventilation, dynamic [F]fluoro-2-deoxy-D-glucose scans were acquired to quantify metabolic activation, indicating local neutrophilic inflammation, in the same regions of interest. MEASUREMENTS AND MAIN RESULTS Baseline regional tidal strain had a significant effect on [F]fluoro-2-deoxy-D-glucose net uptake rate Ki in high-strain lipopolysaccharide (p = 0.036) and on phosphorylation rate k3 in high-strain (p = 0.027) and high-strain lipopolysaccharide (p = 0.004). Lipopolysaccharide exposure increased the k3-tidal strain slope three-fold (p = 0.009), without significant lung edema. The low-strain lipopolysaccharide group showed lower baseline regional tidal strain (0.33 ± 0.17) than high-strain (1.21 ± 0.62; p < 0.001) or high-strain lipopolysaccharide (1.26 ± 0.44; p < 0.001) and lower k3 (p < 0.001) and Ki (p < 0.05) than high-strain lipopolysaccharide. CONCLUSIONS Local inflammation develops proportionally to regional tidal strain during early lung injury. The regional inflammatory effect of strain is greatly amplified by IV lipopolysaccharide. Tidal strain enhances local [F]fluoro-2-deoxy-D-glucose uptake primarily by increasing the rate of intracellular [F]fluoro-2-deoxy-D-glucose phosphorylation.
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Affiliation(s)
- Tyler J. Wellman
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tilo Winkler
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eduardo L.V. Costa
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Guido Musch
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - R. Scott Harris
- Pulmonary and Critical Care Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jose G. Venegas
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Cornejo RA, Díaz JC, Tobar EA, Bruhn AR, Ramos CA, González RA, Repetto CA, Romero CM, Gálvez LR, Llanos O, Arellano DH, Neira WR, Díaz GA, Zamorano AJ, Pereira GL. Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2014; 188:440-8. [PMID: 23348974 DOI: 10.1164/rccm.201207-1279oc] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Positive end-expiratory pressure (PEEP) and prone positioning may induce lung recruitment and affect alveolar dynamics in acute respiratory distress syndrome (ARDS). Whether there is interdependence between the effects of PEEP and prone positioning on these variables is unknown. OBJECTIVES To determine the effects of high PEEP and prone positioning on lung recruitment, cyclic recruitment/derecruitment, and tidal hyperinflation and how these effects are influenced by lung recruitability. METHODS Mechanically ventilated patients (Vt 6 ml/kg ideal body weight) underwent whole-lung computed tomography (CT) during breath-holding sessions at airway pressures of 5, 15, and 45 cm H2O and Cine-CTs on a fixed thoracic transverse slice at PEEP 5 and 15 cm H2O. CT images were repeated in supine and prone positioning. A recruitment maneuver at 45 cm H2O was performed before each PEEP change. Lung recruitability was defined as the difference in percentage of nonaerated tissue between 5 and 45 cm H2O. Cyclic recruitment/de-recruitment and tidal hyperinflation were determined as tidal changes in percentage of nonaerated and hyperinflated tissue, respectively. MEASUREMENTS AND MAIN RESULTS Twenty-four patients with ARDS were included. Increasing PEEP from 5 to 15 cm H2O decreased nonaerated tissue (501 ± 201 to 322 ± 132 grams; P < 0.001) and increased tidal-hyperinflation (0.41 ± 0.26 to 0.57 ± 0.30%; P = 0.004) in supine. Prone positioning further decreased nonaerated tissue (322 ± 132 to 290 ± 141 grams; P = 0.028) and reduced tidal hyperinflation observed at PEEP 15 in supine patients (0.57 ± 0.30 to 0.41 ± 0.22%). Cyclic recruitment/de-recruitment only decreased when high PEEP and prone positioning were applied together (4.1 ± 1.9 to 2.9 ± 0.9%; P = 0.003), particularly in patients with high lung recruitability. CONCLUSIONS Prone positioning enhances lung recruitment and decreases alveolar instability and hyperinflation observed at high PEEP in patients with ARDS.
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Affiliation(s)
- Rodrigo A Cornejo
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile.
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Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med 2014; 188:1286-93. [PMID: 24134414 DOI: 10.1164/rccm.201308-1532ci] [Citation(s) in RCA: 283] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In the prone position, computed tomography scan densities redistribute from dorsal to ventral as the dorsal region tends to reexpand while the ventral zone tends to collapse. Although gravitational influence is similar in both positions, dorsal recruitment usually prevails over ventral derecruitment, because of the need for the lung and its confining chest wall to conform to the same volume. The final result of proning is that the overall lung inflation is more homogeneous from dorsal to ventral than in the supine position, with more homogeneously distributed stress and strain. As the distribution of perfusion remains nearly constant in both postures, proning usually improves oxygenation. Animal experiments clearly show that prone positioning delays or prevents ventilation-induced lung injury, likely due in large part to more homogeneously distributed stress and strain. Over the last 15 years, five major trials have been conducted to compare the prone and supine positions in acute respiratory distress syndrome, regarding survival advantage. The sequence of trials enrolled patients who were progressively more hypoxemic; exposure to the prone position was extended from 8 to 17 hours/day, and lung-protective ventilation was more rigorously applied. Single-patient and meta-analyses drawing from the four major trials showed significant survival benefit in patients with PaO2/FiO2 lower than 100. The latest PROSEVA (Proning Severe ARDS Patients) trial confirmed these benefits in a formal randomized study. The bulk of data indicates that in severe acute respiratory distress syndrome, carefully performed prone positioning offers an absolute survival advantage of 10-17%, making this intervention highly recommended in this specific population subset.
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Affiliation(s)
- Luciano Gattinoni
- 1 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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