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Buiteman-Kruizinga LA, Serpa Neto A, Botta M, List SS, de Boer BH, van Velzen P, Bühler PK, Wendel Garcia PD, Schultz MJ, van der Heiden PLJ, Paulus F, for the INTELLiPOWER–investigators. Effect of automated versus conventional ventilation on mechanical power of ventilation-A randomized crossover clinical trial. PLoS One 2024; 19:e0307155. [PMID: 39078857 PMCID: PMC11288413 DOI: 10.1371/journal.pone.0307155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/29/2024] [Indexed: 08/02/2024] Open
Abstract
INTRODUCTION Mechanical power of ventilation, a summary parameter reflecting the energy transferred from the ventilator to the respiratory system, has associations with outcomes. INTELLiVENT-Adaptive Support Ventilation is an automated ventilation mode that changes ventilator settings according to algorithms that target a low work-and force of breathing. The study aims to compare mechanical power between automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation and conventional ventilation in critically ill patients. MATERIALS AND METHODS International, multicenter, randomized crossover clinical trial in patients that were expected to need invasive ventilation > 24 hours. Patients were randomly assigned to start with a 3-hour period of automated ventilation or conventional ventilation after which the alternate ventilation mode was selected. The primary outcome was mechanical power in passive and active patients; secondary outcomes included key ventilator settings and ventilatory parameters that affect mechanical power. RESULTS A total of 96 patients were randomized. Median mechanical power was not different between automated and conventional ventilation (15.8 [11.5-21.0] versus 16.1 [10.9-22.6] J/min; mean difference -0.44 (95%-CI -1.17 to 0.29) J/min; P = 0.24). Subgroup analyses showed that mechanical power was lower with automated ventilation in passive patients, 16.9 [12.5-22.1] versus 19.0 [14.1-25.0] J/min; mean difference -1.76 (95%-CI -2.47 to -10.34J/min; P < 0.01), and not in active patients (14.6 [11.0-20.3] vs 14.1 [10.1-21.3] J/min; mean difference 0.81 (95%-CI -2.13 to 0.49) J/min; P = 0.23). CONCLUSIONS In this cohort of unselected critically ill invasively ventilated patients, automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation did not reduce mechanical power. A reduction in mechanical power was only seen in passive patients. STUDY REGISTRATION Clinicaltrials.gov (study identifier NCT04827927), April 1, 2021. URL OF TRIAL REGISTRY RECORD https://clinicaltrials.gov/study/NCT04827927?term=intellipower&rank=1.
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Affiliation(s)
- Laura A. Buiteman-Kruizinga
- Department of Intensive Care, Reinier de Graaf Hospital, Delft, the Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
- Australian and New Zealand Intensive Care–Research Centre (ANZIC–RC), Monash University, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
| | - Stephanie S. List
- Department of Intensive Care, Dijklander Hospital ‘Location Hoorn’, Hoorn, the Netherlands
| | - Ben H. de Boer
- Department of Intensive Care, Dijklander Hospital ‘Location Hoorn’, Hoorn, the Netherlands
| | - Patricia van Velzen
- Department of Intensive Care, Dijklander Hospital ‘Location Hoorn’, Hoorn, the Netherlands
| | - Philipp Karl Bühler
- Institute of Intensive Care Medicine, University Hospital Zürich, Zürich, Switzerland
| | | | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University Wien, Vienna, Austria
| | | | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
- ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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Bernardi MH, Bettex D, Buiteman-Kruizinga LA, de Bie A, Hoffmann M, de Kleijn J, Serafini SC, Molenaar MA, Paulus F, Peršec J, Neto AS, Schuepbach R, Severgnini P, Šribar A, Schultz MJ, Tschernko E. POStoperative INTELLiVENT-adaptive support VEntilation in cardiac surgery patients (POSITiVE) II-study protocol of a randomized clinical trial. Trials 2024; 25:449. [PMID: 38961468 PMCID: PMC11223327 DOI: 10.1186/s13063-024-08296-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND One single-center randomized clinical trial showed that INTELLiVENT-adaptive support ventilation (ASV) is superior to conventional ventilation with respect to the quality of ventilation in post-cardiac surgery patients. Other studies showed that this automated ventilation mode reduces the number of manual interventions at the ventilator in various types of critically ill patients. In this multicenter study in patients post-cardiac surgery, we test the hypothesis that INTELLiVENT-ASV is superior to conventional ventilation with respect to the quality of ventilation. METHODS "POStoperative INTELLiVENT-adaptive support VEntilation in cardiac surgery patients II (POSITiVE II)" is an international, multicenter, two-group randomized clinical superiority trial. In total, 328 cardiac surgery patients will be randomized. Investigators screen patients aged > 18 years of age, scheduled for elective cardiac surgery, and expected to receive postoperative ventilation in the ICU for longer than 2 h. Patients either receive automated ventilation by means of INTELLiVENT-ASV or ventilation that is not automated by means of a conventional ventilation mode. The primary endpoint is quality of ventilation, defined as the proportion of postoperative ventilation time characterized by exposure to predefined optimal, acceptable, and critical (injurious) ventilatory parameters in the first two postoperative hours. One major secondary endpoint is ICU team staff workload, captured by the ventilator software collecting manual settings on alarms. Patient-centered endpoints include duration of postoperative ventilation and length of stay in ICU. DISCUSSION POSITiVE II is the first international, multicenter, randomized clinical trial designed to confirm that POStoperative INTELLiVENT-ASV is superior to non-automated conventional ventilation and secondary to determine if this closed-loop ventilation mode reduces ICU team staff workload. The results of POSITiVE II will support intensive care teams in their choices regarding the use of automated ventilation in postoperative care of uncomplicated cardiac surgery patients. TRIAL REGISTRATION Clinicaltrials.gov NCT06178510 . Registered on December 4, 2023.
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Affiliation(s)
- Martin H Bernardi
- Department of Anesthesia, General Intensive Care and Pain Management--Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Dominique Bettex
- University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Laura A Buiteman-Kruizinga
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
- Department of Intensive Care, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Ashley de Bie
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Matthias Hoffmann
- University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Janine de Kleijn
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Simon Corrado Serafini
- Department of Anesthesia, General Intensive Care and Pain Management--Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Manon A Molenaar
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Jasminka Peršec
- Clinical Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paolo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Reto Schuepbach
- University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Paolo Severgnini
- Cardiac Surgery Intensive Care Unit, ASST Dei Sette Laghi, University of Insubria, Varese, Italy
| | - Andrej Šribar
- Clinical Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Marcus J Schultz
- Department of Anesthesia, General Intensive Care and Pain Management--Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Edda Tschernko
- Department of Anesthesia, General Intensive Care and Pain Management--Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Stivi T, Padawer D, Dirini N, Nachshon A, Batzofin BM, Ledot S. Using Artificial Intelligence to Predict Mechanical Ventilation Weaning Success in Patients with Respiratory Failure, Including Those with Acute Respiratory Distress Syndrome. J Clin Med 2024; 13:1505. [PMID: 38592696 PMCID: PMC10934889 DOI: 10.3390/jcm13051505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 04/10/2024] Open
Abstract
The management of mechanical ventilation (MV) remains a challenge in intensive care units (ICUs). The digitalization of healthcare and the implementation of artificial intelligence (AI) and machine learning (ML) has significantly influenced medical decision-making capabilities, potentially enhancing patient outcomes. Acute respiratory distress syndrome, an overwhelming inflammatory lung disease, is common in ICUs. Most patients require MV. Prolonged MV is associated with an increased length of stay, morbidity, and mortality. Shortening the MV duration has both clinical and economic benefits and emphasizes the need for better MV weaning management. AI and ML models can assist the physician in weaning patients from MV by providing predictive tools based on big data. Many ML models have been developed in recent years, dealing with this unmet need. Such models provide an important prediction regarding the success of the individual patient's MV weaning. Some AI models have shown a notable impact on clinical outcomes. However, there are challenges in integrating AI models into clinical practice due to the unfamiliar nature of AI for many physicians and the complexity of some AI models. Our review explores the evolution of weaning methods up to and including AI and ML as weaning aids.
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Affiliation(s)
- Tamar Stivi
- Department of Anesthesia, Critical Care and Pain Medicine, Hadassah Medical Center, Ein Kerem, POB 12000, Jerusalem 9112001, Israel; (N.D.); (A.N.); (B.M.B.); (S.L.)
| | - Dan Padawer
- Department of Pulmonary Medicine, Hadassah Medical Center, Ein Kerem, POB 12000, Jerusalem 9112001, Israel;
- Faculty of Medicine, Hebrew University of Jerusalem, Campus Ein Kerem, Jerusalem 9112102, Israel
| | - Noor Dirini
- Department of Anesthesia, Critical Care and Pain Medicine, Hadassah Medical Center, Ein Kerem, POB 12000, Jerusalem 9112001, Israel; (N.D.); (A.N.); (B.M.B.); (S.L.)
| | - Akiva Nachshon
- Department of Anesthesia, Critical Care and Pain Medicine, Hadassah Medical Center, Ein Kerem, POB 12000, Jerusalem 9112001, Israel; (N.D.); (A.N.); (B.M.B.); (S.L.)
| | - Baruch M. Batzofin
- Department of Anesthesia, Critical Care and Pain Medicine, Hadassah Medical Center, Ein Kerem, POB 12000, Jerusalem 9112001, Israel; (N.D.); (A.N.); (B.M.B.); (S.L.)
| | - Stephane Ledot
- Department of Anesthesia, Critical Care and Pain Medicine, Hadassah Medical Center, Ein Kerem, POB 12000, Jerusalem 9112001, Israel; (N.D.); (A.N.); (B.M.B.); (S.L.)
- Faculty of Medicine, Hebrew University of Jerusalem, Campus Ein Kerem, Jerusalem 9112102, Israel
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Nijbroek SGLH, Roozeman JP, Ettayeby S, Rosenberg NM, van Meenen DMP, Cherpanath TGV, Lagrand WK, Tepaske R, Klautz RJM, Serpa Neto A, Schultz MJ. Closed-Loop ventilation using sidestream versus mainstream capnography for automated adjustments of minute ventilation-A randomized clinical trial in cardiac surgery patients. PLoS One 2023; 18:e0289412. [PMID: 37611007 PMCID: PMC10446221 DOI: 10.1371/journal.pone.0289412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/18/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND INTELLiVENT-Adaptive Support Ventilation (ASV) is a closed-loop ventilation mode that uses capnography to adjust tidal volume (VT) and respiratory rate according to a user-set end-tidal CO2 (etCO2) target range. We compared sidestream versus mainstream capnography with this ventilation mode with respect to the quality of breathing in patients after cardiac surgery. METHODS Single-center, single-blinded, non-inferiority, randomized clinical trial in adult patients scheduled for elective cardiac surgery that were expected to receive at least two hours of postoperative ventilation in the ICU. Patients were randomized 1:1 to closed-loop ventilation with sidestream or mainstream capnography. Each breath was classified into a zone based on the measured VT, maximum airway pressure, etCO2 and pulse oximetry. The primary outcome was the proportion of breaths spent in a predefined 'optimal' zone of ventilation during the first three hours of postoperative ventilation, with a non-inferiority margin for the difference in the proportions set at -20%. Secondary endpoints included the proportion of breaths in predefined 'acceptable' and 'critical' zones of ventilation, and the proportion of breaths with hypoxemia. RESULTS Of 80 randomized subjects, 78 were included in the intention-to-treat analysis. We could not confirm the non-inferiority of closed-loop ventilation using sidestream with respect to the proportion of breaths in the 'optimal' zone (mean ratio 0.87 [0.77 to ∞]; P = 0.116 for non-inferiority). The proportion of breaths with hypoxemia was higher in the sidestream capnography group versus the mainstream capnography group. CONCLUSIONS We could not confirm that INTELLiVENT-ASV using sidestream capnography is non-inferior to INTELLiVENT-ASV using mainstream capnography with respect to the quality of breathing in subjects receiving postoperative ventilation after cardiac surgery. TRIAL REGISTRATION NCT04599491 (clinicaltrials.gov).
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Affiliation(s)
- Sunny G. L. H. Nijbroek
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Jan-Paul Roozeman
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Sarah Ettayeby
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Neeltje M. Rosenberg
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Internal Medicine, Spaarne Hospital, Haarlem, The Netherlands
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Wim K. Lagrand
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Robert Tepaske
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Robert J. M. Klautz
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Australian and New Zealand Intensive Care Research Centre (ANZIC–RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Critical Care, Austin Hospital, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paolo, Brazil
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
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Abstract
PURPOSE OF REVIEW The last 25 years have seen considerable development in modes of closed-loop ventilation and there are now several of them commercially available. They not only offer potential benefits for the individual patient, but may also improve the organization within the intensive care unit (ICU). Clinicians are showing both greater interest and willingness to address the issues of a caregiver shortage and overload of bedside work in the ICU. This article reviews the clinical benefits of using closed-loop ventilation modes, with a focus on control of oxygenation, lung protection, and weaning. RECENT FINDINGS Closed-loop ventilation modes are able to maintain important physiological variables, such as oxygen saturation measured by pulse oximetry, tidal volume (VT), driving pressure (ΔP), and mechanical power (MP), within target ranges aimed at ensuring continuous lung protection. In addition, these modes adapt the ventilator support to the patient's needs, promoting diaphragm activity and preventing over-assistance. Some studies have shown the potential of these modes to reduce the duration of both weaning and mechanical ventilation. SUMMARY Recent studies have primarily demonstrated the safety, efficacy, and feasibility of using closed-loop ventilation modes in the ICU and postsurgery patients. Large, multicenter randomized controlled trials are needed to assess their impact on important short- and long-term clinical outcomes, the organization of the ICU, and cost-effectiveness.
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Affiliation(s)
- Jean-Michel Arnal
- Service de réanimation polyvalente, Hôpital Sainte Musse, Toulon, France
- Department of Research and New Technologies, Hamilton Medical, Bonaduz, Switzerland
| | - Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Christopher Howard
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, USA
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