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Macías Paredes A, Alvarez JM, Pérez N, Puy C, Peñacoba P, Segura M, Antón A. Controlled cycles in spontaneous-timed noninvasive ventilation: Incidence and associated factors. Respir Med 2022; 204:107005. [DOI: 10.1016/j.rmed.2022.107005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 10/31/2022]
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2
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Doerschug KC. Patient-Ventilator Synchrony. Clin Chest Med 2022; 43:511-518. [PMID: 36116818 DOI: 10.1016/j.ccm.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient-ventilator asynchrony develops when the ventilator output does not match the efforts of the patient and contributes to excess work of breathing, lung injury, and mortality. Asynchronies are categorized as trigger (breath initiation), flow (delivery of the breath), and cycle (transition from inspiration to expiration). Clinicians should be skilled at ventilator waveform analysis to detect patient-ventilator asynchronies and make informed ventilator adjustments. Ventilator overdrive suppresses respiratory drive and reduces asynchrony, while other adjustments specific to the asynchrony are also useful.
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Affiliation(s)
- Kevin C Doerschug
- Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52246, USA.
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De Oliveira B, Aljaberi N, Taha A, Abduljawad B, Hamed F, Rahman N, Mallat J. Patient-Ventilator Dyssynchrony in Critically Ill Patients. J Clin Med 2021; 10:jcm10194550. [PMID: 34640566 PMCID: PMC8509510 DOI: 10.3390/jcm10194550] [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: 08/08/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Patient–ventilator dyssynchrony is a mismatch between the patient’s respiratory efforts and mechanical ventilator delivery. Dyssynchrony can occur at any phase throughout the respiratory cycle. There are different types of dyssynchrony with different mechanisms and different potential management: trigger dyssynchrony (ineffective efforts, autotriggering, and double triggering); flow dyssynchrony, which happens during the inspiratory phase; and cycling dyssynchrony (premature cycling and delayed cycling). Dyssynchrony has been associated with patient outcomes. Thus, it is important to recognize and address these dyssynchronies at the bedside. Patient–ventilator dyssynchrony can be detected by carefully scrutinizing the airway pressure–time and flow–time waveforms displayed on the ventilator screens along with assessing the patient’s comfort. Clinicians need to know how to depict these dyssynchronies at the bedside. This review aims to define the different types of dyssynchrony and then discuss the evidence for their relationship with patient outcomes and address their potential management.
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Affiliation(s)
- Bruno De Oliveira
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Nahla Aljaberi
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Ahmed Taha
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Baraa Abduljawad
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195, USA
- Faculty of Medicine, Normandy University, UNICAEN, ED 497, 1400 Caen, France
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier de Lens, 62300 Lens, France
- Correspondence:
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Affiliation(s)
- Neil MacIntyre
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Craig Rackley
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Felix Khusid
- Department of Respiratory Therapy, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
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Pérez J, Dorado JH, Papazian AC, Berastegui M, Gilgado DI, Cardoso GP, Cesio C, Accoce M. Titration and characteristics of pressure-support ventilation use in Argentina: an online cross-sectional survey study. Rev Bras Ter Intensiva 2020; 32:81-91. [PMID: 32401994 PMCID: PMC7206961 DOI: 10.5935/0103-507x.20200013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022] Open
Abstract
Objective To identify common practices related to the use and titration of pressure-support ventilation (PC-CSV - pressure control-continuous spontaneous ventilation) in patients under mechanical ventilation and to analyze diagnostic criteria for over-assistance and under-assistance. The secondary objective was to compare the responses provided by physician, physiotherapists and nurses related to diagnostic criteria for over-assistance and under-assistance. Methods An online survey was conducted using the Survey Monkey tool. Physicians, nurses and physiotherapists from Argentina with access to PC-CSV in their usual clinical practice were included. Results A total of 509 surveys were collected from October to December 2018. Of these, 74.1% were completed by physiotherapists. A total of 77.6% reported using PC-CSV to initiate the partial ventilatory support phase, and 43.8% of respondents select inspiratory pressure support level based on tidal volume. The main objective for selecting positive end-expiratory pressure (PEEP) level was to decrease the work of breathing. High tidal volume was the primary variable for detecting over-assistance, while the use of accessory respiratory muscles was the most commonly chosen for under-assistance. Discrepancies were observed between physicians and physiotherapists in relation to the diagnostic criteria for over-assistance. Conclusion The most commonly used mode to initiate the partial ventilatory support phase was PC-CSV. The most frequently selected variable to guide the titration of inspiratory pressure support level was tidal volume, and the main objective of PEEP was to decrease the work of breathing. Over-assistance was detected primarily by high tidal volume, while under-assistance by accessory respiratory muscles activation. Discrepancies were observed among professions in relation to the diagnostic criteria for over-assistance, but not for under-assistance.
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Affiliation(s)
- Joaquin Pérez
- Sanatorio Anchorena de San Martín, San Martín, Buenos Aires, Argentina
| | | | | | | | | | | | - Cristian Cesio
- Sanatorio Anchorena de San Martín, San Martín, Buenos Aires, Argentina
| | - Matías Accoce
- Sanatorio Anchorena de San Martín, San Martín, Buenos Aires, Argentina
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Patient–Ventilator Asynchronies during Polysomnography. Ann Am Thorac Soc 2018; 15:1229-1233. [DOI: 10.1513/annalsats.201803-196cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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DiBlasi RM, Crotwell DN, Poli J, Hotz J, Cogen JD, Carter E. A pilot study to assess short-term physiologic outcomes of transitioning infants with severe bronchopulmonary dysplasia from ICU to two subacute ventilators. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2018; 54:01. [PMID: 29636639 PMCID: PMC5875982 DOI: 10.29390/cjrt-2018-001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction This study was designed to evaluate short-term physiologic outcomes of transitioning neonates with bronchopulmonary dysplasia (BPD) from intensive care unit (ICU) ventilators to both the Trilogy 202 (Philips Healthcare, Andover, MA) and LTV 1200 (CareFusion, Yorba Linda, CA) subacute ventilators. Methods Six infants with BPD requiring tracheostomies for support with a neonatal-specific ICU ventilator underwent placement of esophageal balloon catheters, airway pressure transducers, flow sensors, oxygen saturation (SpO2), and end tidal carbon dioxide (PETCO2) monitors. Noninvasive gas exchange, airflow, and airway and esophageal pressures (PES) were recorded following 20 min on the ICU ventilator. The infants were placed on the Trilogy 202 and LTV 1200 ventilators in random order at identical settings as the ICU ventilator. We measured noninvasive gas exchange, pressure-rate product (respiratory rate × ΔPES), ventilator response times, and the percentage of spontaneous breaths that triggered the ventilator at 20 min in each subject while being supported with each of the different subacute ventilators. Results The mean (SD) weight of the six infants was 4.983 (0.56) kg. There were no differences in heart rate (p = 0.51) or SpO2 (p = 0.97) but lower PETCO2, ΔPES, respiratory rate, pressure rate-product, response times, and greater percentage of subject initiated breaths that triggered the ventilator (p < 0.05) was observed with the Trilogy 202 than the LTV 1200. All six infants transitioned successfully from the ICU ventilator to the Trilogy 202 ventilator. Conclusion In this small group of infants with BPD, the Trilogy 202 ventilator performed better than the LTV 1200. The improved subject efforts, per cent subject triggering, and response times observed with the Trilogy are likely related to differences in triggering algorithms, location of triggering mechanisms, and gas delivery system performance within the ventilators. These pilot data may be useful for informing future clinical study design and understanding differences in the level of support provided by different subacute ventilators in infants with BPD.
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Affiliation(s)
- Robert M DiBlasi
- Center for Developmental Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA.,Respiratory Care Department, Seattle Children's Hospital, Seattle, WA, USA
| | - Dave N Crotwell
- Respiratory Care Department, Seattle Children's Hospital, Seattle, WA, USA
| | - Jonathan Poli
- Center for Developmental Therapeutics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Justin Hotz
- Respiratory Care Department, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Edward Carter
- Division of Pulmonary and Sleep Medicine, Banner Health, Phoenix, AZ, USA
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Junhasavasdikul D, Telias I, Grieco DL, Chen L, Gutierrez CM, Piraino T, Brochard L. Expiratory Flow Limitation During Mechanical Ventilation. Chest 2018; 154:948-962. [PMID: 29432712 DOI: 10.1016/j.chest.2018.01.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/27/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022] Open
Abstract
Expiratory flow limitation (EFL) is present when the flow cannot rise despite an increase in the expiratory driving pressure. The mechanisms of EFL are debated but are believed to be related to the collapsibility of small airways. In patients who are mechanically ventilated, EFL can exist during tidal ventilation, representing an extreme situation in which lung volume cannot decrease, regardless of the expiratory driving forces. It is a key factor for the generation of auto- or intrinsic positive end-expiratory pressure (PEEP) and requires specific management such as positioning and adjustment of external PEEP. EFL can be responsible for causing dyspnea and patient-ventilator dyssynchrony, and it is influenced by the fluid status of the patient. EFL frequently affects patients with COPD, obesity, and heart failure, as well as patients with ARDS, especially at low PEEP. EFL is, however, most often unrecognized in the clinical setting despite being associated with complications of mechanical ventilation and poor outcomes such as postoperative pulmonary complications, extubation failure, and possibly airway injury in ARDS. Therefore, prompt recognition might help the management of patients being mechanically ventilated who have EFL and could potentially influence outcome. EFL can be suspected by using different means, and this review summarizes the methods to specifically detect EFL during mechanical ventilation.
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Affiliation(s)
- Detajin Junhasavasdikul
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Domenico Luca Grieco
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli," Rome, Italy
| | - Lu Chen
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Cinta Millan Gutierrez
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Thomas Piraino
- Department of Respiratory Therapy, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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Sleep-Disordered Breathing in Neuromuscular Disease: Diagnostic and Therapeutic Challenges. Chest 2017; 152:880-892. [PMID: 28372949 DOI: 10.1016/j.chest.2017.03.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/23/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Normal sleep-related rapid eye movement sleep atonia, reduced lung volumes, reduced chemosensitivity, and impaired airway dilator activity become significant vulnerabilities in the setting of neuromuscular disease. In that context, the compounding effects of respiratory muscle weakness and disease-specific features that promote upper airway collapse or cause dilated cardiomyopathy contribute to various sleep-disordered breathing events. The reduction in lung volumes with neuromuscular disease is further compromised by sleep and the supine position, exaggerating the tendency for upper airway collapse and desaturation with sleep-disordered breathing events. The most commonly identified events are diaphragmatic/pseudo-central, due to a decrease in the rib cage contribution to the tidal volume during phasic rapid eye movement sleep. Obstructive and central sleep apneas are also common. Noninvasive ventilation can improve survival and quality of sleep but should be used with caution in the context of dilated cardiomyopathy or significant bulbar symptoms. Noninvasive ventilation can also trigger sleep-disordered breathing events, including ineffective triggering, autotriggering, central sleep apnea, and glottic closure, which compromise the potential benefits of the intervention by increasing arousals, reducing adherence, and impairing sleep architecture. Polysomnography plays an important diagnostic and therapeutic role by correctly categorizing sleep-disordered events, identifying sleep-disordered breathing triggered by noninvasive ventilation, and improving noninvasive ventilation settings. Optimal management may require dedicated hypoventilation protocols and a technical staff well versed in the identification and troubleshooting of respiratory events.
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Abstract
Ventilatory muscle fatigue is a reversible loss of the ability to generate force or velocity of contraction in response to increased elastic and resistive loads. Mechanical ventilation should provide support without imposing additional loads from the ventilator (dys-synchrony). Interactive breaths optimize this relationship but require that patient effort and the ventilator response be synchronous during breath initiation, flow delivery, and termination. Proper delivery considers all 3 phases and uses clinical data, ventilator graphics, and sometimes a trial-and-error approach to optimize patient-ventilator interactions. Newer modes optimize interactions but await good clinical outcome data before routine use.
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Affiliation(s)
- Daniel Gilstrap
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Box 102355, Hanes House Room 101, Durham, NC 27710, USA.
| | - John Davies
- Respiratory Care Services, Duke University Hospital, Box 3911 Duke North, Erwin Road, Durham, NC 27710, USA
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11
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Bergin SP, Rackley CR. Managing Respiratory Failure in Obstructive Lung Disease. Clin Chest Med 2016; 37:659-667. [PMID: 27842746 DOI: 10.1016/j.ccm.2016.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Exacerbations of obstructive lung disease are common causes of acute respiratory failure. Short-acting bronchodilators and systemic glucocorticoids are the foundation of pharmacologic management. For patients requiring ventilator support, use of noninvasive ventilation reduces the risk of mortality and progression to invasive mechanical ventilation. Challenges associated with invasive ventilation include ventilator dyssynchrony, air trapping, and dynamic hyperinflation. Careful monitoring and adjustment of ventilatory support parameters helps to optimize the patient-ventilator interaction and minimizes the risk of associated morbidity. Extracorporeal life support is an emerging treatment for refractory hypercapnic respiratory failure associated with obstructive lung disease.
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Affiliation(s)
- Stephen P Bergin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Craig R Rackley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.
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Natalini G, Tuzzo D, Rosano A, Testa M, Grazioli M, Pennestrì V, Amodeo G, Berruto F, Fiorillo M, Peratoner A, Tinnirello A, Filippini M, Marsilia PF, Minelli C, Bernardini A. Effect of external PEEP in patients under controlled mechanical ventilation with an auto-PEEP of 5 cmH2O or higher. Ann Intensive Care 2016; 6:53. [PMID: 27306887 PMCID: PMC4909663 DOI: 10.1186/s13613-016-0158-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/05/2016] [Indexed: 12/16/2022] Open
Abstract
Background In some patients with auto-positive end-expiratory pressure (auto-PEEP), application of PEEP lower than auto-PEEP maintains a constant total PEEP, therefore reducing the inspiratory threshold load without detrimental cardiovascular or respiratory effects. We refer to these patients as “complete PEEP-absorbers.” Conversely, adverse effects of PEEP application could occur in patients with auto-PEEP when the total PEEP rises as a consequence. From a pathophysiological perspective, all subjects with flow limitation are expected to be “complete PEEP-absorbers,” whereas PEEP should increase total PEEP in all other patients. This study aimed to empirically assess the extent to which flow limitation alone explains a “complete PEEP-absorber” behavior (i.e., absence of further hyperinflation with PEEP), and to identify other factors associated with it. Methods One hundred patients with auto-PEEP of at least 5 cmH2O at zero end-expiratory pressure (ZEEP) during controlled mechanical ventilation were enrolled. Total PEEP (i.e., end-expiratory plateau pressure) was measured both at ZEEP and after applied PEEP equal to 80 % of auto-PEEP measured at ZEEP. All measurements were repeated three times, and the average value was used for analysis. Results Forty-seven percent of the patients suffered from chronic pulmonary disease and 52 % from acute pulmonary disease; 61 % showed flow limitation at ZEEP, assessed by manual compression of the abdomen. The mean total PEEP was 7 ± 2 cmH2O at ZEEP and 9 ± 2 cmH2O after the application of PEEP (p < 0.001). Thirty-three percent of the patients were “complete PEEP-absorbers.” Multiple logistic regression was used to predict the behavior of “complete PEEP-absorber.” The best model included a respiratory rate lower than 20 breaths/min and the presence of flow limitation. The predictive ability of the model was excellent, with an overoptimism-corrected area under the receiver operating characteristics curve of 0.89 (95 % CI 0.80–0.97). Conclusions Expiratory flow limitation was associated with both high and complete “PEEP-absorber” behavior, but setting a relatively high respiratory rate on the ventilator can prevent from observing complete “PEEP-absorption.” Therefore, the effect of PEEP application in patients with auto-PEEP can be accurately predicted at the bedside by measuring the respiratory rate and observing the flow-volume loop during manual compression of the abdomen.
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Affiliation(s)
- Giuseppe Natalini
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy.
| | - Daniele Tuzzo
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Antonio Rosano
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Marco Testa
- Department of Anesthesia and Intensive Care, SS. Annunziata Hospital, Savigliano, Italy
| | - Michele Grazioli
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Vincenzo Pennestrì
- Department of Anesthesia and Intensive Care, Misericordia Hospital, Grosseto, Italy
| | - Guido Amodeo
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Naples, Italy
| | - Francesco Berruto
- Department of Anesthesia and Intensive Care, Agnelli Hospital, Pinerolo, Italy
| | - Marialinda Fiorillo
- Department of Anesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Alberto Peratoner
- Department of Anesthesia and Intensive Care, Cattinara Hospital, Trieste, Italy
| | - Andrea Tinnirello
- Department of Anesthesia and Intensive Care, Mellino Mellini Hospital, Chiari, Italy
| | - Matteo Filippini
- Department of Anesthesia, Critical Care Medicine and Emergency, University of Brescia at Spedali Civili, Brescia, Italy
| | - Paolo F Marsilia
- Department of Anesthesia and Intensive Care, Cardarelli Hospital, Naples, Italy
| | - Cosetta Minelli
- Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College, London, UK
| | - Achille Bernardini
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy
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Davidson AC, Banham S, Elliott M, Kennedy D, Gelder C, Glossop A, Church AC, Creagh-Brown B, Dodd JW, Felton T, Foëx B, Mansfield L, McDonnell L, Parker R, Patterson CM, Sovani M, Thomas L. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016; 71 Suppl 2:ii1-35. [DOI: 10.1136/thoraxjnl-2015-208209] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Liu L, Xia F, Yang Y, Longhini F, Navalesi P, Beck J, Sinderby C, Qiu H. Neural versus pneumatic control of pressure support in patients with chronic obstructive pulmonary diseases at different levels of positive end expiratory pressure: a physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:244. [PMID: 26059238 PMCID: PMC4487968 DOI: 10.1186/s13054-015-0971-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 06/01/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Intrinsic positive end-expiratory pressure (PEEPi) is a "threshold" load that must be overcome to trigger conventional pneumatically-controlled pressure support (PSP) in chronic obstructive pulmonary disease (COPD). Application of extrinsic PEEP (PEEPe) reduces trigger delays and mechanical inspiratory efforts. Using the diaphragm electrical activity (EAdi), neurally controlled pressure support (PSN) could hypothetically eliminate asynchrony and reduce mechanical inspiratory effort, hence substituting the need for PEEPe. The primary objective of this study was to show that PSN can reduce the need for PEEPe to improve patient-ventilator interaction and to reduce both the "pre-trigger" and "total inspiratory" neural and mechanical efforts in COPD patients with PEEPi. A secondary objective was to evaluate the impact of applying PSN on breathing pattern. METHODS Twelve intubated and mechanically ventilated COPD patients with PEEPi ≥ 5 cm H2O underwent comparisons of PSP and PSN at different levels of PEEPe (at 0 %, 40 %, 80 %, and 120 % of static PEEPi, for 12 minutes at each level on average), at matching peak airway pressure. We measured flow, airway pressure, esophageal pressure, and EAdi, and analyzed neural and mechanical efforts for triggering and total inspiration. Patient-ventilator interaction was analyzed with the NeuroSync index. RESULTS Mean airway pressure and PEEPe were comparable for PSP and PSN at same target levels. During PSP, the NeuroSync index was 29 % at zero PEEPe and improved to 21 % at optimal PEEPe (P < 0.05). During PSN, the NeuroSync index was lower (<7 %, P < 0.05) regardless of PEEPe. Both pre-trigger (P < 0.05) and total inspiratory mechanical efforts (P < 0.05) were consistently higher during PSP compared to PSN at same PEEPe. The change in total mechanical efforts between PSP at PEEPe0% and PSN at PEEPe0% was not different from the change between PSP at PEEPe0% and PSP at PEEPe80%. CONCLUSION PSN abolishes the need for PEEPe in COPD patients, improves patient-ventilator interaction, and reduces the inspiratory mechanical effort to breathe. TRIAL REGISTRATION Clinicaltrials.gov NCT02114567 . Registered 04 November 2013.
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Affiliation(s)
- Ling Liu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Feiping Xia
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Yi Yang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Federico Longhini
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China. .,Department of Translational Medicine, Eastern Piedmont University "A. Avogadro", Novara, Italy.
| | - Paolo Navalesi
- Department of Translational Medicine, Eastern Piedmont University "A. Avogadro", Novara, Italy. .,Anaesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy. .,CRRF Mons. L. Novarese, Moncrivello, VC, Italy.
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada. .,Department of Pediatrics, University of Toronto, Toronto, Ontario, M5G 1X8, Canada. .,Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada. .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada. .,Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
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15
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Diaphragmatic electrical activity: a new tool to assess lung hyperinflation? Anesthesiology 2014; 121:447-9. [PMID: 25046571 DOI: 10.1097/aln.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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16
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Navalesi P, Frigerio P, Patzlaff A, Häußermann S, Henseke P, Kubitschek M. Prolonged weaning: from the intensive care unit to home. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:264-72. [PMID: 24975297 DOI: 10.1016/j.rppneu.2014.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/28/2014] [Accepted: 04/29/2014] [Indexed: 11/18/2022] Open
Abstract
Weaning is the process of withdrawing mechanical ventilation which starts with the first spontaneous breathing trial (SBT). Based on the degree of difficulty and duration, weaning is classified as simple, difficult and prolonged. Prolonged weaning, which includes patients who fail 3 SBTs or are still on mechanical ventilation 7 days after the first SBT, affects a relatively small fraction of mechanically ventilated ICU patients but these, however, requires disproportionate resources. There are several potential causes which can lead to prolonged weaning. It is nonetheless important to understand the problem from the point of view of each individual patient in order to adopt appropriate treatment and define precise prognosis. An otherwise stable patient who remains on mechanical ventilation will be considered for transfer to a specialized weaning unit (SWU). Though there is not a precise definition, SWU can be considered as highly specialized and protected environments for patients requiring mechanical ventilation despite resolution of the acute disorder. Proper staffing, well defined short-term and long-term goals, attention to psychological and social problems represent key determinants of SWU success. Some patients cannot be weaned, either partly or entirely, and may require long-term home mechanical ventilation. In these cases the logistics relating to caregivers and the equipment must be carefully considered and addressed.
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Affiliation(s)
- P Navalesi
- Department of Translational Medicine, Eastern Piedmont University, Novara Anesthesia and Intensive Care, Sant'Andrea Hospital, Vercelli, CRRF Mons. L. Novarese, Moncrivello, VC, Italy
| | - P Frigerio
- Spinal Cord Unit, Niguarda-Ca' Granda Hospital, Milano, Italy
| | - A Patzlaff
- Inamed GmbH, Robert-Koch-Allee 29, 82131 Gauting, Germany
| | - S Häußermann
- Inamed GmbH, Robert-Koch-Allee 29, 82131 Gauting, Germany
| | - P Henseke
- GBU Healthcare, Linde Gas Headquarters, Seitnerstrasse 70, 82049 Pullach, Germany
| | - M Kubitschek
- GBU Healthcare, Linde Gas Headquarters, Seitnerstrasse 70, 82049 Pullach, Germany.
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Gilstrap D, MacIntyre N. Patient-ventilator interactions. Implications for clinical management. Am J Respir Crit Care Med 2013; 188:1058-68. [PMID: 24070493 DOI: 10.1164/rccm.201212-2214ci] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Assisted/supported modes of mechanical ventilation offer significant advantages over controlled modes in terms of ventilator muscle function/recovery and patient comfort (and sedation needs). However, assisted/supported breaths must interact with patient demands during all three phases of breath delivery: trigger, target, and cycle. Synchronous interactions match ventilator support with patient demands; dyssynchronous interactions do not. Dyssynchrony imposes high pressure loads on ventilator muscles, promoting muscle overload/fatigue and increasing sedation needs. On current modes of ventilation there are a number of features that can monitor and enhance synchrony. These include adjustments of the trigger variable, the use of pressure versus fixed flow targeted breaths, and a number of manipulations of the cycle variable. Clinicians need to know how to use these modalities and monitor them properly, especially understanding airway pressure and flow graphics. Future strategies are emerging that have theoretical appeal but they await good clinical outcome studies before they become commonplace.
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Affiliation(s)
- Daniel Gilstrap
- 1 Department of Medicine, Duke University, Durham, North Carolina
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18
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Schmidt M, Raux M, Morelot-Panzini C, Similowski T, Demoule A. Dyspnée au cours de l’assistance ventilatoire mécanique. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0534-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Acute exacerbations and respiratory failure in chronic obstructive pulmonary disease. Ann Am Thorac Soc 2008; 5:530-5. [PMID: 18453367 DOI: 10.1513/pats.200707-088et] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) describe the phenomenon of sudden worsening in airway function and respiratory symptoms in patients with COPD. These exacerbations can range from self-limited diseases to episodes of florid respiratory failure requiring mechanical ventilation. The average patient with COPD experiences two such episodes annually, and they account for significant consumption of health care resources. Although bacterial infections are the most common causes of AECOPD, viral infections and environmental stresses are also implicated. AECOPD episodes can be triggered or complicated by other comorbidities, such as heart disease, other lung diseases (e.g., pulmonary emboli, aspiration, pneumothorax), or systemic processes. Pharmacologic management includes bronchodilators, corticosteroids, and antibiotics in most patients. Oxygen, physical therapy, mucolytics, and airway clearance devices may be useful in selected patients. In hypercapneic respiratory failure, noninvasive positive pressure ventilation may allow time for other therapies to work and thus avoid endotracheal intubation. If the patient requires invasive mechanical ventilation, the focus should be on avoiding ventilator-induced lung injury and minimizing intrinsic positive end-expiratory pressure. These may require limiting ventilation and "permissive hypercapnia." Although mild episodes of AECOPD are generally reversible, more severe forms of respiratory failure are associated with a substantial mortality and a prolonged period of disability in survivors.
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20
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Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis. Intensive Care Med 2008; 34:1865-72. [DOI: 10.1007/s00134-008-1201-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2008] [Accepted: 06/15/2008] [Indexed: 10/21/2022]
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21
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Reduction of patient-ventilator asynchrony by reducing tidal volume during pressure-support ventilation. Intensive Care Med 2008; 34:1477-86. [PMID: 18437356 DOI: 10.1007/s00134-008-1121-9] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 03/27/2008] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify ventilatory setting adjustments that improve patient-ventilator synchrony during pressure-support ventilation in ventilator-dependent patients by reducing ineffective triggering events without decreasing tolerance. DESIGN AND SETTING Prospective physiological study in a 13-bed medical intensive care unit in a university hospital. PATIENTS AND PARTICIPANTS Twelve intubated patients with more than 10% of ineffective breaths while receiving pressure-support ventilation. INTERVENTIONS Flow, airway-pressure, esophageal-pressure, and gastric-pressure signals were used to measure patient inspiratory effort. To decrease ineffective triggering the following ventilator setting adjustments were randomly adjusted: pressure support reduction, insufflation time reduction, and change in end-expiratory pressure. MEASUREMENTS AND RESULTS Reducing pressure support from 20.0 cm H(2)O (IQR 19.5-20) to 13.0 (12.0-14.0) reduced tidal volume [10.2ml /kg predicted body weight (7.2-11.5) to 5.9 (4.9-6.7)] and minimized ineffective triggering events [45% of respiratory efforts (36-52) to 0% (0-7)], completely abolishing ineffective triggering in two-thirds of patients. The ventilator respiratory rate increased due to unmasked wasted efforts, with no changes in patient respiratory rate [26.5 breaths/min (23.1-31.9) vs. 29.4 (24.6-34.5)], patient effort, or arterial PCO(2). Shortening the insufflation time reduced ineffective triggering events and patient effort, while applying positive end-expiratory pressure had no influence on asynchrony. CONCLUSIONS Markedly reducing pressure support or inspiratory duration to reach a tidal volume of about 6 ml/kg predicted body weight eliminated ineffective triggering in two-thirds of patients with weaning difficulties and a high percentage of ineffective efforts without inducing excessive work of breathing or modifying patient respiratory rate.
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22
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Abstract
Mechanical ventilatory support allows patients who have CAO to gain time for pharmacologic treatment to work and to avoid and/or recover from respiratory muscle fatigue. The cornerstone to avoiding associated morbidity with mechanical ventilation in these patients is to prevent dynamic hyperinflation of the lung by limiting minute ventilation and maximizing time for expiration and by inducing synchronization between the patient and mechanical ventilator. When mechanical ventilation is necessary, NPPV should be considered first, whenever possible, in these patients. Patients who have CAO requiring mechanical ventilatory support have an increased risk of death following such an event. Therefore, careful followup is needed after hospital discharge.
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Affiliation(s)
- Younsuck Koh
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap Dong Songpa-Ku, Seoul 138-736, Korea.
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23
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Graham AS, Chandrashekharaiah G, Citak A, Wetzel RC, Newth CJL. Positive end-expiratory pressure and pressure support in peripheral airways obstruction. Intensive Care Med 2006; 33:120-7. [PMID: 17111110 DOI: 10.1007/s00134-006-0445-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Accepted: 10/09/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Children with peripheral airways obstruction suffer the negative effects of intrinsic positive end-expiratory pressure: increased work of breathing and difficulty triggering assisted ventilatory support. We examined whether external positive end-expiratory pressure to offset intrinsic positive end-expiratory pressure decreases work of breathing in children with peripheral airways obstruction. The change in work of breathing with incremental pressure support was also tested. DESIGN AND SETTING Prospective clinical trial in a pediatric intensive care unit. PATIENTS Eleven mechanically ventilated, spontaneously breathing children with peripheral airways obstruction. INTERVENTIONS Work of breathing (using pressure-rate product as a surrogate) was measured in three tiers: (a) Increasing pressure support over zero end-expiratory pressure. (b) Increasing applied positive end-expiratory pressure and fixed pressure support. The level of applied positive end-expiratory pressure at which pressure-rate product was least determined the compensatory positive end-expiratory pressure. (c) Increasing pressure support over compensatory (fixed) positive end-expiratory pressure. MEASUREMENTS AND RESULTS Increases in pressure support alone decreased pressure-rate product from mean 724+/-311 to 403+/-192 cmH2O/min. Applied positive end-expiratory pressure alone decreased pressure-rate product from mean 608+/-301 to 250+/-169 cmH2O/min. The lowest pressure-rate product (136+/-128 cmH2O/min) was achieved using compensatory positive end-expiratory pressure (12+/-4 cmH2O) with pressure support 16 cmH2O. CONCLUSIONS For children with peripheral airways obstruction who require assisted ventilation, work of breathing during spontaneous breaths is decreased by the application of either compensatory positive end-expiratory pressure or pressure support.
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Affiliation(s)
- Alan S Graham
- Department of Pediatrics, Division of Pediatric Critical Care, Oregon Health and Science University, 707 S.W. Gaines Street, Portland, OR 97239-2901, USA.
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24
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Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L. Patient-ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 2006; 32:1515-22. [PMID: 16896854 DOI: 10.1007/s00134-006-0301-8] [Citation(s) in RCA: 449] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Accepted: 06/29/2006] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The incidence, pathophysiology, and consequences of patient-ventilator asynchrony are poorly known. We assessed the incidence of patient-ventilator asynchrony during assisted mechanical ventilation and we identified associated factors. METHODS Sixty-two consecutive patients requiring mechanical ventilation for more than 24 h were included prospectively as soon as they triggered all ventilator breaths: assist-control ventilation (ACV) in 11 and pressure-support ventilation (PSV) in 51. MEASUREMENTS Gross asynchrony detected visually on 30-min recordings of flow and airway pressure was quantified using an asynchrony index. RESULTS Fifteen patients (24%) had an asynchrony index greater than 10% of respiratory efforts. Ineffective triggering and double-triggering were the two main asynchrony patterns. Asynchrony existed during both ACV and PSV, with a median number of episodes per patient of 72 (range 13-215) vs. 16 (4-47) in 30 min, respectively (p=0.04). Double-triggering was more common during ACV than during PSV, but no difference was found for ineffective triggering. Ineffective triggering was associated with a less sensitive inspiratory trigger, higher level of pressure support (15 cmH(2)O, IQR 12-16, vs. 17.5, IQR 16-20), higher tidal volume, and higher pH. A high incidence of asynchrony was also associated with a longer duration of mechanical ventilation (7.5 days, IQR 3-20, vs. 25.5, IQR 9.5-42.5). CONCLUSIONS One-fourth of patients exhibit a high incidence of asynchrony during assisted ventilation. Such a high incidence is associated with a prolonged duration of mechanical ventilation. Patients with frequent ineffective triggering may receive excessive levels of ventilatory support.
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Affiliation(s)
- Arnaud W Thille
- Université Paris XII, INSERM U651, Réanimation Médicale, AP-HP Hôpital Henri Mondor, Faculté de Médecine, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France.
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25
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Glérant JC, Leleu O, Rose D, Mayeux I, Jounieaux V. Oxygen consumption and PEEPe in ventilated COPD patients. Respir Physiol Neurobiol 2005; 146:117-24. [PMID: 15766900 DOI: 10.1016/j.resp.2004.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2004] [Indexed: 10/26/2022]
Abstract
The intrinsic positive-end-expiratory pressure (PEEPi) increases the inspiratory load, the cost of breathing and thus oxygen consumption (V(O2)). It has been shown that applying an extrinsic positive-end-expiratory pressure (PEEPe) reduces the inspiratory threshold load but the optimal PEEPe level is still in debate. We hypothesize that the best level of PEEPe could induce a decrease in V(O2) by reducing the V(O2) demands from PEEPi. Nine mechanically ventilated COPD patients were included. The level of PEEPe was determined in accordance with the static PEEPi. V(O2) was measured using an automatic gas analyser during synchronized intermittent mandatory ventilation (SIMV): without PEEPe, with a PEEPe equal to 50% of static PEEPi and with a PEEPe equal to 100% of static PEEPi. Static PEEPi appeared to be significantly correlated with the degree of airflow obstruction (FEV1) (P<0.05). Applying a PEEPe equal to static PEEPi resulted in a significant decrease in V(O2) (P<0.05) whereas the change in V(O2) proved to be unpredictable for a PEEPe level of 50% of static PEEPi. In conclusion, V(O2) decreases progressively when increasing PEEPe up to a level equal to 100% of static PEEPi. Thus, in mechanically ventilated COPD patients with a FEV1 < or = 1000 ml, applying a PEEPe of 5 cmH2O should be recommended.
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Affiliation(s)
- J-Ch Glérant
- Respiratory Department and Intensive Care Unit, 80054 Amiens Cedex 1, France
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27
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Needleman JP, Sykes JA, Schroeder SA, Singer LP. Noninvasive Positive Pressure Ventilation in the Treatment of Pediatric Status Asthmaticus. ACTA ACUST UNITED AC 2004. [DOI: 10.1089/pai.2004.17.272] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Mechanical ventilation is the second most frequently performed therapeutic intervention after treatment for cardiac arrhythmias in intensive care units today. Countless lives have been saved with its use despite being associated with a greater than 30% in-hospital mortality rate. As life expectancies increase and people with chronic illnesses survive longer, artificial support with mechanical ventilation is also expected to rise. In one survey, over half of senior internal medicine residents reported their training on mechanical ventilation as inadequate, whereas the majority of critical care nurses reported having received no formal education on its use. Technological advances resulting in the availability of sleeker ventilators with graphic waveform displays and new modes of ventilation have challenged the bedside clinicians to incorporate this new data along with evidenced-based research into their daily practice. A review of current thoughts on mechanical ventilation and weaning is presented.
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Affiliation(s)
- Denise Fenstermacher
- Medical Intensive Care Unit, University of Illinois Medical Center at Chicago, Chicago, IL 60612, USA.
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29
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Girault C, Breton L, Richard JC, Tamion F, Vandelet P, Aboab J, Leroy J, Bonmarchand G. Mechanical effects of airway humidification devices in difficult to wean patients. Crit Care Med 2003; 31:1306-11. [PMID: 12771595 DOI: 10.1097/01.ccm.0000063284.92122.0e] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the influence of airway humidification devices on the efficacy of ventilation in difficult to wean patients. DESIGN A prospective, randomized, controlled physiologic study. SETTING A 22-bed medical intensive care unit in a university hospital. PATIENTS Chronic respiratory failure patients. INTERVENTIONS Performances of a heated humidifier and a heat and moisture exchanger were evaluated on diaphragmatic muscle activity, breathing pattern, gas exchange, and respiratory comfort during weaning from mechanical ventilation by using pressure support ventilation. Eleven patients with chronic respiratory failure were submitted to four pressure support ventilation sequences by using the heated humidifier and the heat and moisture exchanger at two different levels of pressure support ventilation (7 and 15 cm H(2)O). MEASUREMENT AND MAIN RESULTS Compared with the heated humidifier and regardless of the pressure support ventilation level used, the heat and moisture exchanger significantly increased all of the inspiratory effort variables (inspiratory work of breathing expressed in J/L and J/min, pressure time product, changes in esophageal pressure, and transdiaphragmatic pressure; p <.05) and dynamic intrinsic positive end-expiratory pressure (p <.05). Similarly, the heat and moisture exchanger produced a significant increase in Paco(2) (p <.01) responsible for severe respiratory acidosis (p <.05), which was insufficiently compensated for despite a significant increase in minute ventilation (p <.05). This resulted in respiratory discomfort for all patients with the heat and moisture exchanger (p <.01). Adverse effects were partially counterbalanced by increasing the pressure support ventilation level with the heat and moisture exchanger by >or=8 cm H(2)O. CONCLUSIONS The type of airway humidification device used may negatively influence the mechanical efficacy of ventilation and, unless the pressure support ventilation level is considerably increased, the use of a heat and moisture exchanger should not be recommended in difficult or potentially difficult to wean patients with chronic respiratory failure.
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Affiliation(s)
- Christophe Girault
- Medical Intensive Care Department, Rouen University Hospital-Charles Nicolle, France
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30
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Affiliation(s)
- Y Koh
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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31
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Tung A. Perioperative Ventilation of the Vascular Surgery Patient. Semin Cardiothorac Vasc Anesth 2000. [DOI: 10.1177/108925320000400408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although cardiovascular disease represents the most com mon comorbidity in patients undergoing vascular surgery, perioperative ventilatory issues can also play a vital role in achieving good outcomes. Postoperative respiratory failure is uncommon after carotid endarterectomy or peripheral revascularization procedures, the risk of pulmonary compli cations following intra-abdominal or intrathoracic vascular surgery is high. In addition to primary lung diseases such as chronic obstructive pulmonary disease, associated organ dysfunction syndromes such as stroke, renal failure, and congestive heart failure can also contribute to respiratory morbidity. An approach to minimizing respiratory complica tions begins with a careful preoperative search for ways to maximize pulmonary function and establishment of targets for postoperative weaning. Intraoperative attention should be paid to intraoperative management of bronchospasm, auto-positive end-expiratory pressure, and acid-base status. Postoperative management should strive for rapid extuba tion, continuation of pharmacologic conditioning programs begun preoperatively, and consideration of the use of post operative regional analgesia for patients with severe lung disease.
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Affiliation(s)
- Avery Tung
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
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32
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Abstract
Practice guidelines on weaning should be based on the results of several well-designed randomized studies performed over the last decade. One of those studies demonstrated that immediate extubation after successful trials of spontaneous breathing expedites weaning and reduces the duration of mechanical ventilation as compared with a more gradual discontinuation of ventilatory support. Two other studies showed that the ability to breathe spontaneously can be adequately tested by performing a trial with either T-tube or pressure support of 7 cmH2O lasting either 30 or 120 min. In patients with unsuccessful weaning trials, a gradual withdrawal for mechanical ventilation can be attempted while factors responsible for the ventilatory dependence are corrected. Two randomized studies found that, in difficult-to-wean patients, synchronized intermittent mandatory ventilation (SIMV) is the most ineffective [corrected] method of weaning.
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Affiliation(s)
- I Alía
- Hospital Universitario de Getafe, Madrid, Spain
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33
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Abstract
Weaning patients from mechanical ventilation in the intensive care unit can be difficult. In patients requiring prolonged ventilatory support it has been demonstrated that conventional weaning criteria are frequently incorrect. In this group measurement of respiratory work may be of benefit. Until recently, estimation of the work of breathing in patients receiving mechanical ventilation was logistically difficult. The availability of a computerized bedside monitoring device potentially allows easier estimation of the work of breathing at the bedside. The results of preliminary studies utilizing such monitoring are provocative: they highlight the phenomenon of nosocomial respiratory failure and challenge our clinical ability to determine patient workloads and timing of extubation. The potential benefits of work of breathing measurement, in particular the avoidance of respiratory muscle fatigue, earlier extubation, reduced duration of mechanical ventilation, reduction in ICU and hospital length of stay, and most importantly, a reduction in patient morbidity are yet to be demonstrated and concerns still exist about the monitor's accuracy.
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Affiliation(s)
- C J French
- Division of Anaesthesia, Western Hospital, Melbourne, Victoria, Australia
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Kress JP, O'Connor MF, Schmidt GA. Clinical examination reliably detects intrinsic positive end-expiratory pressure in critically ill, mechanically ventilated patients. Am J Respir Crit Care Med 1999; 159:290-4. [PMID: 9872852 DOI: 10.1164/ajrccm.159.1.9805011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Critically ill patients requiring mechanical ventilation often develop intrinsic positive end-expiratory pressure (PEEPi). Methods for its detection include an expiratory flow waveform display (not always available), an esophageal pressure transducer (invasive), or a relaxed or paralyzed patient. We sought to determine the accuracy of clinical examination for detecting PEEPi. Examiners blinded to waveform analysis assessed patients for the presence of PEEPi by inspection/palpation and auscultation. If either inspection/palpation or auscultation demonstrated PEEPi, it was said to be present by clinical exam. Clinicians with various levels of experience (attending, resident, student) made 503 observations of 71 patients. Sensitivity (SENS), specificity (SPEC), positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios were determined for inspection/palpation, auscultation, and clinical exam. PEEPi was present during 69.8% of observations. SENS, SPEC, and PPV of clinical exam were 0.72, 0.91, and 0.95 respectively for the examiners as a whole. Likelihood ratio for PEEPi detection by clinical exam was 8.35. Attending intensivists displayed SPEC and PPV of 1.0. NPV was only 0.58 (likelihood ratio 0.31). We conclude that the clinical exam is very good for detecting PEEPi at all experience levels; and further, that the clinical exam is only modestly useful for ruling out PEEPi, therefore, other tests should be used if PEEPi is not detected by clinical exam.
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Affiliation(s)
- J P Kress
- Departments of Medicine and Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
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36
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Manthous CA, Schmidt GA, Hall JB. Liberation from mechanical ventilation: a decade of progress. Chest 1998; 114:886-901. [PMID: 9743181 DOI: 10.1378/chest.114.3.886] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Multiple complications associated with mechanical ventilation mandate that clinicians expeditiously define and reverse the pathophysiologic processes that precipitate respiratory failure and then, detect the earliest point that a patient can breathe without the ventilator. Over the past decade, numerous laboratory and clinical studies have been reported that may inform transformation of the "art of weaning" to the science of liberation. We review these studies and use them to formulate a systematic approach to assure early, safe, and successful liberation of patients from mechanical ventilation.
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Affiliation(s)
- C A Manthous
- Pulmonary and Critical Care Division, Bridgeport Hospital and Yale University School of Medicine, Conn 06610, USA
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