1
|
Spina S, Marrazzo F, Morais CA, Victor M, Forlini C, Guarnieri M, Bastia L, Giudici R, Bassi G, Xin Y, Cereda M, Amato M, Langer T, Berra L, Fumagalli R. Modulation of pulmonary blood flow in patients with acute respiratory failure. Nitric Oxide 2023; 136-137:1-7. [PMID: 37172929 DOI: 10.1016/j.niox.2023.05.001] [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: 03/07/2023] [Revised: 04/19/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Impairment of ventilation and perfusion (V/Q) matching is a common mechanism leading to hypoxemia in patients with acute respiratory failure requiring intensive care unit (ICU) admission. While ventilation has been thoroughly investigated, little progress has been made to monitor pulmonary perfusion at the bedside and treat impaired blood distribution. The study aimed to assess real-time changes in regional pulmonary perfusion in response to a therapeutic intervention. METHODS Single-center prospective study that enrolled adult patients with ARDS caused by SARS-Cov-2 who were sedated, paralyzed, and mechanically ventilated. The distribution of pulmonary perfusion was assessed through electrical impedance tomography (EIT) after the injection of a 10-ml bolus of hypertonic saline. The therapeutic intervention consisted in the administration of inhaled nitric oxide (iNO), as rescue therapy for refractory hypoxemia. Each patient underwent two 15-minute steps at 0 and 20 ppm iNO, respectively. At each step, respiratory, gas exchange, and hemodynamic parameters were recorded, and V/Q distribution was measured, with unchanged ventilatory settings. RESULTS Ten 65 [56-75] years old patients with moderate (40%) and severe (60%) ARDS were studied 10 [4-20] days after intubation. Gas exchange improved at 20 ppm iNO (PaO2/FiO2 from 86 ± 16 to 110 ± 30 mmHg, p = 0.001; venous admixture from 51 ± 8 to 45 ± 7%, p = 0.0045; dead space from 29 ± 8 to 25 ± 6%, p = 0.008). The respiratory system's elastic properties and ventilation distribution were unaltered by iNO. Hemodynamics did not change after gas initiation (cardiac output 7.6 ± 1.9 vs. 7.7 ± 1.9 L/min, p = 0.66). The EIT pixel perfusion maps showed a variety of patterns of changes in pulmonary blood flow, whose increase positively correlated with PaO2/FiO2 increase (R2 = 0.50, p = 0.049). CONCLUSIONS The assessment of lung perfusion is feasible at the bedside and blood distribution can be modulated with effects that are visualized in vivo. These findings might lay the foundations for testing new therapies aimed at optimizing the regional perfusion in the lungs.
Collapse
Affiliation(s)
- Stefano Spina
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Francesco Marrazzo
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - CaioC A Morais
- Division of Pneumology (Laboratory of Medical Investigation 09), Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Marcus Victor
- Division of Pneumology (Laboratory of Medical Investigation 09), Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Clarissa Forlini
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marcello Guarnieri
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Luca Bastia
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Riccardo Giudici
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Gabriele Bassi
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Yi Xin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo Amato
- Division of Pneumology (Laboratory of Medical Investigation 09), Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Thomas Langer
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Roberto Fumagalli
- Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| |
Collapse
|
4
|
Balakrishna A, Di Fenza R, Morais CCA, Imber DA, Arora P, Kacmarek RM, De Santis Santiago R, Berra L. Reply to Mezidi et al.: Assessment of Airway Closure and Expiratory Airflow Limitation to Set Positive End-Expiratory Pressure in Morbidly Obese Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 203:392-394. [PMID: 33080156 PMCID: PMC7874309 DOI: 10.1164/rccm.202009-3641le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Aditi Balakrishna
- Massachusetts General Hospital Boston, Massachusetts.,Harvard Medical School Boston, Massachusetts and
| | - Raffaele Di Fenza
- Massachusetts General Hospital Boston, Massachusetts.,Harvard Medical School Boston, Massachusetts and
| | | | - David A Imber
- Massachusetts General Hospital Boston, Massachusetts.,Harvard Medical School Boston, Massachusetts and
| | - Pankaj Arora
- University of Alabama at Birmingham Birmingham, Alabama
| | - Robert M Kacmarek
- Massachusetts General Hospital Boston, Massachusetts.,Harvard Medical School Boston, Massachusetts and
| | | | - Lorenzo Berra
- Massachusetts General Hospital Boston, Massachusetts
| |
Collapse
|
8
|
Florio G, Ferrari M, Bittner EA, De Santis Santiago R, Pirrone M, Fumagalli J, Teggia Droghi M, Mietto C, Pinciroli R, Berg S, Bagchi A, Shelton K, Kuo A, Lai Y, Sonny A, Lai P, Hibbert K, Kwo J, Pino RM, Wiener-Kronish J, Amato MBP, Arora P, Kacmarek RM, Berra L. A lung rescue team improves survival in obesity with acute respiratory distress syndrome. Crit Care 2020; 24:4. [PMID: 31937345 PMCID: PMC6961369 DOI: 10.1186/s13054-019-2709-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Limited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS. METHODS In this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012-2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015-2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring. RESULTS The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13-0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74). CONCLUSION Individualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.
Collapse
Affiliation(s)
- Gaetano Florio
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Matteo Ferrari
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Roberta De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Massimiliano Pirrone
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Maddalena Teggia Droghi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Cristina Mietto
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Riccardo Pinciroli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Sheri Berg
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Aranya Bagchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Kenneth Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Alexander Kuo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Yvonne Lai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Peggy Lai
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Kathryn Hibbert
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Jean Kwo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Richard M Pino
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Jeanine Wiener-Kronish
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
| | - Marcelo B P Amato
- Pulmonary Division, Cardio-Pulmonary Department, Heart Institute (Incor), Hospital Das Clinicas da FMUSP, University of Sao Paulo, Sao Paulo, Brazil
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert M Kacmarek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA
- Department of Respiratory Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02141, USA.
| |
Collapse
|