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de Jager P, Koopman AA, Markhorst DG, Kneyber MCJ. Lung behavior during a staircase high-frequency oscillatory ventilation recruitment maneuver. Intensive Care Med Exp 2024; 12:42. [PMID: 38662081 PMCID: PMC11045697 DOI: 10.1186/s40635-024-00623-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Lung volume optimization maneuvers (LVOM) are necessary to make physiologic use of high-frequency oscillatory ventilation (HFOV), but lung behavior during such maneuvers has not been studied to determine lung volume changes after initiation of HFOV, to quantify recruitment versus derecruitment during the LVOM and to calculate the time to stabilization after a pressure change. METHODS We performed a secondary analysis of prospectively collected data in subjects < 18 years on HFOV. Uncalibrated respiratory inductance plethysmography (RIP) tracings were used to quantify lung recruitment and derecruitment during the LVOM inflation and deflation. The time constant was calculated according to the Niemann model. RESULTS RIP data of 51 subjects (median age 3.5 [1.7-13.3] months) with moderate-to-severe pediatric acute respiratory distress syndrome (PARDS) in 85.4% were analyzed. Lung recruitment and derecruitment occurred during the LVOM inflation phase upon start of HFOV and between and within pressure changes. At 90% of maximum inflation pressure, lung derecruitment already started during the deflation phase. Time to stable lung volume (time constant) could only be calculated in 26.2% of all pressure changes during the inflation and in 21.4% during the deflation phase, independent of continuous distending pressure (CDP). Inability to calculate the time constant was due to lack of stabilization of the RIP signal or no change in any direction. CONCLUSIONS Significant heterogeneity in lung behavior during a staircase incremental-decremental LVOM occurred, underscoring the need for higher initial inflation pressures when transitioning from conventional mechanical ventilation (CMV) and a longer time between pressure changes to allow for equilibration.
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Affiliation(s)
- Pauline de Jager
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Internal Post Code CA 80, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Internal Post Code CA 80, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Dick G Markhorst
- Department of Paediatric Intensive Care, UMC, Amsterdam, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Internal Post Code CA 80, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
- Critical Care, Anaesthesiology, Peri-Operative Medicine and Emergency Medicine, The University of Groningen, Groningen, The Netherlands
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Veneroni C, Dellacà RL, Küng E, Bonomi B, Berger A, Werther T. Oscillometry for personalizing continuous distending pressure maneuvers: an observational study in extremely preterm infants. Respir Res 2024; 25:4. [PMID: 38178216 PMCID: PMC10765834 DOI: 10.1186/s12931-023-02639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024] Open
Abstract
RATIONALE Lung recruitment and continuous distending pressure (CDP) titration are critical for assuring the efficacy of high-frequency ventilation (HFOV) in preterm infants. The limitation of oxygenation (peripheral oxygen saturation, SpO2) in optimizing CDP calls for evaluating other non-invasive bedside measurements. Respiratory reactance (Xrs) at 10 Hz measured by oscillometry reflects lung volume recruitment and tissue strain. In particular, lung volume recruitment and decreased tissue strain result in increased Xrs values. OBJECTIVES In extremely preterm infants treated with HFOV as first intention, we aimed to measure the relationship between CDP and Xrs during SpO2-driven CDP optimization. METHODS In this prospective observational study, extremely preterm infants born before 28 weeks of gestation undergoing SpO2-guided lung recruitment maneuvers were included in the study. SpO2 and Xrs were recorded at each CDP step. The optimal CDP identified by oxygenation (CDPOpt_SpO2) was compared to the CDP providing maximal Xrs on the deflation limb of the recruitment maneuver (CDPXrs). RESULTS We studied 40 infants (gestational age at birth = 22+ 6-27+ 5 wk; postnatal age = 1-23 days). Measurements were well tolerated and provided reliable results in 96% of cases. On average, Xrs decreased during the inflation limb and increased during the deflation limb. Xrs changes were heterogeneous among the infants for the amount of decrease with increasing CDP, the decrease at the lowest CDP of the deflation limb, and the hysteresis of the Xrs vs. CDP curve. In all but five infants, the hysteresis of the Xrs vs. CDP curve suggested effective lung recruitment. CDPOpt_SpO2 and CDPXrs were highly correlated (ρ = 0.71, p < 0.001) and not statistically different (median difference [range] = -1 [-3; 9] cmH2O). However, CDPXrs were equal to CDPOpt_SpO2 in only 6 infants, greater than CDPOpt_SpO2 in 10, and lower in 24 infants. CONCLUSIONS The Xrs changes described provide complementary information to oxygenation. Further investigation is warranted to refine recruitment maneuvers and CPD settings in preterm infants.
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Affiliation(s)
- Chiara Veneroni
- TechRes Lab, Department of Electronics, Information and Biomedical Engineering (DEIB), Politecnico di Milano University, Via G. Colombo 40, Milan, 20133, Italy
| | - Raffaele L Dellacà
- TechRes Lab, Department of Electronics, Information and Biomedical Engineering (DEIB), Politecnico di Milano University, Via G. Colombo 40, Milan, 20133, Italy.
| | - Erik Küng
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Beatrice Bonomi
- TechRes Lab, Department of Electronics, Information and Biomedical Engineering (DEIB), Politecnico di Milano University, Via G. Colombo 40, Milan, 20133, Italy
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Tobias Werther
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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de Jager P, Burgerhof JGM, Koopman AA, Markhorst DG, Kneyber MCJ. Physiologic responses to a staircase lung volume optimization maneuver in pediatric high-frequency oscillatory ventilation. Ann Intensive Care 2020; 10:153. [PMID: 33206258 PMCID: PMC7672171 DOI: 10.1186/s13613-020-00771-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 11/07/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Titration of the continuous distending pressure during a staircase incremental-decremental pressure lung volume optimization maneuver in children on high-frequency oscillatory ventilation is traditionally driven by oxygenation and hemodynamic responses, although validity of these metrics has not been confirmed. METHODS Respiratory inductance plethysmography values were used construct pressure-volume loops during the lung volume optimization maneuver. The maneuver outcome was evaluated by three independent investigators and labeled positive if there was an increase in respiratory inductance plethysmography values at the end of the incremental phase. Metrics for oxygenation (SpO2, FiO2), proximal pressure amplitude, tidal volume and transcutaneous measured pCO2 (ptcCO2) obtained during the incremental phase were compared between outcome maneuvers labeled positive and negative to calculate sensitivity, specificity, and the area under the receiver operating characteristic curve. Ventilation efficacy was assessed during and after the maneuver by measuring arterial pH and PaCO2. Hemodynamic responses during and after the maneuver were quantified by analyzing heart rate, mean arterial blood pressure and arterial lactate. RESULTS 41/54 patients (75.9%) had a positive maneuver albeit that changes in respiratory inductance plethysmography values were very heterogeneous. During the incremental phase of the maneuver, metrics for oxygenation and tidal volume showed good sensitivity (> 80%) but poor sensitivity. The sensitivity of the SpO2/FiO2 ratio increased to 92.7% one hour after the maneuver. The proximal pressure amplitude showed poor sensitivity during the maneuver, whereas tidal volume showed good sensitivity but poor specificity. PaCO2 decreased and pH increased in patients with a positive and negative maneuver outcome. No new barotrauma or hemodynamic instability (increase in age-adjusted heart rate, decrease in age-adjusted mean arterial blood pressure or lactate > 2.0 mmol/L) occurred as a result of the maneuver. CONCLUSIONS Absence of improvements in oxygenation during a lung volume optimization maneuver did not indicate that there were no increases in lung volume quantified using respiratory inductance plethysmography. Increases in SpO2/FiO2 one hour after the maneuver may suggest ongoing lung volume recruitment. Ventilation was not impaired and there was no new barotrauma or hemodynamic instability. The heterogeneous responses in lung volume changes underscore the need for monitoring tools during high-frequency oscillatory ventilation.
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Affiliation(s)
- Pauline de Jager
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Alette A Koopman
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Dick G Markhorst
- Department of Paediatric Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative Medicine & Emergency Medicine, The University of Groningen, Groningen, The Netherlands
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Arabi YM, Mallampalli R, Englert JA, Bosch NA, Walkey AJ, Al-Dorzi HM. Update in Critical Care 2019. Am J Respir Crit Care Med 2020; 201:1050-1057. [PMID: 32176850 DOI: 10.1164/rccm.202002-0285up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Rama Mallampalli
- Division of Pulmonary, Critical Care, and Sleep Medicine, Ohio State Wexner Medical, Center, Columbus, Ohio; and
| | - Joshua A Englert
- Division of Pulmonary, Critical Care, and Sleep Medicine, Ohio State Wexner Medical, Center, Columbus, Ohio; and
| | - Nicholas A Bosch
- Department of Medicine, Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Allan J Walkey
- Department of Medicine, Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Hasan M Al-Dorzi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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de Jager P, Kneyber MCJ. Response to the authors. Ann Intensive Care 2020; 10:77. [PMID: 32514645 PMCID: PMC7278274 DOI: 10.1186/s13613-020-00694-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Pauline de Jager
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin C J Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. .,Critical Care, Anaesthesiology, Perioperative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands.
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