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Fratti I, Pozzi T, Hahn G, Fioccola A, Nicolardi RV, Busana M, Collino F, Moerer O, Camporota L, Gattinoni L. Electrical Impedance Tomography: A Monitoring Tool for Ventilation Induced Lung Injury. Am J Respir Crit Care Med 2024. [PMID: 38701379 DOI: 10.1164/rccm.202311-2121le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 05/01/2024] [Indexed: 05/05/2024] Open
Affiliation(s)
- Isabella Fratti
- University Medical Center Göttingen, 27177, Department of Anesthesiology, Gottingen, Niedersachsen, Germany
- University of Milan, 9304, Department of Health Sciences, Milano, Italy
| | - Tommaso Pozzi
- University Medical Center Göttingen, 27177, Department of Anesthesiology, Gottingen, Niedersachsen, Germany
- University of Milan, 9304, Department of Health Sciences, Milano, Lombardia, Italy
| | - Guenter Hahn
- University Medical Center Göttingen, 27177, Department of Anesthesiology, Gottingen, Niedersachsen, Germany
| | - Antonio Fioccola
- University Medical Center Göttingen, 27177, Department of Anesthesiology, Gottingen, Niedersachsen, Germany
- University of Florence, 9300, Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, Firenze, Toscana, Italy
| | | | - Mattia Busana
- University Medical Center Göttingen, 27177, Department for Anesthesiology, Gottingen, Niedersachsen, Germany
| | - Francesca Collino
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 18691, Department of Anesthesia, Intensive Care and Emergency, Torino, Piemonte, Italy
| | - Onnen Moerer
- University Medical Center Göttingen, 84922, Department of Anesthesiology, Gottingen, Niedersachsen, Germany
| | - Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, 8945, Department of Adult Critical Care, London, United Kingdom of Great Britain and Northern Ireland
| | - Luciano Gattinoni
- University Medical Center Göttingen, 27177, Department of Anesthesiology, Gottingen, Niedersachsen, Germany;
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Camporota L, Collino F, Gattinoni L. Positive or negative pressure: plus ça change, plus c'est la même chose. Intensive Care Med 2024:10.1007/s00134-024-07433-4. [PMID: 38635047 DOI: 10.1007/s00134-024-07433-4] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK.
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, King's College London, London, UK.
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "City of Health and Science" Hospital, Turin, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Bachmann KF, Haenggi M, Jakob SM, Takala J, Gattinoni L, Berger D. Comment on: "A novel 'shunt fraction' method to derive native cardiac output during liberation from central VA ECMO" by Lim, HS. ESC Heart Fail 2024. [PMID: 38605504 DOI: 10.1002/ehf2.14804] [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] [Received: 01/27/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024] Open
Affiliation(s)
- Kaspar F Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Giosa L, Zadek F, Busana M, De Simone G, Brusatori S, Krbec M, Duska F, Brambilla P, Zanella A, Di Masi A, Caironi P, Perez E, Gattinoni L, Langer T. Quantifying pH-induced changes in plasma strong ion difference during experimental acidosis: clinical implications for base excess interpretation. J Appl Physiol (1985) 2024; 136:966-976. [PMID: 38420681 DOI: 10.1152/japplphysiol.00917.2023] [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: 12/26/2023] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/02/2024] Open
Abstract
It is commonly assumed that changes in plasma strong ion difference (SID) result in equal changes in whole blood base excess (BE). However, at varying pH, albumin ionic-binding and transerythrocyte shifts alter the SID of plasma without affecting that of whole blood (SIDwb), i.e., the BE. We hypothesize that, during acidosis, 1) an expected plasma SID (SIDexp) reflecting electrolytes redistribution can be predicted from albumin and hemoglobin's charges, and 2) only deviations in SID from SIDexp reflect changes in SIDwb, and therefore, BE. We equilibrated whole blood of 18 healthy subjects (albumin = 4.8 ± 0.2 g/dL, hemoglobin = 14.2 ± 0.9 g/dL), 18 septic patients with hypoalbuminemia and anemia (albumin = 3.1 ± 0.5 g/dL, hemoglobin = 10.4 ± 0.8 g/dL), and 10 healthy subjects after in vitro-induced isolated anemia (albumin = 5.0 ± 0.2 g/dL, hemoglobin = 7.0 ± 0.9 g/dL) with varying CO2 concentrations (2-20%). Plasma SID increased by 12.7 ± 2.1, 9.3 ± 1.7, and 7.8 ± 1.6 mEq/L, respectively (P < 0.01) and its agreement (bias[limits of agreement]) with SIDexp was strong: 0.5[-1.9; 2.8], 0.9[-0.9; 2.6], and 0.3[-1.4; 2.1] mEq/L, respectively. Separately, we added 7.5 or 15 mEq/L of lactic or hydrochloric acid to whole blood of 10 healthy subjects obtaining BE of -6.6 ± 1.7, -13.4 ± 2.2, -6.8 ± 1.8, and -13.6 ± 2.1 mEq/L, respectively. The agreement between ΔBE and ΔSID was weak (2.6[-1.1; 6.3] mEq/L), worsening with varying CO2 (2-20%): 6.3[-2.7; 15.2] mEq/L. Conversely, ΔSIDwb (the deviation of SID from SIDexp) agreed strongly with ΔBE at both constant and varying CO2: -0.1[-2.0; 1.7], and -0.5[-2.4; 1.5] mEq/L, respectively. We conclude that BE reflects only changes in plasma SID that are not expected from electrolytes redistribution, the latter being predictable from albumin and hemoglobin's charges.NEW & NOTEWORTHY This paper challenges the assumed equivalence between changes in plasma strong ion difference (SID) and whole blood base excess (BE) during in vitro acidosis. We highlight that redistribution of strong ions, in the form of albumin ionic-binding and transerythrocyte shifts, alters SID without affecting BE. We demonstrate that these expected SID alterations are predictable from albumin and hemoglobin's charges, or from the noncarbonic whole blood buffer value, allowing a better interpretation of SID and BE during in vitro acidosis.
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Affiliation(s)
- Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, King's College London, London, United Kingdom
| | - Francesco Zadek
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Serena Brusatori
- Department of pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Martin Krbec
- Department of Anesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czechia
| | - Frantisek Duska
- Department of Anesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czechia
| | - Paolo Brambilla
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Alberto Zanella
- Department of pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Pietro Caironi
- Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Turin, Italy
- Department of Oncology, University of Turin, Turin, Italy
| | - Emanuele Perez
- Department of biomedical and neuromotor sciences, Headquarter of Human physiology, University of Bologna, Bologna, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
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Gattarello S, Lombardo F, Romitti F, D'Albo R, Velati M, Fratti I, Pozzi T, Nicolardi R, Fioccola A, Busana M, Collino F, Herrmann P, Camporota L, Quintel M, Moerer O, Saager L, Meissner K, Gattinoni L. Determinants of acute kidney injury during high-power mechanical ventilation: secondary analysis from experimental data. Intensive Care Med Exp 2024; 12:31. [PMID: 38512544 PMCID: PMC10957825 DOI: 10.1186/s40635-024-00610-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The individual components of mechanical ventilation may have distinct effects on kidney perfusion and on the risk of developing acute kidney injury; we aimed to explore ventilatory predictors of acute kidney failure and the hemodynamic changes consequent to experimental high-power mechanical ventilation. METHODS Secondary analysis of two animal studies focused on the outcomes of different mechanical power settings, including 78 pigs mechanically ventilated with high mechanical power for 48 h. The animals were categorized in four groups in accordance with the RIFLE criteria for acute kidney injury (AKI), using the end-experimental creatinine: (1) NO AKI: no increase in creatinine; (2) RIFLE 1-Risk: increase of creatinine of > 50%; (3) RIFLE 2-Injury: two-fold increase of creatinine; (4) RIFLE 3-Failure: three-fold increase of creatinine; RESULTS: The main ventilatory parameter associated with AKI was the positive end-expiratory pressure (PEEP) component of mechanical power. At 30 min from the initiation of high mechanical power ventilation, the heart rate and the pulmonary artery pressure progressively increased from group NO AKI to group RIFLE 3. At 48 h, the hemodynamic variables associated with AKI were the heart rate, cardiac output, mean perfusion pressure (the difference between mean arterial and central venous pressures) and central venous pressure. Linear regression and receiving operator characteristic analyses showed that PEEP-induced changes in mean perfusion pressure (mainly due to an increase in CVP) had the strongest association with AKI. CONCLUSIONS In an experimental setting of ventilation with high mechanical power, higher PEEP had the strongest association with AKI. The most likely physiological determinant of AKI was an increase of pleural pressure and CVP with reduced mean perfusion pressure. These changes resulted from PEEP per se and from increase in fluid administration to compensate for hemodynamic impairment consequent to high PEEP.
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Affiliation(s)
- Simone Gattarello
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany.
| | - Fabio Lombardo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosanna D'Albo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Mara Velati
- Department of Anesthesia and Intensive Care Medicine Department, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosmery Nicolardi
- Department of Anesthesia and Intensive Care Medicine Department, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Fioccola
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "Città Della Salute E Della Scienza" Hospital, Turin, Italy
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Michael Quintel
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
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Gattinoni L, Collino F, Camporota L. Ventilator induced lung injury: a case for a larger umbrella? Intensive Care Med 2024; 50:275-278. [PMID: 38172299 PMCID: PMC10907410 DOI: 10.1007/s00134-023-07296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Piemonte, Turin, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Centre for Human and Applied Physiological Sciences, Guy's and St. Thomas' NHS Foundation Trust, King's College London, London, UK
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Busana M, Rau A, Lazzari S, Gattarello S, Cressoni M, Biggemann L, Harnisch LO, Giosa L, Vogt A, Saager L, Lotz J, Meller B, Meissner K, Gattinoni L, Moerer O. Causes of Hypoxemia in COVID-19 Acute Respiratory Distress Syndrome: A Combined Multiple Inert Gas Elimination Technique and Dual-energy Computed Tomography Study. Anesthesiology 2024; 140:251-260. [PMID: 37656772 DOI: 10.1097/aln.0000000000004757] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
BACKGROUND Despite the fervent scientific effort, a state-of-the art assessment of the different causes of hypoxemia (shunt, ventilation-perfusion mismatch, and diffusion limitation) in COVID-19 acute respiratory distress syndrome (ARDS) is currently lacking. In this study, the authors hypothesized a multifactorial genesis of hypoxemia and aimed to measure the relative contribution of each of the different mechanism and their relationship with the distribution of tissue and blood within the lung. METHODS In this cross-sectional study, the authors prospectively enrolled 10 patients with COVID-19 ARDS who had been intubated for less than 7 days. The multiple inert gas elimination technique (MIGET) and a dual-energy computed tomography (DECT) were performed and quantitatively analyzed for both tissue and blood volume. Variables related to the respiratory mechanics and invasive hemodynamics (PiCCO [Getinge, Sweden]) were also recorded. RESULTS The sample (51 ± 15 yr; Pao2/Fio2, 172 ± 86 mmHg) had a mortality of 50%. The MIGET showed a shunt of 25 ± 16% and a dead space of 53 ± 11%. Ventilation and perfusion were mismatched (LogSD, Q, 0.86 ± 0.33). Unexpectedly, evidence of diffusion limitation or postpulmonary shunting was also found. In the well aerated regions, the blood volume was in excess compared to the tissue, while the opposite happened in the atelectasis. Shunt was proportional to the blood volume of the atelectasis (R2 = 0.70, P = 0.003). V˙A/Q˙T mismatch was correlated with the blood volume of the poorly aerated tissue (R2 = 0.54, P = 0.016). The overperfusion coefficient was related to Pao2/Fio2 (R2 = 0.66, P = 0.002), excess tissue mass (R2 = 0.84, P < 0.001), and Etco2/Paco2 (R2 = 0.63, P = 0.004). CONCLUSIONS These data support the hypothesis of a highly multifactorial genesis of hypoxemia. Moreover, recent evidence from post-mortem studies (i.e., opening of intrapulmonary bronchopulmonary anastomosis) may explain the findings regarding the postpulmonary shunting. The hyperperfusion might be related to the disease severity. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Anna Rau
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Stefano Lazzari
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany; and Institute for Treatment and Research San Raffaele Scientific Institute, Department of Anesthesia and Intensive Care, Milan, Italy
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany; and Institute for Treatment and Research San Raffaele Scientific Institute, Department of Anesthesia and Intensive Care, Milan, Italy
| | - Massimo Cressoni
- Unit of Radiology, Institute for Treatment and Research Policlinico San Donato, Milan, Italy
| | - Lorenz Biggemann
- Institute for Diagnostic and Interventional Radiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Lars-Olav Harnisch
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Lorenzo Giosa
- Centre for Human and Applied Physiological Sciences, King's College London, London, United Kingdom
| | - Andreas Vogt
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Leif Saager
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany; and Outcomes Research Consortium, Cleveland, Ohio
| | - Joachim Lotz
- Institute for Diagnostic and Interventional Radiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Birgit Meller
- Clinic of Nuclear Medicine, University Medical Center of Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
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Fioccola A, Pozzi T, Fratti I, Nicolardi RV, Romitti F, Busana M, Collino F, Camporota L, Meissner K, Moerer O, Gattinoni L. Impact of mechanical power and positive end expiratory pressure on central vs. mixed oxygen and carbon dioxide related variables in a population of female piglets. Physiol Rep 2024; 12:e15954. [PMID: 38366303 PMCID: PMC10873162 DOI: 10.14814/phy2.15954] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION The use of the pulmonary artery catheter has decreased overtime; central venous blood gases are generally used in place of mixed venous samples. We want to evaluate the accuracy of oxygen and carbon dioxide related parameters from a central versus a mixed venous sample, and whether this difference is influenced by mechanical ventilation. MATERIALS AND METHODS We analyzed 78 healthy female piglets ventilated with different mechanical power. RESULTS There was a significant difference in oxygen-derived parameters between samples taken from the central venous and mixed venous blood (Sv ¯ $$ \overline{v} $$ O2 = 74.6%, ScvO2 = 83%, p < 0.0001). Conversely, CO2-related parameters were similar, with strong correlation. Ventilation with higher mechanical power and PEEP increased the difference between oxygen saturations, (Δ[ScvO2-Sv ¯ $$ \overline{v} $$ O2 ] = 7.22% vs. 10.0% respectively in the low and high MP groups, p = 0.020); carbon dioxide-related parameters remained unchanged (p = 0.344). CONCLUSIONS The venous oxygen saturation (central or mixed) may be influenced by the effects of mechanical ventilation. Therefore, central venous data should be interpreted with more caution when using higher mechanical power. On the contrary, carbon dioxide-derived parameters are more stable and similar between the two sampling sites, independently of mechanical power or positive end expiratory pressures.
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Affiliation(s)
- Antonio Fioccola
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain MedicineUniversity of FlorenceFlorenceItaly
| | - Tommaso Pozzi
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
- Department of Health SciencesUniversity of MilanMilanItaly
| | - Isabella Fratti
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
- Department of Health SciencesUniversity of MilanMilanItaly
| | - Rosmery Valentina Nicolardi
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
- IRCCS San Raffaele Scientific InstituteMilanItaly
| | - Federica Romitti
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Mattia Busana
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | | | - Luigi Camporota
- Department of Adult Critical Care Guy's & St Thomas' NHS foundation TrustLondonUK
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical BiosciencesKing's College LondonLondonUK
| | - Konrad Meissner
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Onnen Moerer
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Luciano Gattinoni
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
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Fioccola A, Nicolardi RV, Pozzi T, Fratti I, Romitti F, Collino F, Reupke V, Bassi GL, Protti A, Santini A, Cressoni M, Busana M, Moerer O, Camporota L, Gattinoni L. Estimation of normal lung weight index in healthy female domestic pigs. Intensive Care Med Exp 2024; 12:6. [PMID: 38273120 PMCID: PMC10811311 DOI: 10.1186/s40635-023-00591-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Lung weight is an important study endpoint to assess lung edema in porcine experiments on acute respiratory distress syndrome and ventilatory induced lung injury. Evidence on the relationship between lung-body weight relationship is lacking in the literature. The aim of this work is to provide a reference equation between normal lung and body weight in female domestic piglets. MATERIALS AND METHODS 177 healthy female domestic piglets from previous studies were included in the analysis. Lung weight was assessed either via a CT-scan before any experimental injury or with a scale after autopsy. The animals were randomly divided in a training (n = 141) and a validation population (n = 36). The relation between body weight and lung weight index (lung weight/body weight, g/kg) was described by an exponential function on the training population. The equation was tested on the validation population. A Bland-Altman analysis was performed to compare the lung weight index in the validation population and its theoretical value calculated with the reference equation. RESULTS A good fit was found between the validation population and the exponential equation extracted from the training population (RMSE = 0.060). The equation to determine lung weight index from body weight was: [Formula: see text] At the Bland and Altman analyses, the mean bias between the real and the expected lung weight index was - 0.26 g/kg (95% CI - 0.96-0.43), upper LOA 3.80 g/kg [95% CI 2.59-5.01], lower LOA - 4.33 g/kg [95% CI = - 5.54-(- 3.12)]. CONCLUSIONS This exponential function might be a valuable tool to assess lung edema in experiments involving 16-50 kg female domestic piglets. The error that can be made due to the 95% confidence intervals of the formula is smaller than the one made considering the lung to body weight as a linear relationship.
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Affiliation(s)
- Antonio Fioccola
- Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Rosmery Valentina Nicolardi
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Verena Reupke
- Department of Experimental Animal Medicine, University of Göttingen, Göttingen, Germany
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Uniting Care Hospitals, Intensive Care Units St Andrew's War Memorial Hospital and The Wesley Hospital, Brisbane, QLD, Australia
- Wesley Medical Research, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Massimo Cressoni
- Unit of Radiology, IRCCS, Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care Guy's & St Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, King's College London, London, UK
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.
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10
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Putensen C, Gattinoni L, Leonhardt S. Electrical Impedance Tomography: Is It Ready to Measure Pulmonary Perfusion Distribution at the Bedside? Anesthesiology 2023; 139:722-725. [PMID: 37934108 DOI: 10.1097/aln.0000000000004770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Affiliation(s)
- Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Steffen Leonhardt
- Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
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11
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Gattinoni L, Citerio G, Slutsky AS. Back to the future: ARDS guidelines, evidence, and opinions. Intensive Care Med 2023; 49:1226-1228. [PMID: 37578520 DOI: 10.1007/s00134-023-07183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Gottingen, Gottingen, Germany.
| | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano - Bicocca, Milan, Italy
- IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Insitute, St. Micheal's Hospital, Unity Health Toronto, Toronto, Canada
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12
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Gattinoni L. Curiosity, Opportunity, and Luck: Were the 1970s Different? Anesthesiology 2023; 139:321-325. [PMID: 37437112 DOI: 10.1097/aln.0000000000004626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Control of Breathing Using an Extracorporeal Membrane Lung. By T Kolobow, L Gattinoni, TA Tomlinson, JE Pierce. Anesthesiology 1977; 46:138-41. Reprinted with permission. Body Position Changes Redistribute Lung Computed-Tomographic Density in Patients with Acute Respiratory Failure. By L Gattinoni, P Pelosi, G Vitale, A Pesenti, L D'Andrea, D Mascheroni. Anesthesiology 1991; 74:15-23. Reprinted with permission. Dr. Gattinoni's scientific career was primarily driven by curiosity. His generation was not formally trained, but he was part of a community of young and enthusiastic colleagues who were forging a new discipline: intensive care medicine. The most significant opportunity of Dr. Gattinoni's career was becoming the research fellow of a visionary genius, Dr. Theodor Kolobow, who focused on extracorporeal carbon dioxide removal after the failure of the first trial on extracorporeal membrane oxygenation. CO2 removal, by allowing control over the intensity of mechanical ventilation, opened the path to "lung rest" to prevent ventilator-induced lung injury. A unique opportunity for research was the spontaneous birth of a network of scientists who became friends in the European Group of Research in Intensive Care Medicine. In this environment, it was possible to develop core concepts such as the "baby lung" and to understand the mechanisms underlying computed tomography-density redistribution in the prone position. Physiology guided us in the 1970s, and understanding mechanisms remains of paramount importance today.
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany; and Emeritus, University of Milan, Milano, Italy
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13
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Brusatori S, Zinnato C, Pozzi T, Camporota L, Marini JJ, Gattinoni L. Reply to Jha: Understanding the Pathophysiological and Clinical Changes in Lung Injury Models. Am J Respir Crit Care Med 2023; 208:633-634. [PMID: 37315321 PMCID: PMC10492238 DOI: 10.1164/rccm.202305-0869le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/14/2023] [Indexed: 06/16/2023] Open
Affiliation(s)
- Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences – London, London, United Kingdom; and
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, Minnesota
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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14
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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15
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D'Albo R, Romitti F, Camporota L, Moerer O, Busana M, Gattinoni L. Gas volumes corrections in Intensive Care Unit: needed or pointless? J Appl Physiol (1985) 2023. [PMID: 37345856 PMCID: PMC10390049 DOI: 10.1152/japplphysiol.00225.2023] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
The conditions of temperature, pressure and saturation in which respiratory gas volumes are expressed (STPD, ATPS or BTPS) are physiologically relevant, but often ignored or unknown in clinical practice. In this study we aimed to investigate whether and at which extent the gas volumes corrections, either in natural and artificial lung, may alter key respiratory and metabolic variables and the possible clinical consequences. We primarily referred to the effects of gas volumes corrections on three physiological variables: physiological dead space, venous admixture and total VCO2 during extracorporeal support. We used three physiological models in which calculations of these variables have been performed with and without correction of gas volumes, both in a theoretical model and in 448 patients. The lack of gas volumes correction leads to an error in the computation of physiological dead space fraction between 0.05 and 0.15, both in the theoretical model and in the patients population. The venous admixture was minimally affected by the absence of correction (0.01-0.04 error). During extracorporeal support, if the VCO2 of natural and membrane lung are expressed in different conditions, potentially large errors (0-18.4%) may occur in the computation of total VCO2 (VCO2tot=VCO2 ML+VCO2NL). This may lead to inappropriate settings of mechanical ventilation with higher plateau pressure. As the dead space and the CO2 sharing between natural and artificial lung are relevant both as prognostic index and as a guide for appropriate mechanical ventilation, their inappropriate computation may lead to erroneous categorization of the patients and inappropriate mechanical treatment.
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Affiliation(s)
- Rosanna D'Albo
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Onnen Moerer
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Universitätsmedizin Göttingen, Göttingen, Germany
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16
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Pozzi T, Collino F, Brusatori S, Romitti F, Busana M, Moerer O, Camporota L, Chiumello D, Coppola S, Gattinoni L. Specific Respiratory System Compliance in COVID-19 and Non COVID-19 ARDS. Am J Respir Crit Care Med 2023. [PMID: 37311259 PMCID: PMC10395712 DOI: 10.1164/rccm.202302-0223le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
- Tommaso Pozzi
- University of Milan, 9304, Department of Pathophysiology and Transplantation, Milano, Lombardia, Italy
| | - Francesca Collino
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 18691, Department of Anesthesia, Intensive Care and Emergency , Torino, Piemonte, Italy
| | - Serena Brusatori
- Università degli Studi di Milano, 9304, Department of Pathophysiology and Transplantation, Milano, Lombardia, Italy
| | - Federica Romitti
- University of Göttingen, Department of Anaesthesiology, Göttingen, Germany
| | - Mattia Busana
- University of Goettingen, Department for Anesthesiology, Goettingen, Germany
| | - Onnen Moerer
- University Medical Center Göttingen, 84922, Department of Anesthesiology, Gottingen, Niedersachsen, Germany
| | - Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, Department of Adult Critical Care, London, United Kingdom of Great Britain and Northern Ireland
| | - Davide Chiumello
- Università degli Studi di Milano, Dipartimento di Scienze della Salute, Milano, Italy
| | - Silvia Coppola
- ASST Santi Paolo e Carlo, 444273, Department of Anesthesia and Intensive Care, Milano, Lombardia, Italy
| | - Luciano Gattinoni
- University of Göttingen, Department of Anaesthesiology, Göttingen, Germany;
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17
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Brusatori S, Zinnato C, Busana M, Romitti F, Gattarello S, Palumbo MM, Pozzi T, Steinberg I, Palermo P, Lazzari S, Maj R, Velati M, D’Albo R, Wassong J, Meissner K, Lombardo F, Herrmann P, Quintel M, Moerer O, Camporota L, Marini JJ, Meissner K, Gattinoni L. High- versus Low-Flow Extracorporeal Respiratory Support in Experimental Hypoxemic Acute Lung Injury. Am J Respir Crit Care Med 2023; 207:1183-1193. [PMID: 36848321 PMCID: PMC10161753 DOI: 10.1164/rccm.202212-2194oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 12/01/2022] [Accepted: 02/21/2023] [Indexed: 02/28/2023] Open
Abstract
Rationale: In the EOLIA (ECMO to Rescue Lung Injury in Severe ARDS) trial, oxygenation was similar between intervention and conventional groups, whereas [Formula: see text]e was reduced in the intervention group. Comparable reductions in ventilation intensity are theoretically possible with low-flow extracorporeal CO2 removal (ECCO2R), provided oxygenation remains acceptable. Objectives: To compare the effects of ECCO2R and extracorporeal membrane oxygenation (ECMO) on gas exchange, respiratory mechanics, and hemodynamics in animal models of pulmonary (intratracheal hydrochloric acid) and extrapulmonary (intravenous oleic acid) lung injury. Methods: Twenty-four pigs with moderate to severe hypoxemia (PaO2:FiO2 ⩽ 150 mm Hg) were randomized to ECMO (blood flow 50-60 ml/kg/min), ECCO2R (0.4 L/min), or mechanical ventilation alone. Measurements and Main Results: [Formula: see text]o2, [Formula: see text]co2, gas exchange, hemodynamics, and respiratory mechanics were measured and are presented as 24-hour averages. Oleic acid versus hydrochloric acid showed higher extravascular lung water (1,424 ± 419 vs. 574 ± 195 ml; P < 0.001), worse oxygenation (PaO2:FiO2 = 125 ± 14 vs. 151 ± 11 mm Hg; P < 0.001), but better respiratory mechanics (plateau pressure 27 ± 4 vs. 30 ± 3 cm H2O; P = 0.017). Both models led to acute severe pulmonary hypertension. In both models, ECMO (3.7 ± 0.5 L/min), compared with ECCO2R (0.4 L/min), increased mixed venous oxygen saturation and oxygenation, and improved hemodynamics (cardiac output = 6.0 ± 1.4 vs. 5.2 ± 1.4 L/min; P = 0.003). [Formula: see text]o2 and [Formula: see text]co2, irrespective of lung injury model, were lower during ECMO, resulting in lower PaCO2 and [Formula: see text]e but worse respiratory elastance compared with ECCO2R (64 ± 27 vs. 40 ± 8 cm H2O/L; P < 0.001). Conclusions: ECMO was associated with better oxygenation, lower [Formula: see text]o2, and better hemodynamics. ECCO2R may offer a potential alternative to ECMO, but there are concerns regarding its effects on hemodynamics and pulmonary hypertension.
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Affiliation(s)
- Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Maria Michela Palumbo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Irene Steinberg
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Paola Palermo
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Jona Wassong
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Killian Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Donau Isar Hospital Deggendorf, Deggendorf, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St. Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, United Kingdom; and
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, Minnesota
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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18
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Camporota L, Sanderson B, Worrall S, Ostermann M, Barrett NA, Retter A, Busana M, Collins P, Romitti F, Hunt BJ, Rose L, Gattinoni L, Chiumello D. Relationship between D-dimers and dead-space on disease severity and mortality in COVID-19 acute respiratory distress syndrome: A retrospective observational cohort study. J Crit Care 2023; 77:154313. [PMID: 37116437 PMCID: PMC10129848 DOI: 10.1016/j.jcrc.2023.154313] [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: 10/19/2022] [Revised: 03/13/2023] [Accepted: 04/11/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Despite its diagnostic and prognostic importance, physiologic dead space fraction is not included in the current ARDS definition or severity classification. ARDS caused by COVID-19 (C-ARDS) is characterized by increased physiologic dead space fraction and hypoxemia. Our aim was to investigate the relationship between dead space indices, markers of inflammation, immunothrombosis, severity and intensive care unit (ICU) mortality. RESULTS Retrospective data including demographics, gas exchange, ventilatory parameters, and respiratory mechanics in the first 24 h of invasive ventilation. Plasma concentrations of D-dimers and ferritin were not significantly different across C-ARDS severity categories. Weak relationships were found between D-dimers and VR (r = 0.07, p = 0.13), PETCO2/PaCO2 (r = -0.1, p = 0.02), or estimated dead space fraction (r = 0.019, p = 0.68). Age, PaO2/FiO2, pH, PETCO2/PaCO2 and ferritin, were independently associated with ICU mortality. We found no association between D-dimers or ferritin and any dead-space indices adjusting for PaO2/FiO2, days of ventilation, tidal volume, and respiratory system compliance. CONCLUSIONS We report no association between dead space and inflammatory markers in mechanically ventilated patients with C-ARDS. Our results support theories suggesting that multiple mechanisms, in addition to immunothrombosis, play a role in the pathophysiology of respiratory failure and degree of dead space in C-ARDS.
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Affiliation(s)
- Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK; Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Barnaby Sanderson
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Stephanie Worrall
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Marlies Ostermann
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Nicholas A Barrett
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Andrew Retter
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Patrick Collins
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Louise Rose
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Davide Chiumello
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Italy.
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Marini JJ, Thornton LT, Rocco PRM, Gattinoni L, Crooke PS. Practical assessment of risk of VILI from ventilating power: a conceptual model. Crit Care 2023; 27:157. [PMID: 37081517 PMCID: PMC10120146 DOI: 10.1186/s13054-023-04406-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 01/24/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
At the bedside, assessing the risk of ventilator-induced lung injury (VILI) requires parameters readily measured by the clinician. For this purpose, driving pressure (DP) and end-inspiratory static 'plateau' pressure ([Formula: see text]) of the tidal cycle are unquestionably useful but lack key information relating to associated volume changes and cumulative strain. 'Mechanical power', a clinical term which incorporates all dissipated ('non-elastic') and conserved ('elastic') energy components of inflation, has drawn considerable interest as a comprehensive 'umbrella' variable that accounts for the influence of ventilating frequency per minute as well as the energy cost per tidal cycle. Yet, like the raw values of DP and [Formula: see text], the absolute levels of energy and power by themselves may not carry sufficiently precise information to guide safe ventilatory practice. In previous work we introduced the concept of 'damaging energy per cycle'. Here we describe how-if only in concept-the bedside clinician might gauge the theoretical hazard of delivered energy using easily observed static circuit pressures ([Formula: see text] and positive end expiratory pressure) and an estimate of the maximally tolerated (threshold) non-dissipated ('elastic') airway pressure that reflects the pressure component applied to the alveolar tissues. Because its core inputs are already in use and familiar in daily practice, the simplified mathematical model we propose here for damaging energy and power may promote deeper comprehension of the key factors in play to improve lung protective ventilation.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA.
| | - Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luciano Gattinoni
- Department of Anesthesiology, University of Göttingen, Göttingen, Germany
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
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Chiumello D, Pozzi T, Mereto E, Fratti I, Chiodaroli E, Gattinoni L, Coppola S. Author's response: "Long term feasibility of ultraprotective lung ventilation with low flow extracorporeal carbon dioxide removal (ECCO 2R) in ARDS patients". J Crit Care 2023; 74:154243. [PMID: 36604202 DOI: 10.1016/j.jcrc.2022.154243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy; Department of Health Sciences, University of Milan, Milano, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Elisa Mereto
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Isabella Fratti
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Elena Chiodaroli
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
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Velati M, D'Albo R, Brusatori S, Lombardo F, Maj R, Zinnato C, Gattarello S, Busana M, Romitti F, Moerer O, Meissner K, Gattinoni L. Pathophysiology of COVID-19 pneumonia and respiratory treatment. Minerva Anestesiol 2023:S0375-9393.23.17188-4. [PMID: 37000017 DOI: 10.23736/s0375-9393.23.17188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
COVID-19 pandemic has seen an unprecedented number of patients presenting with acute respiratory distress syndrome to the intensive care units all over the world. Between August and November 2022, we performed research on PubMed screening all publications on COVID-19 disease and respiratory failure and its treatment. In this review we focused on COVID-19 most common manifestations concerning lung function. The respiratory infection develops in three broad phases: early, intermediate, and late. The mainstay of the disease is the frequent presence of severe hypoxemia associated - at least at the beginning - to a near normal lung mechanics and PaCO<inf>2</inf> tension. The management of symptomatic patients, progressing through these temporal phases, is not possible without understanding the pathophysiology underlying the respiratory manifestation.
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Affiliation(s)
- Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Rosanna D'Albo
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen (UMG), Medical University of Göttingen, Göttingen, Germany -
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Maj R, Palermo P, Gattarello S, Brusatori S, D’Albo R, Zinnato C, Velati M, Romitti F, Busana M, Wieditz J, Herrmann P, Moerer O, Quintel M, Meissner K, Sanderson B, Chiumello D, Marini JJ, Camporota L, Gattinoni L. Ventilatory ratio, dead space, and venous admixture in patients with acute respiratory distress syndrome. Br J Anaesth 2023; 130:360-367. [PMID: 36470747 PMCID: PMC9718027 DOI: 10.1016/j.bja.2022.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Ventilatory ratio (VR) has been proposed as an alternative approach to estimate physiological dead space. However, the absolute value of VR, at constant dead space, might be affected by venous admixture and CO2 volume expired per minute (VCO2). METHODS This was a retrospective, observational study of mechanically ventilated patients with acute respiratory distress syndrome (ARDS) in the UK and Italy. Venous admixture was either directly measured or estimated using the surrogate measure PaO2/FiO2 ratio. VCO2 was estimated through the resting energy expenditure derived from the Harris-Benedict formula. RESULTS A total of 641 mechanically ventilated patients with mild (n=65), moderate (n=363), or severe (n=213) ARDS were studied. Venous admixture was measured (n=153 patients) or estimated using the PaO2/FiO2 ratio (n=448). The VR increased exponentially as a function of the dead space, and the absolute values of this relationship were a function of VCO2. At a physiological dead space of 0.6, VR was 1.1, 1.4, and 1.7 in patients with VCO2 equal to 200, 250, and 300, respectively. VR was independently associated with mortality (odds ratio [OR]=2.5; 95% confidence interval [CI], 1.8-3.5), but was not associated when adjusted for VD/VTphys, VCO2, PaO2/FiO2 (ORadj=1.2; 95% CI, 0.7-2.1). These three variables remained independent predictors of ICU mortality (VD/VTphys [ORadj=17.9; 95% CI, 1.8-185; P<0.05]; VCO2 [ORadj=0.99; 95% CI, 0.99-1.00; P<0.001]; and PaO2/FiO2 (ORadj=0.99; 95% CI, 0.99-1.00; P<0.001]). CONCLUSIONS VR is a useful aggregate variable associated with outcome, but variables not associated with ventilation (VCO2 and venous admixture) strongly contribute to the high values of VR seen in patients with severe illness.
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Affiliation(s)
- Roberta Maj
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Palermo
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simone Gattarello
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Serena Brusatori
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Mara Velati
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Romitti
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Johannes Wieditz
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Micheal Quintel
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Barnaby Sanderson
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Davide Chiumello
- Department of Anaesthesiology and Intensive Care, ASST Santi Paolo e Carlo Hospital, University of Milan, Milan, Italy
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, MN, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Luciano Gattinoni
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany.
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23
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Cortes-Puentes GA, Gattinoni L, Marini JJ. Physiology-Based Approach to PEEP Titration in COVID-19 ARDS. Respir Care 2023. [DOI: 10.4187/respcare.10811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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24
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Berger DC, Zwicker L, Nettelbeck K, Casoni D, Heinisch PP, Jenni H, Haenggi M, Gattinoni L, Bachmann KF. Integral assessment of gas exchange during veno-arterial ECMO: accuracy and precision of a modified Fick principle in a porcine model. Am J Physiol Lung Cell Mol Physiol 2023; 324:L102-L113. [PMID: 36511508 PMCID: PMC9870575 DOI: 10.1152/ajplung.00045.2022] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Assessment of native cardiac output during extracorporeal circulation is challenging. We assessed a modified Fick principle under conditions such as dead space and shunt in 13 anesthetized swine undergoing centrally cannulated veno-arterial extracorporeal membrane oxygenation (V-A ECMO, 308 measurement periods) therapy. We assumed that the ratio of carbon dioxide elimination (V̇co2) or oxygen uptake (V̇o2) between the membrane and native lung corresponds to the ratio of respective blood flows. Unequal ventilation/perfusion (V̇/Q̇) ratios were corrected towards unity. Pulmonary blood flow was calculated and compared to an ultrasonic flow probe on the pulmonary artery with a bias of 99 mL/min (limits of agreement -542 to 741 mL/min) with blood content V̇o2 and no-shunt, no-dead space conditions, which showed good trending ability (least significant change from 82 to 129 mL). Shunt conditions led to underestimation of native pulmonary blood flow (bias -395, limits of agreement -1,290 to 500 mL/min). Bias and trending further depended on the gas (O2, CO2) and measurement approach (blood content vs. gas phase). Measurements in the gas phase increased the bias (253 [LoA -1,357 to 1,863 mL/min] for expired V̇o2 bias 482 [LoA -760 to 1,724 mL/min] for expired V̇co2) and could be improved by correction of V̇/Q̇ inequalities. Our results show that common assumptions of the Fick principle in two competing circulations give results with adequate accuracy and may offer a clinically applicable tool. Precision depends on specific conditions. This highlights the complexity of gas exchange in membrane lungs and may further deepen the understanding of V-A ECMO.
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Affiliation(s)
- David C. Berger
- 1Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lena Zwicker
- 1Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kay Nettelbeck
- 1Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,2Experimental Surgery Facility (ESF), Department for BioMedical
Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Daniela Casoni
- 2Experimental Surgery Facility (ESF), Department for BioMedical
Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Paul Phillipp Heinisch
- 3Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Hansjörg Jenni
- 3Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Matthias Haenggi
- 1Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luciano Gattinoni
- 5Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - Kaspar F. Bachmann
- 1Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,4Department of Anesthesiology & Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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25
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Gattarello S, Camporota L, Gattinoni L. COVID-19 pneumonia: Therapeutic implications of its atypical features. Anaesth Crit Care Pain Med 2023; 42:101182. [PMID: 36481694 PMCID: PMC9742678 DOI: 10.1016/j.accpm.2022.101182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Simone Gattarello
- Anesthesia and Intensive Care Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, Department of Adult Critical Care, London, United Kingdom
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.
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Gattinoni L, Brusatori S, D’Albo R, Maj R, Velati M, Zinnato C, Gattarello S, Lombardo F, Fratti I, Romitti F, Saager L, Camporota L, Busana M. Prone position: how understanding and clinical application of a technique progress with time. APS 2023; 1:3. [PMCID: PMC9995262 DOI: 10.1007/s44254-022-00002-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Historical background The prone position was first proposed on theoretical background in 1974 (more advantageous distribution of mechanical ventilation). The first clinical report on 5 ARDS patients in 1976 showed remarkable improvement of oxygenation after pronation. Pathophysiology The findings in CT scans enhanced the use of prone position in ARDS patients. The main mechanism of the improved gas exchange seen in the prone position is nowadays attributed to a dorsal ventilatory recruitment, with a substantially unchanged distribution of perfusion. Regardless of the gas exchange, the primary effect of the prone position is a more homogenous distribution of ventilation, stress and strain, with similar size of pulmonary units in dorsal and ventral regions. In contrast, in the supine position the ventral regions are more expanded compared with the dorsal regions, which leads to greater ventral stress and strain, induced by mechanical ventilation. Outcome in ARDS The number of clinical studies paralleled the evolution of the pathophysiological understanding. The first two clinical trials in 2001 and 2004 were based on the hypothesis that better oxygenation would lead to a better survival and the studies were more focused on gas exchange than on lung mechanics. The equations better oxygenation = better survival was disproved by these and other larger trials (ARMA trial). However, the first studies provided signals that some survival advantages were possible in a more severe ARDS, where both oxygenation and lung mechanics were impaired. The PROSEVA trial finally showed the benefits of prone position on mortality supporting the thesis that the clinical advantages of prone position, instead of improved gas exchange, were mainly due to a less harmful mechanical ventilation and better distribution of stress and strain. In less severe ARDS, in spite of a better gas exchange, reduced mechanical stress and strain, and improved oxygenation, prone position was ineffective on outcome. Prone position and COVID-19 The mechanisms of oxygenation impairment in early COVID-19 are different than in typical ARDS and relate more on perfusion alteration than on alveolar consolidation/collapse, which are minimal in the early phase. Bronchial shunt may also contribute to the early COVID-19 hypoxemia. Therefore, in this phase, the oxygenation improvement in prone position is due to a better matching of local ventilation and perfusion, primarily caused by the perfusion component. Unfortunately, the conditions for improved outcomes, i.e. a better distribution of stress and strain, are almost absent in this phase of COVID-19 disease, as the lung parenchyma is nearly fully inflated. Due to some contradictory results, further studies are needed to better investigate the effect of prone position on outcome in COVID-19 patients. Graphical Abstract ![]()
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | | | - Fabio Lombardo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
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Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022; 26:201. [PMID: 35791021 PMCID: PMC9255488 DOI: 10.1186/s13054-022-04073-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS.
Methods
Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O.
Results
Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients.
Conclusion
Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of ‘paradox’ should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
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Busana M, Zinnato C, Romitti F, Palumbo M, Gattarello S, Sonzogni A, Gersmann AK, Richter A, Herrmann P, Hahn G, Brusatori S, Maj R, Velati M, Moerer O, Meissner K, Barnes T, Quintel M, Marini JJ, Gattinoni L. Energy dissipation during expiration and Ventilator Induced Lung Injury: an experimental animal study. J Appl Physiol (1985) 2022; 133:1212-1219. [PMID: 36173324 DOI: 10.1152/japplphysiol.00426.2022] [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] [Indexed: 11/22/2022] Open
Abstract
The amount of energy delivered to the respiratory system is recognized as a cause of Ventilator Induced Lung Injury (VILI). How energy dissipation within the lung causes damage is still a matter of debate. Expiratory flow control has been proposed as a strategy to reduce the energy dissipated into the respiratory system during expiration and, possibly, VILI. We studied 22 healthy pigs (29±2 kg), which were randomized into a control (n=11) and a valve group (n=11), where the expiratory flow was controlled through a variable resistor. Both groups were ventilated with the same tidal volume, PEEP and inspiratory flow. Electric impedance tomography was continuously acquired. At completion, lung weight, wet to dry ratios and histology were evaluated. The total mechanical power was similar in the control and valve groups (8.54±0.83 J min-1 and 8.42±0.54 J min-1 respectively, p=0.552). The total energy dissipated within the whole system (circuit + respiratory system) was remarkably different (4.34±0.66 vs 2.62±0.31 J/min, p<0.001). However, most of this energy was dissipated across the endotracheal tube (2.87±0.3 vs 1.88±0.2 J/min, p<0.001). The amount dissipated into the respiratory system averaged 1.45±0.5 in controls vs 0.73±0.16 J min-1 in the valve group, p<0.001. Although respiratory mechanics, gas exchange, hemodynamics, wet to dry ratios and histology were similar in the two groups, the decrease of end-expiratory lung impedance was significantly greater in the control group (p=0.02). We conclude that with our experimental conditions, the reduction of energy dissipated in the respiratory system did not lead to appreciable differences in VILI.
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Affiliation(s)
- Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michela Palumbo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aurelio Sonzogni
- Department of Pathology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ann-Kathrin Gersmann
- Institute of Pathology, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
| | - Annika Richter
- Institute of Pathology, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Günter Hahn
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Serena Brusatori
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Roberta Maj
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mara Velati
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Tom Barnes
- University of Greenwich, Park Row, London, United Kingdom
| | - Michael Quintel
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, Minnesota, United States
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Busana M, Camporota L, Gattinoni L. Biochemical shunt: where and how? Eur Respir Rev 2022; 31:31/165/220148. [PMID: 36130787 PMCID: PMC9724832 DOI: 10.1183/16000617.0148-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
G. Harutyunyan and co-workers, in their reply to our correspondence, introduce the fascinating concept of “biochemical shunt” to help explain some of the gas exchange abnormalities reported in patients with early coronavirus disease 2019 (COVID-19). In brief, they assert the plausibility that the oxyhaemoglobin dissociation curve (ODC), which may be normal in the arterial and venous blood, could be altered (i.e. reduced oxygen affinity) in the pulmonary blood flowing through diseased alveolar capillaries. It is not easy for us to understand which COVID-19-related factors, or metabolites, might alter the ODC specifically in the pulmonary circulation, and to what extent they involve the lung parenchyma (partially or totally, where and why). Let us suppose, for example, that the biochemical shunt occurs in the whole parenchyma (nearly fully ventilated in early COVID-19). Response to Harutyunyan et al. “Hypoxaemia in the early stage of COVID-19: prevalence of physical or biochemical factors?”https://bit.ly/3K1NSKu
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Affiliation(s)
- Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany,Luciano Gattinoni ()
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Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022. [PMID: 35791021 DOI: 10.1186/s13054-022-04073-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in 'baby lungs' of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS. METHODS Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O. RESULTS Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients. CONCLUSION Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of 'paradox' should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
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Affiliation(s)
- John Selickman
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA.
| | - Pierre Tawfik
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
| | - David J Dries
- Department of Surgery, Regions Hospital, St Paul, MN, USA
- Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Jonathan Shelver
- Department of Pulmonary and Critical Care Medicine, Methodist Hospital, St. Louis Park, MN, USA
| | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
- Department of Critical Care Medicine, Regions Hospital, St. Paul, MN, USA
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Busana M, Camporota L, Gattinoni L. Hypoxaemia in COVID-19: many pieces to a complex puzzle. Eur Respir Rev 2022; 31:31/164/220090. [PMID: 35768129 DOI: 10.1183/16000617.0090-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 01/13/2023] Open
Affiliation(s)
- Mattia Busana
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Dept of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Luciano Gattinoni
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Chiumello D, Pozzi T, Mereto E, Fratti I, Chiodaroli E, Gattinoni L, Coppola S. Long term feasibility of ultraprotective lung ventilation with low-flow extracorporeal carbon dioxide removal in ARDS patients. J Crit Care 2022; 71:154092. [PMID: 35714453 DOI: 10.1016/j.jcrc.2022.154092] [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: 02/16/2022] [Revised: 05/02/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To explore the feasibility of long-term application of ultraprotective ventilation with low flow ECCO2R support in moderate-severe ARDS patients and the reduction of mechanical power (MP) compared to lung protective ventilation. MATERIAL AND METHODS ARDS patients with PaO2/FiO2 < 200, PEEP of 10 cmH2O, tidal volume 6 ml/Kg of predicted body weight (PBW), plateau pressure > 24 cmH2O, MP > 17 J/min were prospectively enrolled. After 2 h tidal volume was reduced to 4-5 ml/kg, respiratory rate (RR) and PEEP were changed to maintain similar minute ventilation and mean airway pressure (MAP) to those obtained at baseline. After 2 h, ECCO2R support was started, RR was decreased and PEEP was increased to maintain similar PaCO2 and MAP, respectively. RESULTS The only reduction of tidal volume with the increase in RR did not decrease MP. The application of low flow ECCO2R support allowed a reduction of RR from 25 [24-30] to 11 [9-14] bpm and MP from 18 [13-23] to 8 [7-11] J/min. During the following 5 days no changes in mechanics variables and gas exchange occurred. CONCLUSIONS The application of low flow ECCO2R support with ultraprotective ventilation was feasible minimizing the MP without deterioration in oxygenation in ARDS patients.
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Affiliation(s)
- Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy; Department of Health Sciences, University of Milan, Milano, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Elisa Mereto
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Isabella Fratti
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Elena Chiodaroli
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
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Crooke PS, Gattinoni L, Michalik M, Marini JJ. Intracycle power distribution in a heterogeneous multi-compartmental mathematical model: possible links to strain and VILI. Intensive Care Med Exp 2022; 10:21. [PMID: 35641652 PMCID: PMC9156592 DOI: 10.1186/s40635-022-00447-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 01/08/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Repeated expenditure of energy and its generation of damaging strain are required to injure the lung by ventilation (VILI). Mathematical modeling of passively inflated, single-compartment lungs with uniform parameters for resistance and compliance indicates that standard clinical modes (flow patterns) differ impressively with respect to the timing and intensity of energy delivery-the intracycle power (ICP) that determines parenchymal stress and strain. Although measures of elastic ICP may accurately characterize instantaneous rates of global energy delivery, how the ICP component delivered to a compartment affects the VILI-linked variable of strain is determined by compartmental mechanics, compartmental size and mode of gas delivery. We extended our one-compartment model of ICP to a multi-compartment setting that varied those characteristics. MAIN FINDINGS The primary findings of this model/simulation indicate that: (1) the strain and strain rate experienced within a modeled compartment are nonlinear functions of delivered energy and power, respectively; (2) for a given combination of flow profile and tidal volume, resting compartmental volumes influence their resulting maximal strains in response to breath delivery; (3) flow profile is a key determinant of the maximal strain as well as maximal strain rate experienced within a multi-compartment lung. By implication, different clinician-selected flow profiles not only influence the timing of power delivery, but also spatially distribute the attendant strains of expansion among compartments with diverse mechanical properties. Importantly, the contours and magnitudes of the compartmental ICP, strain, and strain rate curves are not congruent; strain and strain rate do not necessarily follow the compartmental ICP, and the hierarchy of amplitudes among compartments for these variables may not coincide. CONCLUSIONS Different flow patterns impact how strain and strain rate develop as compartmental volume crests to its final value. Notably, as inflation proceeds, strain rate may rise or fall even as total strain, a monotonic function of volume, steadily (and predictably) rises. Which flow pattern serves best to minimize the maximal strain rate and VILI risk experienced within any sector, therefore, may strongly depend on the nature and heterogeneity of the mechanical properties of the injured lung.
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Affiliation(s)
- Philip S. Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN USA
| | - Luciano Gattinoni
- Department of Anesthesiology and Intensive Care, Gottingen University, Gottingen, Germany
| | - Michael Michalik
- Department of Medicine, University of Minnesota, Minneapolis, St. Paul, MN USA
| | - John J. Marini
- Pulmonary and Critical Care Medicine, Regions Hospital, University of Minnesota, MS 11203B, 640 Jackson St., Minneapolis, St. Paul, MN 55101-2595 USA
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Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguar Ca' Granda, Milan, Italy
| | - Serena Brusatori
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.
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Lazzari S, Romitti F, Busana M, Vassalli F, Bonifazi M, Macrí MM, Giosa L, Collino F, Heise D, Golinski M, Gattarello S, Harnisch LO, Brusatori S, Maj R, Zinnato C, Meissner K, Quintel M, Mörer O, Marini JJ, Sanderson B, Camporota L, Gattinoni L. End-Tidal to Arterial PCO2 Ratio as Guide to Weaning from Veno-Venous Extra-Corporeal Membrane Oxygenation. Am J Respir Crit Care Med 2022; 206:973-980. [PMID: 35608503 DOI: 10.1164/rccm.202201-0135oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Weaning from veno-venous extracorporeal membrane oxygenation (VV-ECMO) is based on oxygenation and not on carbon dioxide elimination. OBJECTIVE To predict readiness to wean from VV-ECMO Methods: In this multicenter study of mechanically ventilated adults with severe acute respiratory distress syndrome (ARDS) receiving VV-ECMO, we investigated a variable based on CO2 elimination. The study included a prospective interventional study of a physiological cohort (n=26), and a retrospective clinical cohort (n=638). MEASUREMENTS AND MAIN RESULTS Weaning failure in the clinical and physiological cohorts were respectively 37% and 42%. The main cause of failure in the physiological cohort was high inspiratory effort or respiratory rate. All patients exhaled similar amounts of CO2 but in patients who failed the weaning trial minute ventilation was higher to maintain the PaCO2 unchanged. The effort to eliminate one unit-volume of CO2, was double in failing patients [68·9 (42·4-123) vs. 39 (20·1-57) [cmH2O/(L/min)], p=0.007], owing to the higher physiological dead space [68 (58.73) % vs. 54 (41,.64) %; p=0.012]. PetCO2/PaCO2 ratio was a clinical variable strongly associated with weaning outcome at baseline was the, AUC: 0.87 (95%CI 0·71 - one). Similarly, the PetCO2/PaCO2 ratio was associated with weaning outcome in the "clinical cohort" both pre-weaning trial (OR 4·14; 95% CI 1·32 - 12·2; p=0·015), and at a sweep gas flow of zero (OR 13·1; 95% CI 4-44·4; p<0·001). CONCLUSION The primary reason for weaning failure from VV-ECMO is high effort to eliminate CO2. A higher PetCO2/PaCO2 ratio was associated with greater likelihood of weaning from VV-ECMO.
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Affiliation(s)
- Stefano Lazzari
- University of Goettingen, Department for Anesthesiology, Intensive Care and Emergency Medicine, Goettingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Romitti
- University of Göttingen, Department of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - Mattia Busana
- University of Goettingen, Department for Anesthesiology, Intensive Care and Emergency Medicine, Goettingen, Germany
| | - Francesco Vassalli
- University of Göttingen, Department of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - Matteo Bonifazi
- University of Göttingen, Department of Anaesthesiology, Emergency and Intensive Care Medicine , Göttingen, Germany
| | - Matteo Maria Macrí
- University of Gottingen, 9375, Department for Anesthesiology and Intensive Care Medicine Goettingen, DE , Gottingen, Niedersachsen, Germany
| | - Lorenzo Giosa
- University of Turin, 9314, Department of Surgical Sciences , Torino, Italy
| | - Francesca Collino
- University of Göttingen, Department of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - David Heise
- University Medical Center Göttingen, 84922, Department of Anesthesiology, Gottingen, Germany
| | - Martin Golinski
- University Medical Center Göttingen, 84922, Department of anesthesia, Gottingen, Germany
| | - Simone Gattarello
- IRCCS San Raffaele Scientific Institute, Anesthesia and Intensive Care Medicine, Milan, Italy
| | - Lars-Olav Harnisch
- University Medical Center Göttingen, 84922, Department of anesthesia, Gottingen, Germany
| | - Serena Brusatori
- University Medical Center Göttingen, 84922, Department of anesthesia, Göttingen, Germany
| | - Roberta Maj
- University Medical Center Göttingen, 84922, Gottingen, Germany.,IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carmelo Zinnato
- University Medical Center Göttingen, 84922, Gottingen, Germany
| | - Konrad Meissner
- University Hospital of Göttingen, Department of Anesthesiology, Göttingen, Germany
| | - Michael Quintel
- University of Göttingen, Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - Onnen Mörer
- University of Göttingen, Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany
| | - John J Marini
- Regions Hospital, St. Paul, Minnesota, United States
| | - Barnaby Sanderson
- Guy's and Saint Thomas' NHS Foundation Trust, 8945, London, United Kingdom of Great Britain and Northern Ireland
| | - Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, Department of Adult Critical Care, London, United Kingdom of Great Britain and Northern Ireland
| | - Luciano Gattinoni
- University of Göttingen, Department of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen, Germany;
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36
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Romitti F, Busana M, Palumbo MM, Bonifazi M, Giosa L, Vassalli F, Gatta A, Collino F, Steinberg I, Gattarello S, Lazzari S, Palermo P, Nasr A, Gersmann A, Richter A, Herrmann P, Moerer O, Saager L, Camporota L, Marini JJ, Quintel M, Meissner K, Gattinoni L. Mechanical power thresholds during mechanical ventilation: An experimental study. Physiol Rep 2022; 10:e15225. [PMID: 35340133 PMCID: PMC8957661 DOI: 10.14814/phy2.15225] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 06/14/2023] Open
Abstract
The extent of ventilator-induced lung injury may be related to the intensity of mechanical ventilation--expressed as mechanical power. In the present study, we investigated whether there is a safe threshold, below which lung damage is absent. Three groups of six healthy pigs (29.5 ± 2.5 kg) were ventilated prone for 48 h at mechanical power of 3, 7, or 12 J/min. Strain never exceeded 1.0. PEEP was set at 4 cmH2 O. Lung volumes were measured every 12 h; respiratory, hemodynamics, and gas exchange variables every 6. End-experiment histological findings were compared with a control group of eight pigs which did not undergo mechanical ventilation. Functional residual capacity decreased by 10.4% ± 10.6% and 8.1% ± 12.1% in the 7 J and 12 J groups (p = 0.017, p < 0.001) but not in the 3 J group (+1.7% ± 17.7%, p = 0.941). In 3 J group, lung elastance, PaO2 and PaCO2 were worse compared to 7 J and 12 J groups (all p < 0.001), due to lower ventilation-perfusion ratio (0.54 ± 0.13, 1.00 ± 0.25, 1.78 ± 0.36 respectively, p < 0.001). The lung weight was lower (p < 0.001) in the controls (6.56 ± 0.90 g/kg) compared to 3, 7, and 12 J groups (12.9 ± 3.0, 16.5 ± 2.9, and 15.0 ± 4.1 g/kg, respectively). The wet-to-dry ratio was 5.38 ± 0.26 in controls, 5.73 ± 0.52 in 3 J, 5.99 ± 0.38 in 7 J, and 6.13 ± 0.59 in 12 J group (p = 0.03). Vascular congestion was more extensive in the 7 J and 12 J compared to 3 J and control groups. Mechanical ventilation (with anesthesia/paralysis) increase lung weight, and worsen lung histology, regardless of the mechanical power. Ventilating at 3 J/min led to better anatomical variables than at 7 and 12 J/min but worsened the physiological values.
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Affiliation(s)
- Federica Romitti
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Mattia Busana
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | | | - Matteo Bonifazi
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Lorenzo Giosa
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Francesco Vassalli
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Alessandro Gatta
- Department of Anesthesia and Intensive Care“Ceccarini”HospitalAUSL della RomagnaRiccioneItaly
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency“Citta’ della Salute e della Scienza” HospitalTurinItaly
| | - Irene Steinberg
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Simone Gattarello
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Stefano Lazzari
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Paola Palermo
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Ahmed Nasr
- Department of PathologyPapa Giovanni XXIII HospitalBergamoItaly
| | - Ann‐Kathrin Gersmann
- Institute of PathologyUniversity Medical Center GöttingenUniversity of GöttingenGermany
| | - Annika Richter
- Institute of PathologyUniversity Medical Center GöttingenUniversity of GöttingenGermany
| | - Peter Herrmann
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Onnen Moerer
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Leif Saager
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
- Outcomes Research ConsortiumClevelandOhioUSA
| | - Luigi Camporota
- Department of Adult Critical CareGuy’s and St Thomas’ NHS Foundation TrustHealth Centre for Human and Applied Physiological SciencesLondonUnited Kingdom
| | - John J. Marini
- Department of Pulmonary and Critical Care MedicineUniversity of Minnesota and Regions HospitalSt. PaulMinnesotaUSA
| | - Michael Quintel
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Konrad Meissner
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
| | - Luciano Gattinoni
- Department of AnesthesiologyUniversity Medical Center GöttingenGöttingenGermany
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Abstract
PURPOSE OF REVIEW More than 230 million people have tested positive for severe acute respiratory syndrome-coronavirus-2 infection globally by September 2021. The infection affects primarily the function of the respiratory system, where ∼20% of infected individuals develop coronavirus-19 disease (COVID-19) pneumonia. This review provides an update on the pathophysiology of the COVID-19 acute lung injury. RECENT FINDINGS In patients with COVID-19 pneumonia admitted to the intensive care unit, the PaO2/FiO2 ratio is typically <26.7 kPa (200 mmHg), whereas lung volume appears relatively unchanged. This hypoxaemia is likely determined by a heterogeneous mismatch of pulmonary ventilation and perfusion, mainly associated with immunothrombosis, endothelialitis and neovascularisation. During the disease, lung weight, elastance and dead space can increase, affecting respiratory drive, effort and dyspnoea. In some severe cases, COVID-19 pneumonia may lead to irreversible pulmonary fibrosis. SUMMARY This review summarises the fundamental pathophysiological features of COVID-19 in the context of the respiratory system. It provides an overview of the key clinical manifestations of COVID-19 pneumonia, including gas exchange impairment, altered pulmonary mechanics and implications of abnormal chemical and mechanical stimuli. It also critically discusses the clinical implications for mechanical ventilation therapy.
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Affiliation(s)
- Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust
| | - John N Cronin
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Department of Anaesthetics, Royal Brompton and Harefield, part of Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
- Department of Biomechanics, University of Nebraska Omaha, Omaha, Nebraska, USA
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38
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075 Göttingen, Germany
| | - Silvia Coppola
- Department of Anesthesiology and Intensive Care, ASST Santi Paolo e Carlo Hospital, University of Milan, Milan, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Gattinoni L, Marini JJ. In search of the Holy Grail: identifying the best PEEP in ventilated patients. Intensive Care Med 2022; 48:728-731. [PMID: 35513707 PMCID: PMC9205826 DOI: 10.1007/s00134-022-06698-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 03/04/2022] [Accepted: 04/06/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - John J. Marini
- Pulmonary and Critical Care Medicine, Regions Hospital and University of Minnesota, St. Paul, MN USA
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40
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Gattinoni L, Gattarello S, Steinberg I, Busana M, Palermo P, Lazzari S, Romitti F, Quintel M, Meissner K, Marini JJ, Chiumello D, Camporota L. COVID-19 pneumonia: pathophysiology and management. Eur Respir Rev 2021; 30:30/162/210138. [PMID: 34670808 PMCID: PMC8527244 DOI: 10.1183/16000617.0138-2021] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/08/2021] [Indexed: 12/23/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) pneumonia is an evolving disease. We will focus on the development of its pathophysiologic characteristics over time, and how these time-related changes determine modifications in treatment. In the emergency department: the peculiar characteristic is the coexistence, in a significant fraction of patients, of severe hypoxaemia, near-normal lung computed tomography imaging, lung gas volume and respiratory mechanics. Despite high respiratory drive, dyspnoea and respiratory rate are often normal. The underlying mechanism is primarily altered lung perfusion. The anatomical prerequisites for PEEP (positive end-expiratory pressure) to work (lung oedema, atelectasis, and therefore recruitability) are lacking. In the high-dependency unit: the disease starts to worsen either because of its natural evolution or additional patient self-inflicted lung injury (P-SILI). Oedema and atelectasis may develop, increasing recruitability. Noninvasive supports are indicated if they result in a reversal of hypoxaemia and a decreased inspiratory effort. Otherwise, mechanical ventilation should be considered to avert P-SILI. In the intensive care unit: the primary characteristic of the advance of unresolved COVID-19 disease is a progressive shift from oedema or atelectasis to less reversible structural lung alterations to lung fibrosis. These later characteristics are associated with notable impairment of respiratory mechanics, increased arterial carbon dioxide tension (PaCO2), decreased recruitability and lack of response to PEEP and prone positioning. COVID-19 pneumonia cannot be correctly described, analysed and treated if the time-factor is not taken into accounthttps://bit.ly/3AOKxc4
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Affiliation(s)
- Luciano Gattinoni
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Simone Gattarello
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Irene Steinberg
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Mattia Busana
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Paola Palermo
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Stefano Lazzari
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Federica Romitti
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Quintel
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,Dept of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | - Konrad Meissner
- Dept of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - John J Marini
- Dept of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Davide Chiumello
- Dept of Anesthesia and Intensive Care, San Paolo Hospital, University of Milan, Milan, Italy
| | - Luigi Camporota
- Dept of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
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41
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Coppola S, Chiumello D, Busana M, Giola E, Palermo P, Pozzi T, Steinberg I, Roli S, Romitti F, Lazzari S, Gattarello S, Palumbo M, Herrmann P, Saager L, Quintel M, Meissner K, Camporota L, Marini JJ, Centanni S, Gattinoni L. Correction to: Role of total lung stress on the progression of early COVID‑19 pneumonia. Intensive Care Med 2021; 48:387-388. [PMID: 34905078 PMCID: PMC8669222 DOI: 10.1007/s00134-021-06589-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Silvia Coppola
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Mattia Busana
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Emanuele Giola
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Paola Palermo
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Irene Steinberg
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Stefano Roli
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Stefano Lazzari
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Michela Palumbo
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | - Konrad Meissner
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Stefano Centanni
- Respiratory Unit, San Paolo Hospital, Dipartimento Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.
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Marini JJ, Crooke PS, Tawfik P, Chatburn RL, Dries DJ, Gattinoni L. Intracycle power and ventilation mode as potential contributors to ventilator-induced lung injury. Intensive Care Med Exp 2021; 9:55. [PMID: 34719749 PMCID: PMC8557972 DOI: 10.1186/s40635-021-00420-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 06/23/2021] [Accepted: 10/07/2021] [Indexed: 11/23/2022] Open
Abstract
Background High rates of inflation energy delivery coupled with transpulmonary tidal pressures of sufficient magnitude may augment the risk of damage to vulnerable, stress-focused units within a mechanically heterogeneous lung. Apart from flow amplitude, the clinician-selected flow waveform, a relatively neglected dimension of inflation power, may distribute inflation energy of each inflation cycle non-uniformly among alveoli with different mechanical properties over the domains of time and space. In this initial step in modeling intracycle power distribution, our primary objective was to develop a mathematical model of global intracycle inflation power that uses clinician-measurable inputs to allow comparisons of instantaneous ICP profiles among the flow modes commonly encountered in clinical practice: constant, linearly decelerating, exponentially decelerating (pressure control), and spontaneous (sinusoidal). Methods We first tested the predictions of our mathematical model of passive inflation with the actual physical performance of a mechanical ventilator–lung system that simulated ventilation to three types of patients: normal, severe ARDS, and severe airflow obstruction. After verification, model predictions were then generated for 5000 ‘virtual ARDS patients’. Holding constant the tidal volume and inflation time between modes, the validated model then varied the flow profile and quantitated the resulting intensity and timing of potentially damaging ‘elastic’ energy and intracycle power (pressure–flow product) developed in response to random combinations of machine settings and severity levels for ARDS. Results Our modeling indicates that while the varied flow patterns ultimately deliver similar total amounts of alveolar energy during each breath, they differ profoundly regarding the potentially damaging pattern with which that energy distributes over time during inflation. Pressure control imposed relatively high maximal intracycle power. Conclusions Flow amplitude and waveform may be relatively neglected and modifiable determinants of VILI risk when ventilating ARDS. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00420-9.
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Affiliation(s)
- John J Marini
- Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, Minneapolis/St. Paul, MN, 55101, USA. .,Regions Hospital, MS-11203B, 640 Jackson St, St. Paul, MN, 55101, USA.
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
| | - Pierre Tawfik
- Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, Minneapolis/St. Paul, MN, 55101, USA
| | - Robert L Chatburn
- Department of Medicine and Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David J Dries
- Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, Minneapolis/St. Paul, MN, 55101, USA
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany
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Herrmann P, Busana M, Cressoni M, Lotz J, Moerer O, Saager L, Meissner K, Quintel M, Gattinoni L. Using Artificial Intelligence for Automatic Segmentation of CT Lung Images in Acute Respiratory Distress Syndrome. Front Physiol 2021; 12:676118. [PMID: 34594233 PMCID: PMC8476971 DOI: 10.3389/fphys.2021.676118] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 03/04/2021] [Accepted: 08/17/2021] [Indexed: 01/17/2023] Open
Abstract
Knowledge of gas volume, tissue mass and recruitability measured by the quantitative CT scan analysis (CT-qa) is important when setting the mechanical ventilation in acute respiratory distress syndrome (ARDS). Yet, the manual segmentation of the lung requires a considerable workload. Our goal was to provide an automatic, clinically applicable and reliable lung segmentation procedure. Therefore, a convolutional neural network (CNN) was used to train an artificial intelligence (AI) algorithm on 15 healthy subjects (1,302 slices), 100 ARDS patients (12,279 slices), and 20 COVID-19 (1,817 slices). Eighty percent of this populations was used for training, 20% for testing. The AI and manual segmentation at slice level were compared by intersection over union (IoU). The CT-qa variables were compared by regression and Bland Altman analysis. The AI-segmentation of a single patient required 5–10 s vs. 1–2 h of the manual. At slice level, the algorithm showed on the test set an IOU across all CT slices of 91.3 ± 10.0, 85.2 ± 13.9, and 84.7 ± 14.0%, and across all lung volumes of 96.3 ± 0.6, 88.9 ± 3.1, and 86.3 ± 6.5% for normal lungs, ARDS and COVID-19, respectively, with a U-shape in the performance: better in the lung middle region, worse at the apex and base. At patient level, on the test set, the total lung volume measured by AI and manual segmentation had a R2 of 0.99 and a bias −9.8 ml [CI: +56.0/−75.7 ml]. The recruitability measured with manual and AI-segmentation, as change in non-aerated tissue fraction had a bias of +0.3% [CI: +6.2/−5.5%] and −0.5% [CI: +2.3/−3.3%] expressed as change in well-aerated tissue fraction. The AI-powered lung segmentation provided fast and clinically reliable results. It is able to segment the lungs of seriously ill ARDS patients fully automatically.
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Affiliation(s)
- Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Joachim Lotz
- Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.,Department of Anesthesiology, DONAUISAR Klinikum Deggendorf, Deggendorf, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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44
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, Göttingen 37075, Germany.
| | - Mattia Busana
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, and Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, and Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
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45
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Gattarello S, Pasticci I, Busana M, Lazzari S, Palermo P, Palumbo MM, Romitti F, Steinberg I, Collino F, Vassalli F, Langer T, Moerer O, Saager L, Herrmann P, Cadringher P, Meissner K, Quintel M, Gattinoni L. Role of Fluid and Sodium Retention in Experimental Ventilator-Induced Lung Injury. Front Physiol 2021; 12:743153. [PMID: 34588999 PMCID: PMC8473803 DOI: 10.3389/fphys.2021.743153] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 07/17/2021] [Accepted: 08/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Ventilator-induced lung injury (VILI) via respiratory mechanics is deeply interwoven with hemodynamic, kidney and fluid/electrolyte changes. We aimed to assess the role of positive fluid balance in the framework of ventilation-induced lung injury. Methods:Post-hoc analysis of seventy-eight pigs invasively ventilated for 48 h with mechanical power ranging from 18 to 137 J/min and divided into two groups: high vs. low pleural pressure (10.0 ± 2.8 vs. 4.4 ± 1.5 cmH2O; p < 0.01). Respiratory mechanics, hemodynamics, fluid, sodium and osmotic balances, were assessed at 0, 6, 12, 24, 48 h. Sodium distribution between intracellular, extracellular and non-osmotic sodium storage compartments was estimated assuming osmotic equilibrium. Lung weight, wet-to-dry ratios of lung, kidney, liver, bowel and muscle were measured at the end of the experiment. Results: High pleural pressure group had significant higher cardiac output (2.96 ± 0.92 vs. 3.41 ± 1.68 L/min; p < 0.01), use of norepinephrine/epinephrine (1.76 ± 3.31 vs. 5.79 ± 9.69 mcg/kg; p < 0.01) and total fluid infusions (3.06 ± 2.32 vs. 4.04 ± 3.04 L; p < 0.01). This hemodynamic status was associated with significantly increased sodium and fluid retention (at 48 h, respectively, 601.3 ± 334.7 vs. 1073.2 ± 525.9 mmol, p < 0.01; and 2.99 ± 2.54 vs. 6.66 ± 3.87 L, p < 0.01). Ten percent of the infused sodium was stored in an osmotically inactive compartment. Increasing fluid and sodium retention was positively associated with lung-weight (R2 = 0.43, p < 0.01; R2 = 0.48, p < 0.01) and with wet-to-dry ratio of the lungs (R2 = 0.14, p < 0.01; R2 = 0.18, p < 0.01) and kidneys (R2 = 0.11, p = 0.02; R2 = 0.12, p = 0.01). Conclusion: Increased mechanical power and pleural pressures dictated an increase in hemodynamic support resulting in proportionally increased sodium and fluid retention and pulmonary edema.
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Affiliation(s)
- Simone Gattarello
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Iacopo Pasticci
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Stefano Lazzari
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Paola Palermo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Maria Michela Palumbo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Irene Steinberg
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Francesco Vassalli
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Paolo Cadringher
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany.,Department of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
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Coppola S, Chiumello D, Busana M, Giola E, Palermo P, Pozzi T, Steinberg I, Roli S, Romitti F, Lazzari S, Gattarello S, Palumbo M, Herrmann P, Saager L, Quintel M, Meissner K, Camporota L, Marini JJ, Centanni S, Gattinoni L. Role of total lung stress on the progression of early COVID-19 pneumonia. Intensive Care Med 2021; 47:1130-1139. [PMID: 34529118 PMCID: PMC8444534 DOI: 10.1007/s00134-021-06519-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/27/2021] [Indexed: 01/20/2023]
Abstract
Purpose We investigated if the stress applied to the lung during non-invasive respiratory support may contribute to the coronavirus disease 2019 (COVID-19) progression. Methods Single-center, prospective, cohort study of 140 consecutive COVID-19 pneumonia patients treated in high-dependency unit with continuous positive airway pressure (n = 131) or non-invasive ventilation (n = 9). We measured quantitative lung computed tomography, esophageal pressure swings and total lung stress. Results Patients were divided in five subgroups based on their baseline PaO2/FiO2 (day 1): non-CARDS (median PaO2/FiO2 361 mmHg, IQR [323–379]), mild (224 mmHg [211–249]), mild-moderate (173 mmHg [164–185]), moderate-severe (126 mmHg [114–138]) and severe (88 mmHg [86–99], p < 0.001). Each subgroup had similar median lung weight: 1215 g [1083–1294], 1153 [888–1321], 968 [858–1253], 1060 [869–1269], and 1127 [937–1193] (p = 0.37). They also had similar non-aerated tissue fraction: 10.4% [5.9–13.7], 9.6 [7.1–15.8], 9.4 [5.8–16.7], 8.4 [6.7–12.3] and 9.4 [5.9–13.8], respectively (p = 0.85). Treatment failure of CPAP/NIV occurred in 34 patients (24.3%). Only three variables, at day one, distinguished patients with negative outcome: PaO2/FiO2 ratio (OR 0.99 [0.98–0.99], p = 0.02), esophageal pressure swing (OR 1.13 [1.01–1.27], p = 0.032) and total stress (OR 1.17 [1.06–1.31], p = 0.004). When these three variables were evaluated together in a multivariate logistic regression analysis, only the total stress was independently associated with negative outcome (OR 1.16 [1.01–1.33], p = 0.032). Conclusions In early COVID-19 pneumonia, hypoxemia is not linked to computed tomography (CT) pathoanatomy, differently from typical ARDS. High lung stress was independently associated with the failure of non-invasive respiratory support. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06519-7.
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Affiliation(s)
- Silvia Coppola
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Mattia Busana
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Emanuele Giola
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Paola Palermo
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Irene Steinberg
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Stefano Roli
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Stefano Lazzari
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Michela Palumbo
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | - Konrad Meissner
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Stefano Centanni
- Respiratory Unit, San Paolo Hospital, Dipartimento Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.
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47
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Affiliation(s)
- L Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany. .,Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA.
| | - J J Marini
- Department of Anesthesiology, Medical University of Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.,Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
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48
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Bonifazi M, Meessen J, Pérez A, Vasques F, Busana M, Vassalli F, Novelli D, Bernasconi R, Signori C, Masson S, Romitti F, Giosa L, Macrì M, Pasticci I, Palumbo MM, Mota F, Costa M, Caironi P, Latini R, Quintel M, Gattinoni L. Albumin Oxidation Status in Sepsis Patients Treated With Albumin or Crystalloids. Front Physiol 2021; 12:682877. [PMID: 34447316 PMCID: PMC8383812 DOI: 10.3389/fphys.2021.682877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/22/2021] [Accepted: 07/07/2021] [Indexed: 11/24/2022] Open
Abstract
Inflammation and oxidative stress characterize sepsis and determine its severity. In this study, we investigated the relationship between albumin oxidation and sepsis severity in a selected cohort of patients from the Albumin Italian Outcome Study (ALBIOS). A retrospective analysis was conducted on the oxidation forms of human albumin [human mercapto-albumin (HMA), human non-mercapto-albumin form 1 (HNA1) and human non-mercapto-albumin form 2 (HNA2)] in 60 patients with severe sepsis or septic shock and 21 healthy controls. The sepsis patients were randomized (1:1) to treatment with 20% albumin and crystalloid solution or crystalloid solution alone. The albumin oxidation forms were measured at day 1 and day 7. To assess the albumin oxidation forms as a function of oxidative stress, the 60 sepsis patients, regardless of the treatment, were grouped based on baseline sequential organ failure assessment (SOFA) score as surrogate marker of oxidative stress. At day 1, septic patients had significantly lower levels of HMA and higher levels of HNA1 and HNA2 than healthy controls. HMA and HNA1 concentrations were similar in patients treated with albumin or crystalloids at day 1, while HNA2 concentration was significantly greater in albumin-treated patients (p < 0.001). On day 7, HMA was significantly higher in albumin-treated patients, while HNA2 significantly increased only in the crystalloids-treated group, reaching values comparable with the albumin group. When pooling the septic patients regardless of treatment, albumin oxidation was similar across all SOFA groups at day 1, but at day 7 HMA was lower at higher SOFA scores. Mortality rate was independently associated with albumin oxidation levels measured at day 7 (HMA log-rank = 0.027 and HNA2 log-rank = 0.002), irrespective of treatment group. In adjusted regression analyses for 90-day mortality, this effect remained significant for HMA and HNA2. Our data suggest that the oxidation status of albumin is modified according to the time of exposure to oxidative stress (differences between day 1 and day 7). After 7 days of treatment, lower SOFA scores correlate with higher albumin antioxidant capacity. The trend toward a positive effect of albumin treatment, while not statistically significant, warrants further investigation.
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Affiliation(s)
- Matteo Bonifazi
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Jennifer Meessen
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alba Pérez
- Bioscience Research Group, Grifols, Barcelona, Spain
| | - Francesco Vasques
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Francesco Vassalli
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Deborah Novelli
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Roberto Bernasconi
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Chiara Signori
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Serge Masson
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Federica Romitti
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Lorenzo Giosa
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Matteo Macrì
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Iacopo Pasticci
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Maria Michela Palumbo
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | | | | | - Pietro Caironi
- Department of Anaesthesia and Critical Care, AOU "S. Luigi Gonzaga, Turin, Italy.,Department of Oncology, University of Turin, Turin, Italy
| | - Roberto Latini
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Michael Quintel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Göttingen, Germany
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Abstract
Acute respiratory distress syndrome (ARDS) is an acute respiratory illness characterised by bilateral chest radiographical opacities with severe hypoxaemia due to non-cardiogenic pulmonary oedema. The COVID-19 pandemic has caused an increase in ARDS and highlighted challenges associated with this syndrome, including its unacceptably high mortality and the lack of effective pharmacotherapy. In this Seminar, we summarise current knowledge regarding ARDS epidemiology and risk factors, differential diagnosis, and evidence-based clinical management of both mechanical ventilation and supportive care, and discuss areas of controversy and ongoing research. Although the Seminar focuses on ARDS due to any cause, we also consider commonalities and distinctions of COVID-19-associated ARDS compared with ARDS from other causes.
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Affiliation(s)
- Nuala J Meyer
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
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50
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Abstract
As exemplified by prone positioning, regional variations of lung and chest wall properties provide possibilities for modifying transpulmonary pressures and suggest that clinical interventions related to the judicious application of external pressure may yield benefit. Recent observations made in late-phase patients with severe ARDS caused by COVID-19 (C-ARDS) have revealed unexpected mechanical responses to local chest wall compressions over the sternum and abdomen in the supine position that challenge the clinician's assumptions and conventional bedside approaches to lung protection. These findings appear to open avenues for mechanism-defining research investigation with possible therapeutic implications for all forms and stages of ARDS.
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Affiliation(s)
- John J Marini
- Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, 640 Jackson St., Minneapolis/St. Paul, Minnesota, 55101, USA.
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany
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