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Wittenstein J, Huhle R, Mutschke AK, Piorko S, Kramer T, Dorfinger L, Tempel F, Jäger M, Schweigert M, Mauer R, Koch T, Richter T, Scharffenberg M, Gama de Abreu M. Comparative effects of variable versus conventional volume-controlled one-lung ventilation on gas exchange and respiratory system mechanics in thoracic surgery patients: A randomized controlled clinical trial. J Clin Anesth 2024; 95:111444. [PMID: 38583224 DOI: 10.1016/j.jclinane.2024.111444] [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: 11/06/2023] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Mechanical ventilation with variable tidal volumes (V-VCV) has the potential to improve lung function during general anesthesia. We tested the hypothesis that V-VCV compared to conventional volume-controlled ventilation (C-VCV) would improve intraoperative arterial oxygenation and respiratory system mechanics in patients undergoing thoracic surgery under one-lung ventilation (OLV). METHODS Patients were randomized to V-VCV (n = 39) or C-VCV (n = 39). During OLV tidal volume of 5 mL/kg predicted body weight (PBW) was used. Both groups were ventilated with a positive end-expiratory pressure (PEEP) of 5 cm H2O, inspiration to expiration ratio (I:E) of 1:1 (during OLV) and 1:2 during two-lung ventilation, the respiratory rate (RR) titrated to arterial pH, inspiratory peak-pressure ≤ 40 cm H2O and an inspiratory oxygen fraction of 1.0. RESULTS Seventy-five out of 78 Patients completed the trial and were analyzed (dropouts were excluded). The partial pressure of arterial oxygen (PaO2) 20 min after the start of OLV did not differ among groups (V-VCV: 25.8 ± 14.6 kPa vs C-VCV: 27.2 ± 15.3 kPa; mean difference [95% CI]: 1.3 [-8.2, 5.5], P = 0.700). Furthermore, intraoperative gas exchange, intraoperative adverse events, need for rescue maneuvers due to desaturation and hypercapnia, incidence of postoperative pulmonary and extra-pulmonary complications, and hospital free days at day 30 after surgery did not differ between groups. CONCLUSIONS In thoracic surgery patients under OLV, V-VCV did not improve oxygenation or respiratory system mechanics compared to C-VCV. Ethical Committee: EK 420092019. TRIAL REGISTRATION at the German Clinical Trials Register: DRKS00022202 (16.06.2020).
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Affiliation(s)
- Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Anne-Kathrin Mutschke
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Sarah Piorko
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Tim Kramer
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Laurin Dorfinger
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Franz Tempel
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Maxim Jäger
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Michael Schweigert
- Department of Thoracic Surgery, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - René Mauer
- Faculty of Medicine Carl Gustav Carus, Institute for Medical Informatics and Biometry (IMB), Technische Universität, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Torsten Richter
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States.
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Serafini SC, van Meenen DMP, Pisani L, Neto AS, Ball L, de Abreu MG, Algera AG, Azevedo L, Bellani G, Dondorp AM, Fan E, Laffey JG, Pham T, Tschernko EM, Schultz MJ, van der Woude MCE. Different ventilation intensities among various categories of patients ventilated for reasons other than ARDS--A pooled analysis of 4 observational studies. J Crit Care 2024; 81:154531. [PMID: 38341938 DOI: 10.1016/j.jcrc.2024.154531] [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: 12/19/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
PURPOSE We investigated driving pressure (ΔP) and mechanical power (MP) and associations with clinical outcomes in critically ill patients ventilated for reasons other than ARDS. MATERIALS AND METHODS Individual patient data analysis of a pooled database that included patients from four observational studies of ventilation. ΔP and MP were compared among invasively ventilated non-ARDS patients with sepsis, with pneumonia, and not having sepsis or pneumonia. The primary endpoint was ΔP; secondary endpoints included MP, ICU mortality and length of stay, and duration of ventilation. RESULTS This analysis included 372 (11%) sepsis patients, 944 (28%) pneumonia patients, and 2040 (61%) patients ventilated for any other reason. On day 1, median ΔP was higher in sepsis (14 [11-18] cmH2O) and pneumonia patients (14 [11-18]cmH2O), as compared to patients not having sepsis or pneumonia (13 [10-16] cmH2O) (P < 0.001). Median MP was also higher in sepsis and pneumonia patients. ΔP, as opposed to MP, was associated with ICU mortality in sepsis and pneumonia patients. CONCLUSIONS The intensity of ventilation differed between patients with sepsis or pneumonia and patients receiving ventilation for any other reason; ΔP was associated with higher mortality in sepsis and pneumonia patients. REGISTRATION This post hoc analysis was not registered; the individual studies that were merged into the used database were registered at clinicaltrials.gov: NCT01268410 (ERICC), NCT02010073 (LUNG SAFE), NCT01868321 (PRoVENT), and NCT03188770 (PRoVENT-iMiC).
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Affiliation(s)
- Simon Corrado Serafini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands.
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Section of Operational Research, Doctors with Africa, Padova, Italy; Department of Anesthesiology and Intensive Care Medicine, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Marcelo Gama de Abreu
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luciano Azevedo
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Department of Emergency Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Centro Interdipartimentale di Scienze Mediche (CISMed), Università di Trento, Italy; UOC anesthesia and Intensive Care 1, Ospedale Santa Chiara, APSS, Trento, Italy
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals Ireland, Galway, Ireland
| | - Tai Pham
- Equipe d'Epidémiologie Respiratoire integrative, Université Paris-Saclay, Paris, France; Department of Intensive Care, Hôpital de Bicêtre, Paris, France
| | - Edda M Tschernko
- Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK; Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
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Gama de Abreu M, Costa ELV. Mechanical Energy and Power: Time to Incorporate Them into Routine Monitoring of Mechanical Ventilation? Anesthesiology 2024; 140:877-880. [PMID: 38592353 DOI: 10.1097/aln.0000000000004927] [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: 04/10/2024]
Affiliation(s)
- Marcelo Gama de Abreu
- Division of Intensive Care and Resuscitation, Outcomes Research Consortium, and Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Integrated Hospital-Care Institute, Cleveland Clinic, Cleveland, Ohio
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Wittenstein J, Scharffenberg M, Fröhlich J, Rothmann C, Ran X, Zhang Y, Chai Y, Yang X, Müller S, Koch T, Huhle R, Gama de Abreu M. Effects of positive end-expiratory pressure on pulmonary perfusion distribution and intrapulmonary shunt during one-lung ventilation in pigs A randomized crossover study. Anesthesiology 2024:140057. [PMID: 38625679 DOI: 10.1097/aln.0000000000005014] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND During one-lung ventilation (OLV), positive end-expiratory pressure (PEEP) can improve lung aeration, but might over-distend lung units and increase intrapulmonary shunt. We hypothesized that higher PEEP shifts pulmonary perfusion from the ventilated to the non-ventilated lung, resulting in a U-shaped relationship with intrapulmonary shunt during OLV. METHODS In nine anesthetized female pigs, a thoracotomy was performed and intravenous lipopolysaccharide infused to mimic the inflammatory response of thoracic surgery. Animals underwent OLV in supine position with PEEP of 0 cmH2O, 5 cmH2O, titrated to best respiratory system compliance, and 15 cmH2O (PEEP0, PEEP5, PEEPtitr, and PEEP15, respectively, 45 min each, Latin square sequence). Respiratory, hemodynamic, and gas exchange variables were measured. The distributions of perfusion and ventilation were determined by i.v. fluorescent microspheres and computed tomography, respectively. RESULTS Compared to two lung ventilation, the driving pressure increased with OLV, irrespective of the PEEP level. During OLV, cardiac output was lower at PEEP15 (5.5 ± 1.5 l/min) than PEEP0 (7.6 ± 3 l/min) and PEEP5 (7.4 ± 2.9 l/min; P=0.004), while the intrapulmonary shunt was highest at PEEP0 (PEEP0: 48.1 ± 14.4 %; PEEP5: 42.4 ± 14.8 %; PEEPtitr: 37.8 ± 11.0 %; PEEP15: 39.0 ± 10.7 %; P=0.027). The relative perfusion of the ventilated lung did not differ among PEEP levels (PEEP0: 65.0 ± 10.6 %; PEEP5:68.7 ± 8.7 %; PEEPtitr: 68.2 ± 10.5 %; PEEP15: 58.4 ± 12.8%; P=0.096), but the centers of relative perfusion and ventilation in the ventilated lung shifted from ventral to dorsal, and from cranial to caudal zones with increasing PEEP. CONCLUSION In this experimental model of thoracic surgery, higher PEEP during OLV did not shift the perfusion from the ventilated to the non-ventilated lung, thus not increasing intrapulmonary shunt. TRIAL REGISTRATION This study was registered and approved by the Landesdirektion Dresden, Germany (25-5131/496/33).
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Affiliation(s)
- Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Jonathan Fröhlich
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Carolin Rothmann
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Xi Ran
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Yingying Zhang
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, P. R. China
| | - Yusen Chai
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Xiuli Yang
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Sabine Müller
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Marcelo Gama de Abreu
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Chhabada S, Skinner C, Kopac O, Castro P, Mascha EJ, Wang D, Gama de Abreu M, Turan A, Sessler DI, Ruetzler K. Association Between Age- and Sex-Specific Body Mass Index Percentile and Multiple Intubation Attempts: A Retrospective Cohort Analysis. Anesth Analg 2024; 138:821-828. [PMID: 36920865 DOI: 10.1213/ane.0000000000006400] [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: 03/16/2023]
Abstract
BACKGROUND Obesity distorts airways and slightly complicates intubations in adults, but whether obesity complicates pediatric intubations remains unclear. We, therefore, tested the primary hypothesis that increasing age- and sex-specific body mass index (BMI) percentile is associated with difficult intubation, defined as >1 intubation attempt. METHODS We conducted a retrospective analysis of pediatric patients between 2 and 18 years of age who had noncardiac surgery with oral endotracheal intubation. We assessed the association between BMI percentile and difficult intubation, defined as >1 intubation attempt, using a confounder-adjusted multivariable logistic regression model. Secondarily, we assessed whether the main association depended on preoperative substantial airway abnormality status or age group. RESULTS A total of 9339 patients were included in the analysis. Median [quartiles] age- and sex-specific BMI percentile was 70 [33, 93], and 492 (5.3%) patients had difficult intubation. There was no apparent association between age- and sex-specific BMI percentile and difficult intubation. The estimated odds ratio (OR) for having difficult intubation for a 10-unit increase in BMI percentile was 0.98 (95% confidence interval [CI], 0.95-1.005) and was consistent across the 3 age groups of early childhood, middle childhood, and early adolescence (interaction P = .53). Patients with preoperative substantial airway abnormalities had lower odds of difficult intubation per 10-unit increase in BMI percentile, with OR (95% CI) of 0.83 (0.70-0.98), P = .01. CONCLUSIONS Age- and sex-specific BMI percentile was not associated with difficult intubation in children between 2 and 18 years of age. As in adults, obesity in children does not much complicate intubation.
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Affiliation(s)
| | - Chelsea Skinner
- General Anesthesiology Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Pilar Castro
- From the Departments of Pediatric and Congenital Cardiac Anesthesia
| | - Edward J Mascha
- Outcomes Research
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dong Wang
- Outcomes Research
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marcelo Gama de Abreu
- Outcomes Research
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- Outcomes Research
- General Anesthesiology Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Kurt Ruetzler
- Outcomes Research
- General Anesthesiology Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Scharffenberg M, Mandelli M, Bluth T, Simonassi F, Wittenstein J, Teichmann R, Birr K, Kiss T, Ball L, Pelosi P, Schultz MJ, Gama de Abreu M, Huhle R. Respiratory mechanics and mechanical power during low vs. high positive end-expiratory pressure in obese surgical patients - A sub-study of the PROBESE randomized controlled trial. J Clin Anesth 2024; 92:111242. [PMID: 37833194 DOI: 10.1016/j.jclinane.2023.111242] [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: 06/08/2023] [Revised: 08/21/2023] [Accepted: 08/26/2023] [Indexed: 10/15/2023]
Abstract
STUDY OBJECTIVE We aimed to characterize intra-operative mechanical ventilation with low or high positive end-expiratory pressure (PEEP) and recruitment manoeuvres (RM) regarding intra-tidal recruitment/derecruitment and overdistension using non-linear respiratory mechanics, and mechanical power in obese surgical patients enrolled in the PROBESE trial. DESIGN Prospective, two-centre substudy of the international, multicentre, two-arm, randomized-controlled PROBESE trial. SETTING Operating rooms of two European University Hospitals. PATIENTS Forty-eight adult obese patients undergoing abdominal surgery. INTERVENTIONS Intra-operative protective ventilation with either PEEP of 12 cmH2O and repeated RM (HighPEEP+RM) or 4 cmH2O without RM (LowPEEP). MEASUREMENTS The index of intra-tidal recruitment/de-recruitment and overdistension (%E2) as well as airway pressure, tidal volume (VT), respiratory rate (RR), resistance, elastance, and mechanical power (MP) were calculated from respiratory signals recorded after anesthesia induction, 1 h thereafter, and end of surgery (EOS). MAIN RESULTS Twenty-four patients were analyzed in each group. PEEP was higher (mean ± SD, 11.7 ± 0.4 vs. 3.7 ± 0.6 cmH2O, P < 0.001) and driving pressure lower (12.8 ± 3.5 vs. 21.7 ± 6.8 cmH2O, P < 0.001) during HighPEEP+RM than LowPEEP, while VT and RR did not differ significantly (7.3 ± 0.6 vs. 7.4 ± 0.8 ml∙kg-1, P = 0.835; and 14.6 ± 2.5 vs. 15.7 ± 2.0 min-1, P = 0.150, respectively). %E2 was higher in HighPEEP+RM than in LowPEEP following induction (-3.1 ± 7.2 vs. -12.4 ± 10.2%; P < 0.001) and subsequent timepoints. Total resistance and elastance (13.3 ± 3.8 vs. 17.7 ± 6.8 cmH2O∙l∙s-2, P = 0.009; and 15.7 ± 5.5 vs. 28.5 ± 8.4 cmH2O∙l, P < 0.001, respectively) were lower during HighPEEP+RM than LowPEEP. Additionally, MP was lower in HighPEEP+RM than LowPEEP group (5.0 ± 2.2 vs. 10.4 ± 4.7 J∙min-1, P < 0.001). CONCLUSIONS In this sub-cohort of PROBESE, intra-operative ventilation with high PEEP and RM reduced intra-tidal recruitment/de-recruitment as well as driving pressure, elastance, resistance, and mechanical power, as compared with low PEEP. TRIAL REGISTRATION The PROBESE study was registered at www. CLINICALTRIALS gov, identifier: NCT02148692 (submission for registration on May 23, 2014).
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Affiliation(s)
- Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Maura Mandelli
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Francesca Simonassi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy
| | - Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Robert Teichmann
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Katharina Birr
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Heinrich-Zille-Strasse 13, 01445 Radebeul, Germany
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy; Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi, 10, 16132 Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy; Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi, 10, 16132 Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Laboratory of Experimental Intensive Care & Anesthesiology (L E I C A), Amsterdam University Medical Centers, location AMC, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA.
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
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Ran X, Müller S, Brunssen C, Huhle R, Scharffenberg M, Schnabel C, Koch T, Gama de Abreu M, Morawietz H, Ferreira JMC, Wittenstein J. Modulation of the hippo-YAP pathway by cyclic stretch in rat type 2 alveolar epithelial cells-a proof-of-concept study. Front Physiol 2023; 14:1253810. [PMID: 37877098 PMCID: PMC10591329 DOI: 10.3389/fphys.2023.1253810] [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] [Received: 07/06/2023] [Accepted: 09/28/2023] [Indexed: 10/26/2023] Open
Abstract
Background: Mechanical ventilation (MV) is a life supporting therapy but may also cause lung damage. This phenomenon is known as ventilator-induced lung injury (VILI). A potential pathomechanisms of ventilator-induced lung injury may be the stretch-induced production and release of cytokines and pro-inflammatory molecules from the alveolar epithelium. Yes-associated protein (YAP) might be regulated by mechanical forces and involved in the inflammation cascade. However, its role in stretch-induced damage of alveolar cells remains poorly understood. In this study, we explored the role of YAP in the response of alveolar epithelial type II cells (AEC II) to elevated cyclic stretch in vitro. We hypothesize that Yes-associated protein activates its downstream targets and regulates the interleukin-6 (IL-6) expression in response to 30% cyclic stretch in AEC II. Methods: The rat lung L2 cell line was exposed to 30% cyclic equibiaxial stretch for 1 or 4 h. Non-stretched conditions served as controls. The cytoskeleton remodeling and cell junction integrity were evaluated by F-actin and Pan-cadherin immunofluorescence, respectively. The gene expression and protein levels of IL-6, Yes-associated protein, Cysteine-rich angiogenic inducer 61 (Cyr61/CCN1), and connective tissue growth factor (CTGF/CCN2) were studied by real-time polymerase chain reaction (RT-qPCR) and Western blot, respectively. Verteporfin (VP) was used to inhibit Yes-associated protein activation. The effects of 30% cyclic stretch were assessed by two-way ANOVA. Statistical significance as accepted at p < 0.05. Results: Cyclic stretch of 30% induced YAP nuclear accumulation, activated the transcription of Yes-associated protein downstream targets Cyr61/CCN1 and CTGF/CCN2 and elevated IL-6 expression in AEC II after 1 hour, compared to static control. VP (2 µM) inhibited Yes-associated protein activation in response to 30% cyclic stretch and reduced IL-6 protein levels. Conclusion: In rat lung L2 AEC II, 30% cyclic stretch activated YAP, and its downstream targets Cyr61/CCN1 and CTGF/CCN2 and proinflammatory IL-6 expression. Target activation was blocked by a Yes-associated protein inhibitor. This novel YAP-dependent pathway could be involved in stretch-induced damage of alveolar cells.
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Affiliation(s)
- Xi Ran
- Department of Intensive Care Medicine, Chongqing General Hospital, Changqing, China
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Sabine Müller
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Coy Brunssen
- Division of Vascular Endothelium and Microcirculation, Department of Medicine III, University Hospital and Medical Faculty Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Christian Schnabel
- Department of Anesthesiology and Intensive Care Medicine, Clinical Sensoring and Monitoring Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Henning Morawietz
- Division of Vascular Endothelium and Microcirculation, Department of Medicine III, University Hospital and Medical Faculty Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany
| | - Jorge M. C. Ferreira
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
| | - Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, TUD Dresden University of Technology, Dresden, Germany
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Wittenstein J, Scharffenberg M, Yang X, Bluth T, Kiss T, Schultz MJ, Rocco PRM, Pelosi P, Gama de Abreu M, Huhle R. Distribution of transpulmonary pressure during one-lung ventilation in pigs at different body positions. Front Physiol 2023; 14:1204531. [PMID: 37601645 PMCID: PMC10436328 DOI: 10.3389/fphys.2023.1204531] [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: 04/12/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Background. Global and regional transpulmonary pressure (PL) during one-lung ventilation (OLV) is poorly characterized. We hypothesized that global and regional PL and driving PL (ΔPL) increase during protective low tidal volume OLV compared to two-lung ventilation (TLV), and vary with body position. Methods. In sixteen anesthetized juvenile pigs, intra-pleural pressure sensors were placed in ventral, dorsal, and caudal zones of the left hemithorax by video-assisted thoracoscopy. A right thoracotomy was performed and lipopolysaccharide administered intravenously to mimic the inflammatory response due to thoracic surgery. Animals were ventilated in a volume-controlled mode with a tidal volume (VT) of 6 mL kg-1 during TLV and of 5 mL kg-1 during OLV and a positive end-expiratory pressure (PEEP) of 5 cmH2O. Global and local transpulmonary pressures were calculated. Lung instability was defined as end-expiratory PL<2.9 cmH2O according to previous investigations. Variables were acquired during TLV (TLVsupine), left lung ventilation in supine (OLVsupine), semilateral (OLVsemilateral), lateral (OLVlateral) and prone (OLVprone) positions randomized according to Latin-square sequence. Effects of position were tested using repeated measures ANOVA. Results. End-expiratory PL and ΔPL were higher during OLVsupine than TLVsupine. During OLV, regional end-inspiratory PL and ΔPL did not differ significantly among body positions. Yet, end-expiratory PL was lower in semilateral (ventral: 4.8 ± 2.9 cmH2O; caudal: 3.1 ± 2.6 cmH2O) and lateral (ventral: 1.9 ± 3.3 cmH2O; caudal: 2.7 ± 1.7 cmH2O) compared to supine (ventral: 4.8 ± 2.9 cmH2O; caudal: 3.1 ± 2.6 cmH2O) and prone position (ventral: 1.7 ± 2.5 cmH2O; caudal: 3.3 ± 1.6 cmH2O), mainly in ventral (p ≤ 0.001) and caudal (p = 0.007) regions. Lung instability was detected more often in semilateral (26 out of 48 measurements; p = 0.012) and lateral (29 out of 48 measurements, p < 0.001) as compared to supine position (15 out of 48 measurements), and more often in lateral as compared to prone position (19 out of 48 measurements, p = 0.027). Conclusion. Compared to TLV, OLV increased lung stress. Body position did not affect stress of the ventilated lung during OLV, but lung stability was lowest in semilateral and lateral decubitus position.
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Affiliation(s)
- Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Xiuli Yang
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Thomas Bluth
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Anaesthesiology, Intensive-Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Marcus J. Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
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Almeida AB, Schweigert M, Spieth P, Dubecz A, de Abreu MG, Richter T, Kellner P. Outcome of Emergency Pulmonary Lobectomy under ECMO Support in Patients with COVID-19. Thorac Cardiovasc Surg 2023. [PMID: 37399834 DOI: 10.1055/s-0043-1770738] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Not much is known about the results of nonelective anatomical lung resections in coronavirus disease 2019 (COVID-19) patients put on extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyze the outcome of lobectomy under ECMO support in patients with acute respiratory failure due to severe COVID-19. METHODS All COVID-19 patients undergoing anatomical lung resection with ECMO support at a German university hospital were included into a prospective database. Study period was April 1, 2020, to April 30, 2021 (first, second, and third waves in Germany). RESULTS A total of nine patients (median age 61 years, interquartile range 10 years) were included. There was virtually no preexisting comorbidity (median Charlson score of comorbidity 0.2). The mean interval between first positive COVID-19 test and surgery was 21.9 days. Clinical symptoms at the time of surgery were sepsis (nine of nine), respiratory failure (nine of nine), acute renal failure (five of nine), pleural empyema (five of nine), lung artery embolism (four of nine), and pneumothorax (two of nine). Mean intensive care unit (ICU) and ECMO days before surgery were 15.4 and 6, respectively. Indications for surgery were bacterial superinfection with lung abscess formation and progressive septic shock (seven of nine) and abscess formation with massive pulmonary hemorrhage into the abscess cavity (two of nine). All patients were under venovenous ECMO with femoral-jugular configuration. Operative procedures were lobectomy (eight) and pneumonectomy (one). Weaning from ECMO was successful in four of nine. In-hospital mortality was five of nine. Mean total ECMO days were 10.3 ± 6.2 and mean total ICU days were 27.7 ± 9.9. Mean length of stay was 28.7 ± 8.8 days. CONCLUSION Emergency surgery under ECMO support seems to open up a perspective for surgical source control in COVID-19 patients with bacterial superinfection and localized pulmonary abscess.
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Affiliation(s)
- Ana Beatriz Almeida
- Department of Surgery, University Hospital Schleswig-Holstein Campus Luebeck, Luebeck, Germany
| | - Michael Schweigert
- Department of Surgery, University Hospital Schleswig-Holstein Campus Luebeck, Luebeck, Germany
| | - Peter Spieth
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Sachsen, Germany
| | - Attila Dubecz
- Department of General and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology, Cleveland Clinic Main Campus Hospital, Cleveland, Ohio, United States
| | - Torsten Richter
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Sachsen, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care, University Hospital Schleswig-Holstein Campus Luebeck, Luebeck, Germany
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Vivona L, Huhle R, Braune A, Scharffenberg M, Wittenstein J, Kiss T, Kircher M, Herzog P, Herzog M, Millone M, Gama de Abreu M, Bluth T. Variable ventilation versus stepwise lung recruitment manoeuvres for lung recruitment: A comparative study in an experimental model of atelectasis. Eur J Anaesthesiol 2023; 40:501-510. [PMID: 36809307 DOI: 10.1097/eja.0000000000001808] [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: 02/23/2023]
Abstract
BACKGROUND Variable ventilation recruits alveoli in atelectatic lungs, but it is unknown how it compares with conventional recruitment manoeuvres. OBJECTIVES To test whether mechanical ventilation with variable tidal volumes and conventional recruitment manoeuvres have comparable effects on lung function. DESIGN Randomised crossover study. SETTING University hospital research facility. ANIMALS Eleven juvenile mechanically ventilated pigs with atelectasis created by saline lung lavage. INTERVENTIONS Lung recruitment was performed using two strategies, both with an individualised optimal positive-end expiratory pressure (PEEP) associated with the best respiratory system elastance during a decremental PEEP trial: conventional recruitment manoeuvres (stepwise increase of PEEP) in pressure-controlled mode) followed by 50 min of volume-controlled ventilation (VCV) with constant tidal volume, and variable ventilation, consisting of 50 min of VCV with random variation in tidal volume. MAIN OUTCOME MEASURES Before and 50 min after each recruitment manoeuvre strategy, lung aeration was assessed by computed tomography, and relative lung perfusion and ventilation (0% = dorsal, 100% = ventral) were determined by electrical impedance tomography. RESULTS After 50 min, variable ventilation and stepwise recruitment manoeuvres decreased the relative mass of poorly and nonaerated lung tissue (percent lung mass: 35.3 ± 6.2 versus 34.2 ± 6.6, P = 0.303); reduced poorly aerated lung mass compared with baseline (-3.5 ± 4.0%, P = 0.016, and -5.2 ± 2.8%, P < 0.001, respectively), and reduced nonaerated lung mass compared with baseline (-7.2 ± 2.5%, P < 0.001; and -4.7 ± 2.8%, P < 0.001 respectively), while the distribution of relative perfusion was barely affected (variable ventilation: -0.8 ± 1.1%, P = 0.044; stepwise recruitment manoeuvres: -0.4 ± 0.9%, P = 0.167). Compared with baseline, variable ventilation and stepwise recruitment manoeuvres increased Pa O 2 (172 ± 85mmHg, P = 0.001; and 213 ± 73 mmHg, P < 0.001, respectively), reduced Pa CO 2 (-9.6 ± 8.1 mmHg, P = 0.003; and -6.7 ± 4.6 mmHg, P < 0.001, respectively), and decreased elastance (-11.4 ± 6.3 cmH 2 O, P < 0.001; and -14.1 ± 3.3 cmH 2 O, P < 0.001, respectively). Mean arterial pressure decreased during stepwise recruitment manoeuvres (-24 ± 8 mmHg, P = 0.006), but not variable ventilation. CONCLUSION In this model of lung atelectasis, variable ventilation and stepwise recruitment manoeuvres effectively recruited lungs, but only variable ventilation did not adversely affect haemodynamics. TRIAL REGISTRATION This study was registered and approved by Landesdirektion Dresden, Germany (DD24-5131/354/64).
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Affiliation(s)
- Luigi Vivona
- From the Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany (LV, RH, AB, MS, JW, TK, PH, MH, MM, MGA, TB), Department of Pathophysiology and Transplantation, University of Milan, Italy (LV), Institute of Nuclear Medicine, University Hospital Carl Gustav Carus, Dresden (AB), Department of Anesthesiology, Elblandklinikum Radebeul, Radebeul (TK), Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe (MK), Drägerwerk AG & Co KGaA, Lübeck, Germany (MK), IRCCS San Martino IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy (MM), Department of Intensive Care and Resuscitation (MGA) and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (MGA)
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11
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Mazzinari G, Zampieri FG, Ball L, Campos NS, Bluth T, Hemmes SN, Ferrando C, Librero J, Soro M, Pelosi P, Gama de Abreu M, Schultz MJ, Serpa Neto A. Effect of intraoperative PEEP with recruitment maneuvers on the occurrence of postoperative pulmonary complications during general anesthesia--protocol for Bayesian analysis of three randomized clinical trials of intraoperative ventilation. F1000Res 2023; 11:1090. [PMID: 37234075 PMCID: PMC10207960 DOI: 10.12688/f1000research.125861.1] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 10/22/2023] Open
Abstract
Background: Using the frequentist approach, a recent meta-analysis of three randomized clinical trials in patients undergoing intraoperative ventilation during general anesthesia for major surgery failed to show the benefit of ventilation that uses high positive end-expiratory pressure with recruitment maneuvers when compared to ventilation that uses low positive end-expiratory pressure without recruitment maneuvers. Methods: We designed a protocol for a Bayesian analysis using the pooled dataset. The multilevel Bayesian logistic model will use the individual patient data. Prior distributions will be prespecified to represent a varying level of skepticism for the effect estimate. The primary endpoint will be a composite of postoperative pulmonary complications (PPC) within the first seven postoperative days, which reflects the primary endpoint of the original studies. We preset a range of practical equivalence to assess the futility of the intervention with an interval of odds ratio (OR) between 0.9 and 1.1 and assess how much of the 95% of highest density interval (HDI) falls between the region of practical equivalence. Ethics and dissemination: The used data derive from approved studies that were published in recent years. The findings of this current analysis will be reported in a new manuscript, drafted by the writing committee on behalf of the three research groups. All investigators listed in the original trials will serve as collaborative authors.
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Affiliation(s)
- Guido Mazzinari
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
| | | | - Lorenzo Ball
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Niklas S. Campos
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
| | - Thomas Bluth
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sabrine N.T. Hemmes
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
| | - Carlos Ferrando
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - Julian Librero
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
| | - Marina Soro
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Paolo Pelosi
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcus J. Schultz
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - PROVHILO investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - iPROVE investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - PROBESE investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
| | - PROVE network investigators
- Perioperative Medicine, Instituto de Investigación Sanitaria la Fe, Valencia, Spain, 46026, Spain
- Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, 46026, Spain
- Academic Research Organization, Albert Einstein Hospital, Sao Paulo, Brazil
- Surgical sciences and integrated diagnostics, University of Genoa, Genoa, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Cardio pulmonary department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidad de de Sao Paulo, Sao Paulo, Brazil
- Pulmonary Engineergin group, Anesthesiology and intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesiology, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Intensive Care, Amsterdam University Medical Centers, location ‘AMC’, Amsterdam, The Netherlands
- Anesthesiology and Critical Care, Hospital Clinic de Barcelona, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases, Instituto de Salud Carlos III, Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Spain
- INCLIVA Clinical Research Institute, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of tropical medicine, Mahidol University, Bangkok, Thailand
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
- Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
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Turan A, Pu X, Gama de Abreu M, Sessler DI. Tidal Volume, Positive End-Expiratory Pressure, and Postoperative Hypoxemia: Reply. Anesthesiology 2023:138194. [PMID: 37166428 DOI: 10.1097/aln.0000000000004555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Fernandez-Bustamante A, Parker RA, Sprung J, Eikermann M, Gama de Abreu M, Ferrando C, Thompson BT, Vidal Melo MF. An anesthesia-centered bundle to reduce postoperative pulmonary complications: The PRIME-AIR study protocol. PLoS One 2023; 18:e0283748. [PMID: 37023031 PMCID: PMC10079125 DOI: 10.1371/journal.pone.0283748] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/05/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) are a major cause of morbidity and mortality after open abdominal surgery. Optimized perioperative lung expansion may minimize the synergistic factors responsible for the multiple-hit perioperative pulmonary dysfunction. This ongoing study will assess whether an anesthesia-centered bundle focused on perioperative lung expansion results in decreased incidence and severity of PPCs after open abdominal surgery. METHODS Prospective multicenter randomized controlled pragmatic trial in 750 adult patients with at least moderate risk for PPCs undergoing prolonged (≥2 hour) open abdominal surgery. Participants are randomized to receive either a bundle intervention focused on perioperative lung expansion or usual care. The bundle intervention includes preoperative patient education, intraoperative protective ventilation with individualized positive end-expiratory pressure to maximize respiratory system compliance, optimized neuromuscular blockade and reversal management, and postoperative incentive spirometry and early mobilization. Primary outcome is the distribution of the highest PPC severity by postoperative day 7. Secondary outcomes include the proportion of participants with: PPC grades 1-2 through POD 7; PPC grades 3-4 through POD 7, 30 and 90; intraoperative hypoxemia, rescue recruitment maneuvers, or cardiovascular events; and any major extrapulmonary postoperative complications. Additional secondary and exploratory outcomes include individual PPCs by POD 7, length of postoperative oxygen therapy or other respiratory support, hospital resource use parameters, Patient-Reported Outcomes Measurements (PROMIS®) questionnaires for dyspnea and fatigue collected before and at days 7, 30 and 90 after surgery, and plasma concentrations of lung injury biomarkers (IL6, IL-8, RAGE, CC16, Ang-2) analyzed from samples obtained before, end of, and 24 hours after surgery. DISCUSSION Participant recruitment for this study started January 2020; results are expected in 2024. At the conclusion of this trial, we will determine if this anesthesia-centered strategy focused on perioperative lung expansion reduces lung morbidity and healthcare utilization after open abdominal surgery. TRIAL REGISTRATION ClinicalTrial.gov NCT04108130.
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Affiliation(s)
- Ana Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Robert A Parker
- Biostatistics Center, Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Marcelo Gama de Abreu
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Carlos Ferrando
- Department of Anesthesiology and Intensive Care, Hospital Clínic Institut D'investigació August Pi i Sunyer, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, United States of America
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Wittenstein J, Huhle R, Leiderman M, Möbius M, Braune A, Tauer S, Herzog P, Barana G, de Ferrari A, Corona A, Bluth T, Kiss T, Güldner A, Schultz MJ, Rocco PRM, Pelosi P, Gama de Abreu M, Scharffenberg M. Effect of patient-ventilator asynchrony on lung and diaphragmatic injury in experimental acute respiratory distress syndrome in a porcine model. Br J Anaesth 2023; 130:e169-e178. [PMID: 34895719 DOI: 10.1016/j.bja.2021.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 01/07/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patient-ventilator asynchrony during mechanical ventilation may exacerbate lung and diaphragm injury in spontaneously breathing subjects. We investigated whether subject-ventilator asynchrony increases lung or diaphragmatic injury in a porcine model of acute respiratory distress syndrome (ARDS). METHODS ARDS was induced in adult female pigs by lung lavage and injurious ventilation before mechanical ventilation by pressure assist-control for 12 h. Mechanically ventilated pigs were randomised to breathe spontaneously with or without induced subject-ventilator asynchrony or neuromuscular block (n=7 per group). Subject-ventilator asynchrony was produced by ineffective, auto-, or double-triggering of spontaneous breaths. The primary outcome was mean alveolar septal thickness (where thickening of the alveolar wall indicates worse lung injury). Secondary outcomes included distribution of ventilation (electrical impedance tomography), lung morphometric analysis, inflammatory biomarkers (gene expression), lung wet-to-dry weight ratio, and diaphragmatic muscle fibre thickness. RESULTS Subject-ventilator asynchrony (median [interquartile range] 28.8% [10.4] asynchronous breaths of total breaths; n=7) did not increase mean alveolar septal thickness compared with synchronous spontaneous breathing (asynchronous breaths 1.0% [1.6] of total breaths; n=7). There was no difference in mean alveolar septal thickness throughout upper and lower lung lobes between pigs randomised to subject-ventilator asynchrony vs synchronous spontaneous breathing (87.3-92.2 μm after subject-ventilator asynchrony, compared with 84.1-95.0 μm in synchronised spontaneous breathing;). There were also no differences between groups in wet-to-dry weight ratio, diaphragmatic muscle fibre thickness, atelectasis, lung aeration, or mRNA expression levels for inflammatory cytokines pivotal in ARDS pathogenesis. CONCLUSIONS Subject-ventilator asynchrony during spontaneous breathing did not exacerbate lung injury and dysfunction in experimental porcine ARDS.
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Affiliation(s)
- Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Mark Leiderman
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Marius Möbius
- Neonatology and Pediatric Critical Care Medicine, Department of Pediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Anja Braune
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Nuclear Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Tauer
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Paul Herzog
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Giulio Barana
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology, Hospital Thurgau AG, Frauenfeld, Switzerland
| | - Alessandra de Ferrari
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesia and Intensive Care, IRCCS AOU San Martino IST, Genoa, Italy
| | - Andrea Corona
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology and Intensive Care, Mater Olbia Hospital, Olbia, Italy
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Andreas Güldner
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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15
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Scharffenberg M, Weiss T, Wittenstein J, Krenn K, Fleming M, Biro P, De Hert S, Hendrickx JFA, Ionescu D, de Abreu MG. Practice of oxygen use in anesthesiology – a survey of the European Society of Anaesthesiology and Intensive Care. BMC Anesthesiol 2022; 22:350. [PMID: 36376798 PMCID: PMC9660141 DOI: 10.1186/s12871-022-01884-2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background Oxygen is one of the most commonly used drugs by anesthesiologists. The World Health Organization (WHO) gave recommendations regarding perioperative oxygen administration, but the practice of oxygen use in anesthesia, critical emergency, and intensive care medicine remains unclear. Methods We conducted an online survey among members of the European Society of Anaesthesiology and Intensive Care (ESAIC). The questionnaire consisted of 46 queries appraising the perioperative period, emergency medicine and in the intensive care, knowledge about current recommendations by the WHO, oxygen toxicity, and devices for supplemental oxygen therapy. Results Seven hundred ninety-eight ESAIC members (2.1% of all ESAIC members) completed the survey. Most respondents were board-certified and worked in hospitals with > 500 beds. The majority affirmed that they do not use specific protocols for oxygen administration. WHO recommendations are unknown to 42% of respondents, known but not followed by 14%, and known and followed by 24% of them. Respondents prefer inspiratory oxygen fraction (FiO2) ≥80% during induction and emergence from anesthesia, but intraoperatively < 60% for maintenance, and higher FiO2 in patients with diseased than non-diseased lungs. Postoperative oxygen therapy is prescribed more commonly according to peripheral oxygen saturation (SpO2), but shortage of devices still limits monitoring. When monitoring is used, SpO2 ≤ 95% is often targeted. In critical emergency medicine, oxygen is used frequently in patients aged ≥80 years, or presenting with respiratory distress, chronic obstructive pulmonary disease, myocardial infarction, and stroke. In the intensive care unit, oxygen is mostly targeted at 96%, especially in patients with pulmonary diseases. Conclusions The current practice of perioperative oxygen therapy among respondents does not follow WHO recommendations or current evidence, and access to postoperative monitoring devices impairs the individualization of oxygen therapy. Further research and additional teaching about use of oxygen are necessary. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01884-2.
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Affiliation(s)
- Martin Scharffenberg
- grid.4488.00000 0001 2111 7257Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thomas Weiss
- grid.4488.00000 0001 2111 7257Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jakob Wittenstein
- grid.4488.00000 0001 2111 7257Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Katharina Krenn
- grid.4488.00000 0001 2111 7257Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany ,grid.22937.3d0000 0000 9259 8492Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Magdalena Fleming
- grid.4488.00000 0001 2111 7257Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany ,Department of Anesthesiology and Intensive Care, Czerniakowski Hospital, Warsaw, Poland
| | - Peter Biro
- grid.412004.30000 0004 0478 9977Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan De Hert
- grid.410566.00000 0004 0626 3303Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital – Ghent University, Ghent, Belgium
| | - Jan F. A. Hendrickx
- grid.416672.00000 0004 0644 9757Department of Anesthesiology, OLV Hospital, Aalst, Belgium ,grid.5342.00000 0001 2069 7798Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium ,grid.410569.f0000 0004 0626 3338Department of Anesthesiology, UZLeuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Department of Cardiovascular Sciences, KULeuven, Leuven, Belgium
| | - Daniela Ionescu
- grid.411040.00000 0004 0571 5814Department of Anaesthesia and Intensive Care, Iuliu Hatieganu University of Medicine and Pharmacy, and Clinical Department of Anaesthesia and Intensive Care, Regional Institute for Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Marcelo Gama de Abreu
- grid.4488.00000 0001 2111 7257Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany ,grid.239578.20000 0001 0675 4725Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 USA ,grid.239578.20000 0001 0675 4725Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 USA
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Ellenberger C, Pelosi P, de Abreu MG, Wrigge H, Diaper J, Hagerman A, Adam Y, Schultz MJ, Licker M. Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure: A substudy of a randomised controlled trial. Eur J Anaesthesiol 2022; 39:875-884. [PMID: 36093886 PMCID: PMC9553219 DOI: 10.1097/eja.0000000000001741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Intra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients. OBJECTIVES To investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry. DESIGN A substudy of a randomised controlled trial. SETTING Tertiary medical centre in Geneva, Switzerland, between 2015 and 2018. PATIENTS One hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min. INTERVENTION Patients were randomised to PEEP of 4 cmH 2 O ( n = 79) or PEEP of 12 cmH 2 O with hourly ARMs ( n = 83). MAIN OUTCOME MEASURES The primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO 2 /FIO 2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry. RESULTS Compared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH 2 O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min -1 m -2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively). CONCLUSION In obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH 2 O with periodic ARMs, compared with intra-operative PEEP of 4 cmH 2 O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation. TRIAL REGISTRATION NCT02148692, https://clinicaltrials.gov/ct2.
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Affiliation(s)
- Christoph Ellenberger
- From the Department of Anaesthesia, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, rue Gabriel-Perret-Gentil (CE, JD, AH, YA, ML), Faculty of Medicine, University of Geneva, Geneva, Switzerland (CE, ML), Department of Surgical Sciences and Integrated Diagnostics, University of Genoa (PP), Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (PP), Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany (MGdA), Department of Outcomes Research (MGdA), Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (MGdA), Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital (HW), Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany (HW), Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands (MJS)
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Dres M, de Abreu MG, Similowski T. Reply to Jha. Am J Respir Crit Care Med 2022; 206:1047-1049. [PMID: 35772169 PMCID: PMC9801999 DOI: 10.1164/rccm.202206-1181le] [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: 01/05/2023] Open
Affiliation(s)
- Martin Dres
- Experimental and Clinical Respiratory NeurophysiologySorbonne University, INSERMParis, France,Medicine Intensive Reanimation (R3S Department)AP-HP, Pitie-Salpetriere HospitalParis, France,Corresponding author (e-mail: )
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care MedicineTechnische Universitat DresdenDresden, Germany,Department of Intensive Care and Resuscitation,Department of Outcomes ResearchCleveland ClinicCleveland, Ohio
| | - Thomas Similowski
- Experimental and Clinical Respiratory NeurophysiologySorbonne University, INSERMParis, France,Medicine Intensive Reanimation (R3S Department)AP-HP, Pitie-Salpetriere HospitalParis, France
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18
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de Carvalho EB, Fonseca ACF, Magalhães R, Pinto EF, Samary CDS, Antunes MA, Baldavira CM, da Silveira LKR, Teodoro WR, de Abreu MG, Capelozzi VL, Felix NS, Pelosi P, Rocco PRM, Silva PL. Effects of different fluid management on lung and kidney during pressure-controlled and pressure-support ventilation in experimental acute lung injury. Physiol Rep 2022; 10:e15429. [PMID: 36065867 PMCID: PMC9446390 DOI: 10.14814/phy2.15429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 07/18/2022] [Revised: 07/22/2022] [Accepted: 07/29/2022] [Indexed: 04/24/2023] Open
Abstract
Optimal fluid management is critical during mechanical ventilation to mitigate lung damage. Under normovolemia and protective ventilation, pulmonary tensile stress during pressure-support ventilation (PSV) results in comparable lung protection to compressive stress during pressure-controlled ventilation (PCV) in experimental acute lung injury (ALI). It is not yet known whether tensile stress can lead to comparable protection to compressive stress in ALI under a liberal fluid strategy (LF). A conservative fluid strategy (CF) was compared with LF during PSV and PCV on lungs and kidneys in an established model of ALI. Twenty-eight male Wistar rats received endotoxin intratracheally. After 24 h, they were treated with CF (minimum volume of Ringer's lactate to maintain normovolemia and mean arterial pressure ≥70 mmHg) or LF (~4 times higher than CF) combined with PSV or PCV (VT = 6 ml/kg, PEEP = 3 cmH2 O) for 1 h. Nonventilated animals (n = 4) were used for molecular biology analyses. CF-PSV compared with LF-PSV: (1) decreased the diffuse alveolar damage score (10 [7.8-12] vs. 25 [23-31.5], p = 0.006), mainly due to edema in axial and alveolar parenchyma; (2) increased birefringence for occludin and claudin-4 in lung tissue and expression of zonula-occludens-1 and metalloproteinase-9 in lung. LF compared with CF reduced neutrophil gelatinase-associated lipocalin and interleukin-6 expression in the kidneys in PSV and PCV. In conclusion, CF compared with LF combined with PSV yielded less lung epithelial cell damage in the current model of ALI. However, LF compared with CF resulted in less kidney injury markers, regardless of the ventilatory strategy.
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Affiliation(s)
- Eduardo Butturini de Carvalho
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
- University of VassourasVassourasRJBrazil
| | - Ana Carolina Fernandes Fonseca
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Raquel Ferreira Magalhães
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Eliete Ferreira Pinto
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Cynthia dos Santos Samary
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Mariana Alves Antunes
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | | | | | | | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Therapy, Technische Universität DresdenUniversity Hospital Carl Gustav CarusDresdenGermany
- Department of Intensive Care and Resuscitation, Anesthesiology InstituteCleveland ClinicClevelandOhioUSA
- Department of Outcomes Research, Anesthesiology InstituteCleveland ClinicClevelandOhioUSA
| | - Vera Luiza Capelozzi
- Department of Pathology, School of MedicineUniversity of São PauloSão PauloBrazil
| | - Nathane Santanna Felix
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated DiagnosticsUniversity of GenoaGenoaItaly
- Anesthesia and Critical Care, San Martino Policlinico HospitalIRCCS for Oncology and NeurosciencesGenoaItaly
| | - Patrícia Rieken Macêdo Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas FilhoFederal University of Rio de JaneiroRio de JaneiroRJBrazil
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Ball L, Serafini SC, Braune A, Güldner A, Bluth T, Spieth P, Huhle R, Scharffenberg M, Wittenstein J, Uhlig C, Robba C, Schultz MJ, Pelosi P, Gama de Abreu M. Changes in lung aeration and respiratory function after open abdominal surgery: a quantitative magnetic resonance imaging study. Acta Anaesthesiol Scand 2022; 66:944-953. [DOI: 10.1111/aas.14111] [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: 02/07/2022] [Revised: 04/13/2022] [Accepted: 06/13/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Lorenzo Ball
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC) Ospedale Policlinico San Martino, IRCCS per l’Oncologia e le Neuroscienze Genova Italy
- Anesthesia and Intensive Care Amsterdam University Medical Centers, location ‘AMC’ Amsterdam The Netherlands
| | - Simon Corrado Serafini
- Department of Surgical Sciences and Integrated Diagnostics (DISC) Ospedale Policlinico San Martino, IRCCS per l’Oncologia e le Neuroscienze Genova Italy
| | - Anja Braune
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Thomas Bluth
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Peter Spieth
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Christopher Uhlig
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC) Ospedale Policlinico San Martino, IRCCS per l’Oncologia e le Neuroscienze Genova Italy
- Anesthesia and Intensive Care Amsterdam University Medical Centers, location ‘AMC’ Amsterdam The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care Cleveland Clinic Cleveland OH United States of America
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC) Ospedale Policlinico San Martino, IRCCS per l’Oncologia e le Neuroscienze Genova Italy
- Anesthesia and Intensive Care Amsterdam University Medical Centers, location ‘AMC’ Amsterdam The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group University of Genoa Genova Italy
- Department of Intensive Care and Resuscitation Anesthesiology Institute
- Department of Outcomes Research Anesthesiology Institute
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Dres M, de Abreu MG, Merdji H, Müller-Redetzky H, Dellweg D, Randerath WJ, Mortaza S, Jung B, Bruells C, Moerer O, Scharffenberg M, Jaber S, Besset S, Bitter T, Geise A, Heine A, Malfertheiner MV, Kortgen A, Benzaquen J, Nelson T, Uhrig A, Moenig O, Meziani F, Demoule A, Similowski T. Randomized Clinical Study of Temporary Transvenous Phrenic Nerve Stimulation in Difficult-to-Wean Patients. Am J Respir Crit Care Med 2022; 205:1169-1178. [PMID: 35108175 PMCID: PMC9872796 DOI: 10.1164/rccm.202107-1709oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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] [Indexed: 01/27/2023] Open
Abstract
Rationale: Diaphragm dysfunction is frequently observed in critically ill patients with difficult weaning from mechanical ventilation. Objectives: To evaluate the effects of temporary transvenous diaphragm neurostimulation on weaning outcome and maximal inspiratory pressure. Methods: Multicenter, open-label, randomized, controlled study. Patients aged ⩾18 years on invasive mechanical ventilation for ⩾4 days and having failed at least two weaning attempts received temporary transvenous diaphragm neurostimulation using a multielectrode stimulating central venous catheter (bilateral phrenic stimulation) and standard of care (treatment) (n = 57) or standard of care (control) (n = 55). In seven patients, the catheter could not be inserted, and in seven others, pacing therapy could not be delivered; consequently, data were available for 43 patients. The primary outcome was the proportion of patients successfully weaned. Other endpoints were mechanical ventilation duration, 30-day survival, maximal inspiratory pressure, diaphragm-thickening fraction, adverse events, and stimulation-related pain. Measurements and Main Results: The incidences of successful weaning were 82% (treatment) and 74% (control) (absolute difference [95% confidence interval (CI)], 7% [-10 to 25]), P = 0.59. Mechanical ventilation duration (mean ± SD) was 12.7 ± 9.9 days and 14.1 ± 10.8 days, respectively, P = 0.50; maximal inspiratory pressure increased by 16.6 cm H2O and 4.8 cm H2O, respectively (difference [95% CI], 11.8 [5 to 19]), P = 0.001; and right hemidiaphragm thickening fraction during unassisted spontaneous breathing was +17% and -14%, respectively, P = 0.006, without correlation with changes in maximal inspiratory pressure. Serious adverse event frequency was similar in both groups. Median stimulation-related pain in the treatment group was 0 (no pain). Conclusions: Temporary transvenous diaphragm neurostimulation did not increase the proportion of successful weaning from mechanical ventilation. It was associated with a significant increase in maximal inspiratory pressure, suggesting reversal of the course of diaphragm dysfunction. Clinical trial registered with www.clinicaltrials.gov (NCT03096639) and the European Database on Medical Devices (CIV-17-06-020004).
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Affiliation(s)
- Martin Dres
- Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France;,AP-HP, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, R3S Department, Sorbonne University, Paris, France
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany;,Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio;,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hamid Merdji
- Université de Strasbourg, Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - Holger Müller-Redetzky
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dominic Dellweg
- Department of Pulmonary and Critical Care Medicine, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg, Germany
| | - Winfried J. Randerath
- Institute for Pneumology at the University of Cologne Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Satar Mortaza
- Département de Médecine Intensive, Réanimation et Médecine Hyperbare, CHU d’Angers, Faculté de Santé, Université d’Angers, Angers, France
| | - Boris Jung
- Medical Intensive Care Unit, Lapeyronie Teaching Hospital and PhyMedExp, University of Montpellier, Montpellier, France
| | - Christian Bruells
- Department of Anesthesiology, Aachen University Hospital of the RWTH Aachen, Aachen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Martin Scharffenberg
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, France
| | - Sébastien Besset
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
| | - Thomas Bitter
- Clinic for General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Arnim Geise
- Department of Respiratory Medicine, Allergology and Sleep Medicine/Nuremberg Lung Cancer Center, Paracelsus Medical University, General Hospital Nuremberg, Nuremburg, Germany
| | - Alexander Heine
- Department of Internal Medicine B, Cardiology, Pneumology, Weaning, Infectious Diseases, Intensive Care Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Maximilian V. Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Kortgen
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Jonathan Benzaquen
- Department of Pulmonary Medicine and Oncology, Université Côte d'Azur, CHU de Nice, University Hospital Federation OncoAge, Nice, France
| | - Teresa Nelson
- Technomics Research, LLC, Minneapolis, Minnesota; and
| | - Alexander Uhrig
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Olaf Moenig
- Department of Pulmonary and Critical Care Medicine, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg, Germany
| | - Ferhat Meziani
- Université de Strasbourg, Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France
| | - Alexandre Demoule
- Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France;,AP-HP, Pitié-Salpêtrière Hospital, Médecine Intensive Réanimation, R3S Department, Sorbonne University, Paris, France
| | - Thomas Similowski
- Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, INSERM, UMRS1158, Paris, France;,AP-HP, Pitie-Salpêtrière Hospital, R3S Department, Sorbonne Université, Paris, France
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21
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Mireles-Cabodevila E, Abreu MGD. Classification and Quantification of Patient-Ventilator Interactions: We Need Consensus! Respir Care 2022; 67:620-623. [PMID: 35473853 PMCID: PMC9994245 DOI: 10.4187/respcare.10114] [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: 03/10/2023]
Affiliation(s)
- Eduardo Mireles-Cabodevila
- Cleveland Clinic Lerner College of Medicine of Case Western ReserveSimulation and Advanced Skills Center, Cleveland ClinicCleveland, Ohio
| | - Marcelo Gama de Abreu
- Cleveland Clinic Lerner College of Medicine of Case Western ReserveDepartment of Intensive Care and Resuscitation, Department of Outcomes Research,Anesthesiology Institute, Cleveland ClinicCleveland, Ohio
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22
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Ferreira JMC, Huhle R, Müller S, Schnabel C, Mehner M, Koch T, Gama de Abreu M. Static Stretch Increases the Pro-Inflammatory Response of Rat Type 2 Alveolar Epithelial Cells to Dynamic Stretch. Front Physiol 2022; 13:838834. [PMID: 35480037 PMCID: PMC9035495 DOI: 10.3389/fphys.2022.838834] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 12/18/2021] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Mechanical ventilation (MV) inflicts stress on the lungs, initiating or increasing lung inflammation, so-called ventilator-induced lung injury (VILI). Besides overdistention, cyclic opening-and-closing of alveoli (atelectrauma) is recognized as a potential mechanism of VILI. The dynamic stretch may be reduced by positive end-expiratory pressure (PEEP), which in turn increases the static stretch. We investigated whether static stretch modulates the inflammatory response of rat type 2 alveolar epithelial cells (AECs) at different levels of dynamic stretch and hypothesized that static stretch increases pro-inflammatory response of AECs at given dynamic stretch. Methods: AECs, stimulated and not stimulated with lipopolysaccharide (LPS), were subjected to combinations of static (10, 20, and 30%) and dynamic stretch (15, 20, and 30%), for 1 and 4 h. Non-stretched AECs served as control. The gene expression and secreted protein levels of interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and macrophage inflammatory protein 2 (MIP-2) were studied by real-time polymerase chain reaction (RT-qPCR) and enzyme-linked immunosorbent assay (ELISA), respectively. The effects of static and dynamic stretch were assessed by two-factorial ANOVA with planned effects post-hoc comparison according to Šidák. Statistical significance was considered for p < 0.05. Results: In LPS-stimulated, but not in non-stimulated rat type 2 AECs, compared to non-stretched cells: 1) dynamic stretch increased the expression of amphiregulin (AREG) (p < 0.05), MCP-1 (p < 0.001), and MIP-2 (<0.05), respectively, as well as the protein secretion of IL-6 (p < 0.001) and MCP-1 (p < 0.05); 2) static stretch increased the gene expression of MCP-1 (p < 0.001) and MIP-2, but not AREG, and resulted in higher secretion of IL-6 (p < 0.001), but not MCP-1, while MIP-2 was not detectable in the medium. Conclusion: In rat type 2 AECs stimulated with LPS, static stretch increased the pro-inflammatory response to dynamic stretch, suggesting a potential pro-inflammatory effect of PEEP during mechanical ventilation at the cellular level.
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Affiliation(s)
- Jorge M. C. Ferreira
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- *Correspondence: Jorge M. C. Ferreira,
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Sabine Müller
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Christian Schnabel
- Department of Anesthesiology and Intensive Care Medicine, Clinical Sensoring and Monitoring Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Mirko Mehner
- Department of Anesthesiology and Intensive Care Medicine, Clinical Sensoring and Monitoring Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
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23
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Buhre W, de Korte-de Boer D, de Abreu MG, Scheeren T, Gruenewald M, Hoeft A, Spahn DR, Zarbock A, Daamen S, Westphal M, Brauer U, Dehnhardt T, Schmier S, Baron JF, De Hert S, Gavranović Ž, Cholley B, Vymazal T, Szczeklik W, Bornemann-Cimenti H, Soro Domingo MB, Grintescu I, Jankovic R, Belda J. Prospective, randomized, controlled, double-blind, multi-center, multinational study on the safety and efficacy of 6% Hydroxyethyl starch (HES) sOlution versus an Electrolyte solutioN In patients undergoing eleCtive abdominal Surgery: study protocol for the PHOENICS study. Trials 2022; 23:168. [PMID: 35193648 PMCID: PMC8862305 DOI: 10.1186/s13063-022-06058-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Hydroxyethyl starch (HES) solutions are used for volume therapy to treat hypovolemia due to acute blood loss and to maintain hemodynamic stability. This study was requested by the European Medicines Agency (EMA) to provide more evidence on the long-term safety and efficacy of HES solutions in the perioperative setting. Methods PHOENICS is a randomized, controlled, double-blind, multi-center, multinational phase IV (IIIb) study with two parallel groups to investigate non-inferiority regarding the safety of a 6% HES 130 solution (Volulyte 6%, Fresenius Kabi, Germany) compared with a crystalloid solution (Ionolyte, Fresenius Kabi, Germany) for infusion in patients with acute blood loss during elective abdominal surgery. A total of 2280 eligible patients (male and female patients willing to participate, with expected blood loss ≥ 500 ml, aged > 40 and ≤ 85 years, and ASA Physical status II–III) are randomly assigned to receive either HES or crystalloid solution for the treatment of hypovolemia due to surgery-induced acute blood loss in hospitals in up to 11 European countries. The dosing of investigational products (IP) is individualized to patients’ volume needs and guided by a volume algorithm. Patients are treated with IP for maximally 24 h or until the maximum daily dose of 30 ml/kg body weight is reached. The primary endpoint is the treatment group mean difference in the change from the pre-operative baseline value in cystatin-C-based estimated glomerular filtration rate (eGFR), to the eGFR value calculated from the highest cystatin-C level measured during post-operative days 1-3. Further safety and efficacy parameters include, e.g., combined mortality/major post-operative complications until day 90, renal function, coagulation, inflammation, hemodynamic variables, hospital length of stay, major post-operative complications, and 28-day, 90-day, and 1-year mortality. Discussion The study will provide important information on the long-term safety and efficacy of HES 130/0.4 when administered according to the approved European product information. The results will be relevant for volume therapy of surgical patients. Trial registration EudraCT 2016-002162-30. ClinicalTrials.govNCT03278548
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Affiliation(s)
- Wolfgang Buhre
- Division of Acute and Critical Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Dianne de Korte-de Boer
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthias Gruenewald
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Andreas Hoeft
- Department of Anesthesiology and Operative Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital of Zürich, Zürich, Switzerland.,Anesthesiology, Intensive Care Medicine and OR Facilities, University and University Hospital of Zürich, Zürich, Switzerland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Sylvia Daamen
- European Society of Anaesthesiology and Intensive Care, Brussels, Belgium
| | | | - Ute Brauer
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | - Tamara Dehnhardt
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | - Sonja Schmier
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | | | - Stefan De Hert
- Department of Anesthesioloy and Perioperative Medicine, Gent University Hospital - Gent University, Ghent, Belgium
| | - Željka Gavranović
- Department of Anesthesiology and Intensive Care, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Bernard Cholley
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Paris, France
| | - Tomas Vymazal
- Department of Anesthesiology and Intensive Medicine, University Hospital Motol, Prague, Czech Republic
| | - Wojciech Szczeklik
- Department of Anaesthesiology and Intensive Therapy, 5th Military Clinical Hosptial, Krakow, Poland
| | - Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Marina Blanca Soro Domingo
- Department of Surgery, Clinic University Hospital, Valencia, Spain.,Department of Anesthesia, Reanimation and Pain Therapy, Clinic University Hospital, Valencia, Spain
| | - Ioana Grintescu
- Clinic of Anaesthesia and Intensive Care Medicine, Clinical Emergency Hospital of Bucharest, Bucharest, Romania.,Department of Anaesthesia and Intensive Care Medicine, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania
| | - Radmilo Jankovic
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia
| | - Javier Belda
- Department of Surgery, Clinic University Hospital, Valencia, Spain
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24
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Maiello L, Ball L, Micali M, Iannuzzi F, Scherf N, Hoffmann RT, Gama de Abreu M, Pelosi P, Huhle R. Automatic Lung Segmentation and Quantification of Aeration in Computed Tomography of the Chest Using 3D Transfer Learning. Front Physiol 2022; 12:725865. [PMID: 35185592 PMCID: PMC8854801 DOI: 10.3389/fphys.2021.725865] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Identification of lung parenchyma on computer tomographic (CT) scans in the research setting is done semi-automatically and requires cumbersome manual correction. This is especially true in pathological conditions, hindering the clinical application of aeration compartment (AC) analysis. Deep learning based algorithms have lately been shown to be reliable and time-efficient in segmenting pathologic lungs. In this contribution, we thus propose a novel 3D transfer learning based approach to quantify lung volumes, aeration compartments and lung recruitability. METHODS Two convolutional neural networks developed for biomedical image segmentation (uNet), with different resolutions and fields of view, were implemented using Matlab. Training and evaluation was done on 180 scans of 18 pigs in experimental ARDS (u2Net Pig ) and on a clinical data set of 150 scans from 58 ICU patients with lung conditions varying from healthy, to COPD, to ARDS and COVID-19 (u2Net Human ). One manual segmentations (MS) was available for each scan, being a consensus by two experts. Transfer learning was then applied to train u2Net Pig on the clinical data set generating u2Net Transfer . General segmentation quality was quantified using the Jaccard index (JI) and the Boundary Function score (BF). The slope between JI or BF and relative volume of non-aerated compartment (S JI and S BF , respectively) was calculated over data sets to assess robustness toward non-aerated lung regions. Additionally, the relative volume of ACs and lung volumes (LV) were compared between automatic and MS. RESULTS On the experimental data set, u2Net Pig resulted in JI = 0.892 [0.88 : 091] (median [inter-quartile range]), BF = 0.995 [0.98 : 1.0] and slopes S JI = -0.2 {95% conf. int. -0.23 : -0.16} and S BF = -0.1 {-0.5 : -0.06}. u2Net Human showed similar performance compared to u2Net Pig in JI, BF but with reduced robustness S JI = -0.29 {-0.36 : -0.22} and S BF = -0.43 {-0.54 : -0.31}. Transfer learning improved overall JI = 0.92 [0.88 : 0.94], P < 0.001, but reduced robustness S JI = -0.46 {-0.52 : -0.40}, and affected neither BF = 0.96 [0.91 : 0.98] nor S BF = -0.48 {-0.59 : -0.36}. u2Net Transfer improved JI compared to u2Net Human in segmenting healthy (P = 0.008), ARDS (P < 0.001) and COPD (P = 0.004) patients but not in COVID-19 patients (P = 0.298). ACs and LV determined using u2Net Transfer segmentations exhibited < 5% volume difference compared to MS. CONCLUSION Compared to manual segmentations, automatic uNet based 3D lung segmentation provides acceptable quality for both clinical and scientific purposes in the quantification of lung volumes, aeration compartments, and recruitability.
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Affiliation(s)
- Lorenzo Maiello
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Marco Micali
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Nico Scherf
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Ralf-Thorsten Hoffmann
- Department of Diagnostic and Interventional Radiology, University Hospital Carl Gustav Dresden, Technische Universität Dresden, Dresden, Germany
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Robert Huhle
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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25
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Pisani L, Algera AG, Neto AS, Azevedo L, Pham T, Paulus F, de Abreu MG, Pelosi P, Dondorp AM, Bellani G, Laffey JG, Schultz MJ, Martinez A, Leal L, Jorge Pereira A, de Oliveira Maia M, Neto JA, Piras C, Caser EB, Moreira CL, Braga Gusman P, Dalcomune DM, Ribeiro de Carvalho AG, Gondim LAR, Castelo Branco Reis LM, da Cunha Ribeiro D, de Assis Simões L, Campos RS, Fernandez Versiani dos Anjos JC, Bruzzi Carvalho F, Alves RA, Nunes LB, Réa-Neto Á, de Oliveira MC, Tannous L, Cardoso Gomes B, Rodriguez FB, Abelha P, Lugarinho ME, Japiassu A, de Melo HK, Lopes EA, Varaschin P, de Souza Dantas VC, Freitas Knibel M, Ponte M, de Azambuja Rodrigues PM, Costa Filho RC, Saddy F, Wanderley Castellões TF, Silva SA, Osorio LAG, Mannarino D, Espinoza R, Righy C, Soares M, Salluh J, Tanaka L, Aragão D, Tavares ME, Kehdi MGP, Rezende VMC, Carbonell RCC, Teixeira C, de Oliveira RP, Maccari JG, Castro PS, Berto P, Schwarz P, Torelly AP, Lisboa T, Moraes E, Dal-Pizzol F, Tomasi Damiani C, Ritter C, Ferreira JC, Teixeira Costa R, Caruso P, Amendola CP, de Oliveira AMRR, Silva UVA, Sanches LC, Almeida RDS, Azevedo LC, Park M, Schettino G, Assunção MS, Silva E, Barboza CE, Junior APN, Marzocchi Tierno PFGM, Malbouisson LM, Oliveira L, Cristovao D, Neto ML, Rego Ê, Fernandes FE, Romano MLP, Cavalcanti AB, de Souza Barros D, Rodgers H, Dixon B, Smith R, Kol M, Wong H, Schmid W, Hermans G, Ceunen H, Bourgeois M, Anquez N, Suzumura ÉA, Decruyenaere J, DeCrop L, Neto AS, Souza dos Santos R, Beraldo D, dos Santos MC, Pellegrini JAS, Piras C, Oliveira V, Munhoz C, Meira KL, Peçanha AC, da Silva Ramos FJ, Maia I, Bahl M, Biondi R, Prado D, Pinto SF, Salgado J, Falcão LF, Macruz T, de Oliveira GA, Cavalcanti AB, Romano MLP, Ruas K, Mecatti GC, Caser EB, Gava IA, Carreño N, Morales M, Avendaño R, Aguirre S, Luciano PM, Sribar A, Klaric V, Skilijic S, Dvorscak MB, Krkusek M, Jurjevic M, Karanovic N, Simurina T, Stourac P, Kratochvil M, Pacheco ED, Máca J, Wrigge H, Schlegel C, Treschan TA, Schaefer M, Aytulun A, Kienbaum P, Clarkson K, Jaafar R, Collins D, Mazza BF, Plant R, Melchionda G, Di Lauro E, Cortegiani A, Russotto V, Caione R, Mestria D, Volta CA, Spadaro S, Botteri M, Machado FR, Seghelini E, Brazzi L, Sales G, D'Antini D, Molin A, Severgnini P, Bacuzzi A, Peluso L, Verrastro P, Raimondo P, Ferreira E, Gecaj-Gashi A, Simonis FD, Tuinman PR, Alberts E, van den Hul I, Kuiper M, de Wilde RBP, Koopmans M, Kose I, Zincircioglu Ç, dos Santos RB, Dogan N, Aydin D, Denker AS, Buyukkocak U, Akgun N, Turan G, Senturk E, Demirtürk Z, Özcan PE, Ekinci O, Colombo AS, Saylan S, Eren G, Ulger F, Dilek A, Ulusoy H, Goktas U, Soyoral L, Toman H, Orak Y, Kahveci F, Nogueira AC, Mills GH, Pinder A, Walker R, Harrison J, Snell J, Seasman C, Pearson R, Sharman M, Kaloo C, Bynorth N, Fernandes JB, Matthews K, Hughes C, Rose A, Simeson K, Niska L, Huneke N, Adderly J, Padilla-Harris C, Oliver R, Brohi F, Nóbrega RS, Wilson N, Talbot H, Wilson D, Smith D, Dark P, Evans T, Fisher N, 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Jovanovic B, Surbatovic M, Veljovic M, Van Haren F. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies. The Lancet Global Health 2022; 10:e227-e235. [PMID: 34914899 PMCID: PMC8766316 DOI: 10.1016/s2214-109x(21)00485-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/05/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.
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Hol L, Nijbroek SGLH, Neto AS, Hemmes SNT, Hedenstierna G, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Putensen C, Schmid W, Severgnini P, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ. Geo-economic variations in epidemiology, ventilation management and outcome of patients receiving intraoperative ventilation during general anesthesia- posthoc analysis of an observational study in 29 countries. BMC Anesthesiol 2022; 22:15. [PMID: 34996361 PMCID: PMC8740416 DOI: 10.1186/s12871-021-01560-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this analysis is to determine geo-economic variations in epidemiology, ventilator settings and outcome in patients receiving general anesthesia for surgery. METHODS Posthoc analysis of a worldwide study in 29 countries. Lower and upper middle-income countries (LMIC and UMIC), and high-income countries (HIC) were compared. The coprimary endpoint was the risk for and incidence of postoperative pulmonary complications (PPC); secondary endpoints were intraoperative ventilator settings, intraoperative complications, hospital stay and mortality. RESULTS Of 9864 patients, 4% originated from LMIC, 11% from UMIC and 85% from HIC. The ARISCAT score was 17.5 [15.0-26.0] in LMIC, 16.0 [3.0-27.0] in UMIC and 15.0 [3.0-26.0] in HIC (P = .003). The incidence of PPC was 9.0% in LMIC, 3.2% in UMIC and 2.5% in HIC (P < .001). Median tidal volume in ml kg- 1 predicted bodyweight (PBW) was 8.6 [7.7-9.7] in LMIC, 8.4 [7.6-9.5] in UMIC and 8.1 [7.2-9.1] in HIC (P < .001). Median positive end-expiratory pressure in cmH2O was 3.3 [2.0-5.0]) in LMIC, 4.0 [3.0-5.0] in UMIC and 5.0 [3.0-5.0] in HIC (P < .001). Median driving pressure in cmH2O was 14.0 [11.5-18.0] in LMIC, 13.5 [11.0-16.0] in UMIC and 12.0 [10.0-15.0] in HIC (P < .001). Median fraction of inspired oxygen in % was 75 [50-80] in LMIC, 50 [50-63] in UMIC and 53 [45-70] in HIC (P < .001). Intraoperative complications occurred in 25.9% in LMIC, in 18.7% in UMIC and in 37.1% in HIC (P < .001). Hospital mortality was 0.0% in LMIC, 1.3% in UMIC and 0.6% in HIC (P = .009). CONCLUSION The risk for and incidence of PPC is higher in LMIC than in UMIC and HIC. Ventilation management could be improved in LMIC and UMIC. TRIAL REGISTRATION Clinicaltrials.gov , identifier: NCT01601223.
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Affiliation(s)
- Liselotte Hol
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands. .,Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
| | - Sunny G L H Nijbroek
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
| | - Sabrine N T Hemmes
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Goran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Michael Hiesmayr
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, location AMC, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Gary H Mills
- Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK
| | - Marcos F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnology and Life, ASST Sette Laghi Ospedale di Circolo e Fondazio Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Pain Therapy, Bermannstrost Hospital Halle, Halle, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany.,Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, Università degli Studi di Genova, Genova, Italy.,Anesthesia and Critical Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genova, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Scharffenberg M, Wittenstein J, Ran X, Zhang Y, Braune A, Theilen R, Maiello L, Benzi G, Bluth T, Kiss T, Pelosi P, Rocco PRM, Schultz MJ, Kotzerke J, Gama de Abreu M, Huhle R. Mechanical Power Correlates With Lung Inflammation Assessed by Positron-Emission Tomography in Experimental Acute Lung Injury in Pigs. Front Physiol 2021; 12:717266. [PMID: 34880770 PMCID: PMC8645956 DOI: 10.3389/fphys.2021.717266] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/20/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Mechanical ventilation (MV) may initiate or worsen lung injury, so-called ventilator-induced lung injury (VILI). Although different mechanisms of VILI have been identified, research mainly focused on single ventilator parameters. The mechanical power (MP) summarizes the potentially damaging effects of different parameters in one single variable and has been shown to be associated with lung damage. However, to date, the association of MP with pulmonary neutrophilic inflammation, as assessed by positron-emission tomography (PET), has not been prospectively investigated in a model of clinically relevant ventilation settings yet. We hypothesized that the degree of neutrophilic inflammation correlates with MP. Methods: Eight female juvenile pigs were anesthetized and mechanically ventilated. Lung injury was induced by repetitive lung lavages followed by initial PET and computed tomography (CT) scans. Animals were then ventilated according to the acute respiratory distress syndrome (ARDS) network recommendations, using the lowest combinations of positive end-expiratory pressure and inspiratory oxygen fraction that allowed adequate oxygenation. Ventilator settings were checked and adjusted hourly. Physiological measurements were conducted every 6 h. Lung imaging was repeated 24 h after first PET/CT before animals were killed. Pulmonary neutrophilic inflammation was assessed by normalized uptake rate of 2-deoxy-2-[18F]fluoro-D-glucose (KiS), and its difference between the two PET/CT was calculated (ΔKiS). Lung aeration was assessed by lung CT scan. MP was calculated from the recorded pressure-volume curve. Statistics included the Wilcoxon tests and non-parametric Spearman correlation. Results: Normalized 18F-FDG uptake rate increased significantly from first to second PET/CT (p = 0.012). ΔKiS significantly correlated with median MP (ρ = 0.738, p = 0.037) and its elastic and resistive components, but neither with median peak, plateau, end-expiratory, driving, and transpulmonary driving pressures, nor respiratory rate (RR), elastance, or resistance. Lung mass and volume significantly decreased, whereas relative mass of hyper-aerated lung compartment increased after 24 h (p = 0.012, p = 0.036, and p = 0.025, respectively). Resistance and PaCO2 were significantly higher (p = 0.012 and p = 0.017, respectively), whereas RR, end-expiratory pressure, and MP were lower at 18 h compared to start of intervention. Conclusions: In this model of experimental acute lung injury in pigs, pulmonary neutrophilic inflammation evaluated by PET/CT increased after 24 h of MV, and correlated with MP.
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Affiliation(s)
- Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Xi Ran
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yingying Zhang
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Anja Braune
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Raphael Theilen
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lorenzo Maiello
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Giulia Benzi
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Clinical and Biological Sciences, Service of Anesthesia and Intensive Care, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Thomas Bluth
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcus J. Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jörg Kotzerke
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Ball L, Sutherasan Y, Fiorito M, Dall'Orto A, Maiello L, Vargas M, Robba C, Brunetti I, D'Antini D, Raimondo P, Huhle R, Schultz MJ, Rocco PRM, Gama de Abreu M, Pelosi P. Effects of Different Levels of Variability and Pressure Support Ventilation on Lung Function in Patients With Mild-Moderate Acute Respiratory Distress Syndrome. Front Physiol 2021; 12:725738. [PMID: 34744766 PMCID: PMC8569865 DOI: 10.3389/fphys.2021.725738] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/17/2021] [Indexed: 11/14/2022] Open
Abstract
Background: Variable pressure support ventilation (vPSV) is an assisted ventilation mode that varies the level of pressure support on a breath-by-breath basis to restore the physiological variability of breathing activity. We aimed to compare the effects of vPSV at different levels of variability and pressure support (ΔPS) in patients with acute respiratory distress syndrome (ARDS). Methods: This study was a crossover randomized clinical trial. We included patients with mild to moderate ARDS already ventilated in conventional pressure support ventilation (PSV). The study consisted of two blocks of interventions, and variability during vPSV was set as the coefficient of variation of the ΔPS level. In the first block, the effects of three levels of variability were tested at constant ΔPS: 0% (PSV0%, conventional PSV), 15% (vPSV15%), and 30% (vPSV30%). In the second block, two levels of variability (0% and variability set to achieve ±5 cmH2O variability) were tested at two ΔPS levels (baseline ΔPS and ΔPS reduced by 5 cmH2O from baseline). The following four ventilation strategies were tested in the second block: PSV with baseline ΔPS and 0% variability (PSVBL) or ±5 cmH2O variability (vPSVBL), PSV with ΔPS reduced by 5 cmH2O and 0% variability (PSV−5) or ±5 cmH2O variability (vPSV−5). Outcomes included gas exchange, respiratory mechanics, and patient-ventilator asynchronies. Results: The study enrolled 20 patients. In the first block of interventions, oxygenation and respiratory mechanics parameters did not differ between vPSV15% and vPSV30% compared with PSV0%. The variability of tidal volume (VT) was higher with vPSV15% and vPSV30% compared with PSV0%. The incidence of asynchronies and the variability of transpulmonary pressure (PL) were higher with vPSV30% compared with PSV0%. In the second block of interventions, different levels of pressure support with and without variability did not change oxygenation. The variability of VT and PL was higher with vPSV−5 compared with PSV−5, but not with vPSVBL compared with PSVBL. Conclusion: In patients with mild-moderate ARDS, the addition of variability did not improve oxygenation at different pressure support levels. Moreover, high variability levels were associated with worse patient-ventilator synchrony. Clinical Trial Registration:www.clinicaltrials.gov, identifier: NCT01683669.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
| | - Yuda Sutherasan
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Martina Fiorito
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Antonella Dall'Orto
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Maiello
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
| | - Davide D'Antini
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anaesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Pasquale Raimondo
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anaesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Robert Huhle
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Centers, Location Academic Medical Center (AMC), Amsterdam, Netherlands.,Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genova, Italy
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Defosse J, Schieren M, Loop T, von Dossow V, Wappler F, de Abreu MG, Gerbershagen MU. Current practice of thoracic anaesthesia in Europe - a survey by the European Society of Anaesthesiology Part I - airway management and regional anaesthesia techniques. BMC Anesthesiol 2021; 21:266. [PMID: 34719390 PMCID: PMC8558093 DOI: 10.1186/s12871-021-01480-w] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/13/2021] [Indexed: 12/02/2022] Open
Abstract
Background The scientific working group for “Anaesthesia in thoracic surgery” of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) has performed an online survey to assess the current standards of care and structural properties of anaesthesia workstations in thoracic surgery. Methods All members of the European Society of Anaesthesiology (ESA) were invited to participate in the study. Results Thoracic anaesthesia was most commonly performed by specialists/board-certified anaesthetists and/or senior/attending physicians. Across Europe, the double lumen tube (DLT) was most commonly chosen as the primary device for lung separation (461/ 97.3%). Bronchial blockers were chosen less frequently (9/ 1.9%). Throughout Europe, bronchoscopy was not consistently used to confirm correct double lumen tube positioning. Respondents from Eastern Europe (32/ 57.1%) frequently stated that there were not enough bronchoscopes available for every intrathoracic operation. A specific algorithm for difficult airway management in thoracic anaesthesia was available to only 18.6% (n = 88) of the respondents. Thoracic epidural analgesia (TEA) is the most commonly used form of regional analgesia for thoracic surgery in Europe. Ultrasonography was widely available 93,8% (n = 412) throughout Europe and was predominantly used for central line placement and lung diagnostics. Conclusions While certain „gold standards “are widely met, there are also aspects of care requiring substantial improvement in thoracic anaesthesia throughout Europe. Our data suggest that algorithms and standard operating procedures for difficult airway management in thoracic anaesthesia need to be established. A European recommendation for the basic requirements of an anaesthesia workstation for thoracic anaesthesia is expedient and desirable, to improve structural quality and patient safety. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01480-w.
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Affiliation(s)
- Jerome Defosse
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical centre Cologne-Merheim, Cologne, Germany.
| | - Mark Schieren
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical centre Cologne-Merheim, Cologne, Germany
| | - Torsten Loop
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Heart and Diabetes Center North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Frank Wappler
- Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical centre Cologne-Merheim, Cologne, Germany
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, Technische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany.,Department of Intensive Care and Resuscitation, Cleveland Clinic, Anesthesiology Institute, Ohio, USA.,Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Ohio, USA
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30
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Huhle R, Richter T, Gama de Abreu M. Tracking blood pressure changes by means of non-invasive intermittent blood pressure measurements in clinical application. Current Directions in Biomedical Engineering 2021. [DOI: 10.1515/cdbme-2021-2208] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Considering accuracy/precision cut-offs of 5 ± 8 mmHg and cut-off values for inter-class correlation coefficients (ICC=0.37...1, from DIN EN ISO 81060-2), absolute and relative errors in time independent measurement of blood pressure changes with non-invasive intermittent devices (NiBP) are derived mathematically for mean arterial blood pressure range of 40-180 mmHg. As a clinically relevant value for change of arterial blood pressure 20% of the baseline blood pressure is considered. The mean ratio between the change of BP measured by the NiBP and measured by the invasive reference device (TE%) were proposed as quality measure for the evaluation of NiBP device tracking capability. The proposed measure TE%is theoretically independent of absolute accuracy but depends on precision and ICC of a device. NiBP devices show considerable maximum TE% of 41% in tracking mean blood pressure changes respectively. In 10% of the measurements in the low blood pressure range TE% exceeding 100%. The mean 50th/90th TE% percentile over the whole blood pressure range were 25/61%, respectively. Furthermore, TE% was relatively insensitive to assumed blood
pressure range but sensitive to ICC. NiBP devices have high relative error in tracking blood
pressure changes that make those devices not well-suited for tracking blood pressure changes. The proposed tracking error allows the definition of reasonable accuracy/precision requirements of NBP devices.
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Affiliation(s)
- Robert Huhle
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden , Germany
| | - Thorsten Richter
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden , Germany
| | - Marcelo Gama de Abreu
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden , Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio , USA
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Nijbroek SG, Hol L, Swart P, Hemmes SNT, Serpa Neto A, Binnekade JM, Hedenstierna G, Jaber S, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Putensen C, Schmid W, Severgnini P, Wrigge H, Gama de Abreu M, Pelosi P, Schultz MJ. Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study. Eur J Anaesthesiol 2021; 38:1034-1041. [PMID: 33606418 PMCID: PMC9867928 DOI: 10.1097/eja.0000000000001476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation. RESULTS This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT. CONCLUSION In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV. TRIAL REGISTRATION The study was registered at Clinicaltrials.gov, NCT01601223.
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Affiliation(s)
- Sunny G Nijbroek
- From the Department of Intensive Care (SGN, LH, PS, ASN, JMB, MJS), Department of Anaesthesiology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands (SGN, LH, SNTH, MWH), Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia (ASN), Hedenstierna Laboratory, Department of Clinical Physiology, Uppsala University Hospital, Uppsala, Sweden (GH), Intensive Care Unit, University Hospital of Montpellier and Saint Eloi Hospital, Montpellier University, Montpellier, France (SJ), Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria (MH, WS), Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK (GHM), Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA (MFVM), Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany (CP), Department of Biotechnology and Life Sciences, ASST Sette Laghi Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy (PS), Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle (HW), Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany (MG de A), Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova (PP), IRCCS, Ospedale Policlinico San Martino, Genova, Italy (PP), Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand (MJS) and Nuffield Department of Medicine, University of Oxford, Oxford, UK (MJS)
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32
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Wittenstein J, Scharffenberg M, Ran X, Zhang Y, Keller D, Tauer S, Theilen R, Chai Y, Ferreira J, Müller S, Bluth T, Kiss T, Schultz MJ, Rocco PRM, Pelosi P, Gama de Abreu M, Huhle R. Effects of Body Position and Hypovolemia on the Regional Distribution of Pulmonary Perfusion During One-Lung Ventilation in Endotoxemic Pigs. Front Physiol 2021; 12:717269. [PMID: 34566683 PMCID: PMC8461176 DOI: 10.3389/fphys.2021.717269] [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: 05/30/2021] [Accepted: 08/10/2021] [Indexed: 01/28/2023] Open
Abstract
Background: The incidence of hypoxemia during one-lung ventilation (OLV) is as high as 10%. It is also partially determined by the distribution of perfusion. During thoracic surgery, different body positions are used, such as the supine, semilateral, lateral, and prone positions, with such positions potentially influencing the distribution of perfusion. Furthermore, hypovolemia can impair hypoxic vasoconstriction. However, the effects of body position and hypovolemia on the distribution of perfusion remain poorly defined. We hypothesized that, during OLV, the relative perfusion of the ventilated lung is higher in the lateral decubitus position and that hypovolemia impairs the redistribution of pulmonary blood flow. Methods: Sixteen juvenile pigs were anesthetized, mechanically ventilated, submitted to a right-sided thoracotomy, and randomly assigned to one of two groups: (1) intravascular normovolemia or (2) intravascular hypovolemia, as achieved by drawing ~25% of the estimated blood volume (n = 8/group). Furthermore, to mimic thoracic surgery inflammatory conditions, Escherichia coli lipopolysaccharide was continuously infused at 0.5 μg kg-1 h-1. Under left-sided OLV conditions, the animals were further randomized to one of the four sequences of supine, left semilateral, left lateral, and prone positioning. Measurements of pulmonary perfusion distribution with fluorescence-marked microspheres, ventilation distribution by electrical impedance tomography, and gas exchange were then performed during two-lung ventilation in a supine position and after 30 min in each position and intravascular volume status during OLV. Results: During one-lung ventilation, the relative perfusion of the ventilated lung was higher in the lateral than the supine position. The relative perfusion of the non-ventilated lung was lower in the lateral than the supine and prone positions and in semilateral compared with the prone position. During OLV, the highest arterial partial pressure of oxygen/inspiratory fraction of oxygen (PaO2/F I O 2) was achieved in the lateral position as compared with all the other positions. The distribution of perfusion, ventilation, and oxygenation did not differ significantly between normovolemia and hypovolemia. Conclusions: During one-lung ventilation in endotoxemic pigs, the relative perfusion of the ventilated lung and oxygenation were higher in the lateral than in the supine position and not impaired by hypovolemia.
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Affiliation(s)
- Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Xi Ran
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Intensive Care, Chongqing General Hospital, University of Chinese Academy of Science, Chongqing, China
| | - Yingying Zhang
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Diana Keller
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Sebastian Tauer
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Raphael Theilen
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Yusen Chai
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Jorge Ferreira
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Sabine Müller
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany.,Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States.,Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
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Ball L, Volta CA, Saglietti F, Spadaro S, Di Lullo A, De Simone G, Guarnieri M, Della Corte F, Serpa Neto A, Gama de Abreu M, Schultz MJ, Zangrillo A, Pelosi P, Bignami E. Associations Between Expiratory Flow Limitation and Postoperative Pulmonary Complications in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:815-824. [PMID: 34404594 DOI: 10.1053/j.jvca.2021.07.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine whether driving pressure and expiratory flow limitation are associated with the development of postoperative pulmonary complications (PPCs) in cardiac surgery patients. DESIGN Prospective cohort study. SETTING University Hospital San Raffaele, Milan, Italy. PARTICIPANTS Patients undergoing elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the occurrence of a predefined composite of PPCs. The authors determined the association among PPCs and intraoperative ventilation parameters, mechanical power and energy load, and occurrence of expiratory flow limitation (EFL) assessed with the positive end-expiratory pressure test. Two hundred patients were enrolled, of whom 78 (39%) developed one or more PPCs. Patients with PPCs, compared with those without PPCs, had similar driving pressure (mean difference [MD] -0.1 [95% confidence interval (CI), -1.0 to 0.7] cmH2O, p = 0.561), mechanical power (MD 0.5 [95% CI, -0.3 to 1.1] J/m, p = 0.364), and total energy load (MD 95 [95% CI, -78 to 263] J, p = 0.293), but they had a higher incidence of EFL (51% v 38%, p = 0.005). Only EFL was associated independently with the development of PPCs (odds ratio 2.46 [95% CI, 1.28-4.80], p = 0.007). CONCLUSIONS PPCs occurred frequently in this patient population undergoing cardiac surgery. PPCs were associated independently with the presence of EFL but not with driving pressure, total energy load, or mechanical power.
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Affiliation(s)
- Lorenzo Ball
- Anesthesia and Intensive Care Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Carlo Alberto Volta
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Francesco Saglietti
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Antonio Di Lullo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio De Simone
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marcello Guarnieri
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Francesca Della Corte
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
| | | | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
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34
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Swart P, Deliberato RO, Johnson AEW, Pollard TJ, Bulgarelli L, Pelosi P, de Abreu MG, Schultz MJ, Neto AS. Impact of sex on use of low tidal volume ventilation in invasively ventilated ICU patients-A mediation analysis using two observational cohorts. PLoS One 2021; 16:e0253933. [PMID: 34260619 PMCID: PMC8279424 DOI: 10.1371/journal.pone.0253933] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/15/2021] [Indexed: 11/22/2022] Open
Abstract
Background Studies in patients receiving invasive ventilation show important differences in use of low tidal volume (VT) ventilation (LTVV) between females and males. The aims of this study were to describe temporal changes in VT and to determine what factors drive the sex difference in use of LTVV. Methods and findings This is a posthoc analysis of 2 large longitudinal projects in 59 ICUs in the United States, the ‘Medical information Mart for Intensive Care III’ (MIMIC III) and the ‘eICU Collaborative Research DataBase’. The proportion of patients under LTVV (median VT < 8 ml/kg PBW), was the primary outcome. Mediation analysis, a method to dissect total effect into direct and indirect effects, was used to understand which factors drive the sex difference. We included 3614 (44%) females and 4593 (56%) males. Median VT declined over the years, but with a persistent difference between females (from median 10.2 (9.1 to 11.4) to 8.2 (7.5 to 9.1) ml/kg PBW) vs. males (from median 9.2 [IQR 8.2 to 10.1] to 7.3 [IQR 6.6 to 8.0] ml/kg PBW) (P < .001). In females versus males, use of LTVV increased from 5 to 50% versus from 12 to 78% (difference, –27% [–29% to –25%]; P < .001). The sex difference was mainly driven by patients’ body height and actual body weight (adjusted average causal mediation effect, –30% [–33% to –27%]; P < .001, and 4 [3% to 4%]; P < .001). Conclusions While LTVV is increasingly used in females and males, females continue to receive LTVV less often than males. The sex difference is mainly driven by patients’ body height and actual body weight, and not necessarily by sex. Use of LTVV in females could improve by paying more attention to a correct calculation of VT, i.e., using the correct body height.
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Affiliation(s)
- Pien Swart
- Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
- * E-mail:
| | - Rodrigo Octavio Deliberato
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Big Data Analytics Group, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alistair E. W. Johnson
- Laboratory for Computational Physiology, Institute for Medical Engineering & Science, MIT, Cambridge, MA, United States of America
| | - Tom J. Pollard
- Laboratory for Computational Physiology, Institute for Medical Engineering & Science, MIT, Cambridge, MA, United States of America
| | - Lucas Bulgarelli
- Laboratory for Computational Physiology, Institute for Medical Engineering & Science, MIT, Cambridge, MA, United States of America
| | - Paolo Pelosi
- IRCCS San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
- Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A), Amsterdam UMC, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Pulmonary Division, Cardio–Pulmonary Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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35
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Bulte CS, Boer C, Hemmes SN, Neto AS, Binnekade JM, Hedenstierna G, Jaber S, Hiesmayr M, Hollmann MW, Mills GH, Melo MFV, Pearse RM, Putensen C, Schmid W, Severgnini P, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ. The effects of preoperative moderate to severe anaemia on length of hospital stay: A propensity score-matched analysis in non-cardiac surgery patients. Eur J Anaesthesiol 2021; 38:571-581. [PMID: 33399375 PMCID: PMC9867571 DOI: 10.1097/eja.0000000000001412] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anaemia is frequently recorded during preoperative screening and has been suggested to affect outcomes after surgery negatively. OBJECTIVES The objectives were to assess the frequency of moderate to severe anaemia and its association with length of hospital stay. DESIGN Post hoc analysis of the international observational prospective 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study. PATIENTS AND SETTING The current analysis included adult patients requiring general anaesthesia for non-cardiac surgery. Preoperative anaemia was defined as a haemoglobin concentration of 11 g dl-1 or lower, thus including moderate and severe anaemia according to World Health Organisation criteria. MAIN OUTCOME MEASURES The primary outcome was length of hospital stay. Secondary outcomes included hospital mortality, intra-operative adverse events and postoperative pulmonary complications (PPCs). RESULTS Haemoglobin concentrations were available for 8264 of 9864 patients. Preoperative moderate to severe anaemia was present in 7.7% of patients. Multivariable analysis showed that preoperative moderate to severe anaemia was associated with an increased length of hospital stay with a mean difference of 1.3 ((95% CI 0.8 to 1.8) days; P < .001). In the propensity-matched analysis, this association remained present, median 4.0 [IQR 1.0 to 5.0] vs. 2.0 [IQR 0.0 to 5.0] days, P = .001. Multivariable analysis showed an increased in-hospital mortality (OR 2.9 (95% CI 1.1 to 7.5); P = .029), and higher incidences of intra-operative hypotension (36.3 vs. 25.3%; P < .001) and PPCs (17.1 vs. 10.5%; P = .001) in moderately to severely anaemic patients. However, this was not confirmed in the propensity score-matched analysis. CONCLUSIONS In this international cohort of non-cardiac surgical patients, preoperative moderate to severe anaemia was associated with a longer duration of hospital stay but not increased intra-operative complications, PPCs or in-hospital mortality. TRIAL REGISTRATION The LAS VEGAS study was registered at Clinicaltrials.gov, NCT01601223.
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Affiliation(s)
- Carolien S.E. Bulte
- Department of Anaesthesiology, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Sabrine N.T. Hemmes
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paolo, Brazil
| | - Jan M. Binnekade
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Goran Hedenstierna
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Samir Jaber
- Montpellier University Hospital, Saint Eloi Intensive Care Unit and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gary H. Mills
- Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK
| | - Marcos F. Vidal Melo
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Bostan, MA, USA
| | | | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, ASST Sette Laghi Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Universitá degli Studi di Genova, Genova, Italy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marcus J. Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesia (L·E·I·C·A); Mahidol Oxford Tropical Medicine Research Unit (MORU), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, Mahidol University, Bangkok, Thailand, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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36
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Neto AS, Tomlinson G, Sahetya SK, Ball L, Nichol AD, Hodgson C, Cavalcanti AB, Briel M, de Abreu MG, Pelosi P, Schultz MJ, Goligher EC. Higher PEEP for acute respiratory distress syndrome: a Bayesian meta-analysis of randomised clinical trials. CRIT CARE RESUSC 2021; 23:171-182. [PMID: 38045516 PMCID: PMC10692546 DOI: 10.51893/2021.2.oa4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Benefit or harm of higher positive end expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) is controversial. We aimed to assess the impact of higher levels of PEEP in patients with ARDS under a Bayesian framework. Design: Systematic review and Bayesian meta-analysis of randomised clinical trials comparing higher to lower PEEP in adult patients with ARDS. Data sources: MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from 1996 to 1 March 2020. Review methods: We extracted data from high quality randomised clinical trials comparing higher to lower levels of PEEP in adult patients, using low tidal volume in both arms, and conducted a Bayesian meta-analysis using aggregate data from these studies. Results: Eight clinical trials including 3703 patients (n = 1833 for higher PEEP, n = 1870 for lower PEEP) were included. Under a minimally informative prior, the posterior probability of benefit with higher PEEP was 65% (relative risk, 0.97 [95% credible interval, 0.78-1.14]). In patients with moderate-to- severe ARDS, the posterior probability of benefit with higher PEEP was 77% (relative risk, 0.94 [95% credible interval, 0.77-1.13]). Down-weighting studies that employed a maximum recruitment strategy by 100% increased the posterior probability of benefit to 92% under a minimally informative prior. Conclusions: The probability of benefit or harm from routine use of higher PEEP for patients with ARDS ranges from 27% to 86%, and from 14% to 73% depending on one's prior, suggesting continued uncertainty and equipoise regarding the benefit of PEEP If data from trials using a maximum recruitment strategy is discounted to some extent because of uncertainty over the appropriateness of this approach, the available evidence suggests that higher PEEP could be beneficial for moderate-to-severe ARDS. However, well powered randomised clinical trials are needed to confirm these findings.
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Affiliation(s)
- Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Säo Paulo, Brazil
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Ont, Canada
- Toronto General Hospital Research Institute, University of Toronto, Toronto, Ont, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont, Canada
| | - Sarina K. Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md, USA
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Alistair D. Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | | | - Matthias Briel
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ont, Canada
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Research Unit, Mahidol University, Bangkok, Thailand
| | - Ewan C. Goligher
- Department of Medicine, University Health Network, Toronto, Ont, Canada
- Toronto General Hospital Research Institute, University of Toronto, Toronto, Ont, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ont, Canada
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37
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Valk CMA, Swart P, Boers LS, Botta M, Bos LDJ, de Abreu MG, Hol L, Hollmann MW, Horn J, Martin-Loeches I, Mazzinari G, Myatra SN, Nijbroek SG, Rosenberg NM, Stilma W, Tsonas AM, van der Ven WH, Neto AS, Schultz MJ, Paulus F. Practice of adjunctive treatments in critically ill COVID-19 patients-rational for the multicenter observational PRoAcT-COVID study in The Netherlands. Ann Transl Med 2021; 9:813. [PMID: 34268426 PMCID: PMC8246237 DOI: 10.21037/atm-21-764] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/21/2021] [Indexed: 12/15/2022]
Abstract
Background Patients with coronavirus disease 2019 (COVID-19) may need hospitalization for supplemental oxygen, and some need intensive care unit (ICU) admission for escalation of care. Practice of adjunctive and supportive treatments remain uncertain and may vary widely between countries, within countries between hospitals, and possibly even within ICUs. We aim to investigate practice of adjunctive and supportive treatments, and their associations with outcome, in critically ill COVID-19 patients. Methods The ‘PRactice of Adjunctive Treatments in Intensive Care Unit Patients with Coronavirus Disease 2019’ (PRoAcT-COVID) study is a national, observational study to be undertaken in a large set of ICUs in The Netherlands. The PRoAcT-COVID includes consecutive ICU patients, admitted because of COVID-19 to one of the participating ICUs during a 3-month period. Daily follow-up lasts 28 days. The primary endpoint is a combination of adjunctive treatments, including types of oxygen support, ventilation, rescue therapies for hypoxemia refractory to supplementary oxygen or during invasive ventilation, other adjunctive and supportive treatments, and experimental therapies. We will also collect tracheostomy rate, duration of invasive ventilation and ventilator-free days and alive at day 28 (VFD-28), ICU and hospital length of stay, and the mortality rates in the ICU, hospital and at day 90. Discussion The PRoAcT-COVID study is an observational study combining high density treatment data with relevant clinical outcomes. Information on treatment practices, and their associations with outcomes in COVID-19 patients in highly and urgently needed. The results of the PRoAcT-COVID study will be rapidly available, and circulated through online presentations, such as webinars and electronic conferences, and publications in peer-reviewed journals—findings will also be presented at a dedicated website. At request, and after agreement of the PRoAcT-COVID steering committee, source data will be made available through local, regional and national anonymized datasets. Trial registration The PRoAcT-COVID study is registered at clinicaltrials.gov (study identifier NCT04719182).
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Affiliation(s)
- Christel M A Valk
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Pien Swart
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Leonoor S Boers
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Michela Botta
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Liselotte Hol
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | | | - Guido Mazzinari
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Sheila N Myatra
- Department of Intensive Care, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Sunny G Nijbroek
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Neeltje M Rosenberg
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Willemke Stilma
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Ward H van der Ven
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Data Analytics Research and Evaluation (DARE) Center, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.,ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, The Netherlands
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38
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Mazzinari G, Serpa Neto A, Hemmes SNT, Hedenstierna G, Jaber S, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Pearse RM, Putensen C, Schmid W, Severgnini P, Wrigge H, Cambronero OD, Ball L, de Abreu MG, Pelosi P, Schultz MJ. The Association of Intraoperative driving pressure with postoperative pulmonary complications in open versus closed abdominal surgery patients - a posthoc propensity score-weighted cohort analysis of the LAS VEGAS study. BMC Anesthesiol 2021; 21:84. [PMID: 33740885 PMCID: PMC7977277 DOI: 10.1186/s12871-021-01268-y] [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: 11/12/2020] [Accepted: 01/25/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND It is uncertain whether the association of the intraoperative driving pressure (ΔP) with postoperative pulmonary complications (PPCs) depends on the surgical approach during abdominal surgery. Our primary objective was to determine and compare the association of time-weighted average ΔP (ΔPTW) with PPCs. We also tested the association of ΔPTW with intraoperative adverse events. METHODS Posthoc retrospective propensity score-weighted cohort analysis of patients undergoing open or closed abdominal surgery in the 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study, that included patients in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs. The secondary endpoint was a composite of intraoperative adverse events. RESULTS The analysis included 1128 and 906 patients undergoing open or closed abdominal surgery, respectively. The PPC rate was 5%. ΔP was lower in open abdominal surgery patients, but ΔPTW was not different between groups. The association of ΔPTW with PPCs was significant in both groups and had a higher risk ratio in closed compared to open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], P < 0.001 versus 1.05 [95%CI 1.05 to 1.05], P < 0.001; risk difference 0.05 [95%CI 0.04 to 0.06], P < 0.001). The association of ΔPTW with intraoperative adverse events was also significant in both groups but had higher odds ratio in closed compared to open abdominal surgery patients (1.13 [95%CI 1.12- to 1.14], P < 0.001 versus 1.07 [95%CI 1.05 to 1.10], P < 0.001; risk difference 0.05 [95%CI 0.030.07], P < 0.001). CONCLUSIONS ΔP is associated with PPC and intraoperative adverse events in abdominal surgery, both in open and closed abdominal surgery. TRIAL REGISTRATION LAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223 ).
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Affiliation(s)
- Guido Mazzinari
- grid.84393.350000 0001 0360 9602Research Group in Perioperative Medicine, Hospital Universitario y Politécnico la Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain ,grid.84393.350000 0001 0360 9602Department of Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Ary Serpa Neto
- grid.413562.70000 0001 0385 1941Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil ,grid.11899.380000 0004 1937 0722Cardio-Pulmonary Department, Pulmonary Division, Faculdade de Medicina, Instituto do Coração, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil ,grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Sabrine N. T. Hemmes
- grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Goran Hedenstierna
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Samir Jaber
- grid.121334.60000 0001 2097 0141PhyMedExp, INSERM U1046, CNRS UMR 9214, University of Montpellier, Montpellier, France
| | - Michael Hiesmayr
- grid.22937.3d0000 0000 9259 8492Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Markus W. Hollmann
- grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Gary H. Mills
- grid.11835.3e0000 0004 1936 9262Operating Services, Critical Care and Anesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK
| | - Marcos F. Vidal Melo
- grid.32224.350000 0004 0386 9924Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Rupert M. Pearse
- grid.4868.20000 0001 2171 1133Queen Mary University of London, London, UK
| | - Christian Putensen
- grid.15090.3d0000 0000 8786 803XDepartment of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- grid.22937.3d0000 0000 9259 8492Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- grid.18147.3b0000000121724807Department of Biotechnology and Sciences of Life, ASST- Settelaghi Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
| | - Oscar Diaz Cambronero
- grid.84393.350000 0001 0360 9602Research Group in Perioperative Medicine, Hospital Universitario y Politécnico la Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain ,grid.84393.350000 0001 0360 9602Department of Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Lorenzo Ball
- Policlinico San Martino Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa Italy, Genoa, Italy
| | - Marcelo Gama de Abreu
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Policlinico San Martino Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa Italy, Genoa, Italy
| | - Marcus J. Schultz
- grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands ,grid.10223.320000 0004 1937 0490Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand ,grid.4991.50000 0004 1936 8948Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Pisani L, Algera AG, Serpa Neto A, Ahsan A, Beane A, Chittawatanarat K, Faiz A, Haniffa R, Hashemian SM, Hashmi M, Imad HA, Indraratna K, Iyer S, Kayastha G, Krishna B, Ling TL, Moosa H, Nadjm B, Pattnaik R, Sampath S, Thwaites L, Tun NN, Mohd Yunos N, Grasso S, Paulus F, Gama de Abreu M, Pelosi P, Day N, White N, Dondorp AM, Schultz MJ, For The PRoVENT-iMiC Investigators Moru And The Prove Network, Adhikari A, Akaraborworn O, Akhtar A, Alam AKMS, Ali SM, Arumoli J, Asaduzzaman M, Azauddin SNS, Banik D, Bhuiyan SR, Bhurayanontachai R, Chatmongkolchart S, Das S, Das SS, De Silva K, Dilhani YAH, Dissanayake L, Dongre A, Dorasamy D, Duong Bich T, Dutta ML, Edirisooriya M, Farooq A, Fernando M, Gunaratne A, Hamid T, Hanif S, Hasan MS, Hayat M, Hossain M, Hussain T, Idrees F, Jamaluddin MFH, Joseph S, Juntaping K, Kamal S, Karmaker P, Kasi CK, Kassim M, Khaskheli S, Khatoon SN, Khoundabi B, Kongpolprom N, Kudavidanage B, Lam Mihn Y, Malekmohammad M, Mat Nor MB, Mathanalagan S, Memon I, Mithraratne N, Mobasher M, Mondol MK, Mostafa Kamal AH, Nath RK, Navasakulpong A, Nazneed S, Nguyen Thi Thanh H, Nguyen Van K, Nooraei N, Othman Jailani MI, Pangeni R, Petnak T, Pilimatalawwe C, Pinto V, Piriyapatsom A, Pornsuriyasak P, Qadeer A, Raessi Estabragh R, Rahman Chowdhury MA, Ranatunge K, Rehman AU, Reza ST, Roy S, Roy P, Rungruanghiranya S, Salim M, Samaranayake U, Samarasinghe L, Sarkar SA, Shah J, Sigera C, Silachamroon U, Singhatas P, Sultana R, Surasit K, Taher SM, Tai LL, Tajarernmuang P, Tangsujaritvijit V, Taohid TM, Taqi A, Thilakasiri K, Thungtitigul P, Trongtrakul K, Vaas M, Voon CM, Vu Quoc D, Zarudin N. Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study. Am J Trop Med Hyg 2021; 104:1022-1033. [PMID: 33432906 PMCID: PMC7941813 DOI: 10.4269/ajtmh.20-1177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 09/10/2020] [Accepted: 11/22/2020] [Indexed: 01/05/2023] Open
Abstract
Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [V T] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median V T was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8-8.9], 8.0 [6.8-9.2], and 7.0 [5.8-8.4] mL/kg Predicted body weight; P = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5-7], five [5-8], and 10 [5-12] cmH2O; P < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66-71) and 7% (95% CI: 6-8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; P = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; P < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (ROC AUC of 0.62, 95% CI: 0.54-0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of V T is globally in line with current recommendations.
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Affiliation(s)
- Luigi Pisani
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Areef Ahsan
- Department of Critical Care, BIRDEM General Hospital, Dhaka, Bangladesh
| | - Abigail Beane
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Abul Faiz
- Dev Care Foundation, Dhaka, Bangladesh.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Rashan Haniffa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Seyed MohammadReza Hashemian
- Chronic Respiratory Diseases Research Center (CRDRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Hisham Ahmed Imad
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kanishka Indraratna
- Department of Anaesthesia and Intensive Care, Sri Jayewardenepura General Hospital, Colombo, Sri Lanka
| | - Shivakumar Iyer
- Department of Medicine, Bharati Vidyapeeth Medical College, Pune, India
| | - Gyan Kayastha
- Department of Internal Medicine, Patan Academy of Health Science, Kathmandu, Nepal
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St. John's Medical College, Bangalore, India
| | - Tai Li Ling
- Department of Anaesthesia and Intensive Care, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Hassan Moosa
- Department of Intensive Care, Indira Gandhi Memorial Hospital, Malé, Maldives
| | - Behzad Nadjm
- National Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Hanoi, Vietnam
| | | | - Sriram Sampath
- Department of Critical Care Medicine, St. John's Medical College, Bangalore, India
| | - Louise Thwaites
- Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ni Ni Tun
- Medical Action Myanmar, Naypyidaw, Myanmar
| | - Nor'azim Mohd Yunos
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Johor Bahru, Malaysia
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital - IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Nick Day
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nick White
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A) Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Mazzinari G, Diaz-Cambronero O, Serpa Neto A, Martínez AC, Rovira L, Argente Navarro MP, Malbrain MLNG, Pelosi P, Gama de Abreu M, Hollmann MW, Schultz MJ. Modeling intra-abdominal volume and respiratory driving pressure during pneumoperitoneum insufflation-a patient-level data meta-analysis. J Appl Physiol (1985) 2020; 130:721-728. [PMID: 33357006 DOI: 10.1152/japplphysiol.00814.2020] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
During pneumoperitoneum, intra-abdominal pressure (IAP) is usually kept at 12-14 mmHg. There is no clinical benefit in IAP increments if they do not increase intra-abdominal volume IAV. We aimed to estimate IAV (ΔIAV) and respiratory driving pressure changes (ΔPRS) in relation to changes in IAP (ΔIAP). We carried out a patient-level meta-analysis of 204 adult patients with available data on IAV and ΔPRS during pneumoperitoneum from three trials assessing the effect of IAP on postoperative recovery and airway pressure during laparoscopic surgery under general anesthesia. The primary endpoint was ΔIAV, and the secondary endpoint was ΔPRS. The endpoints' response to ΔIAP was modeled using mixed multivariable Bayesian regression to estimate which mathematical function best fitted it. IAP values on the pressure-volume (PV) curve where the endpoint rate of change according to IAP decreased were identified. Abdomino-thoracic transmission (ATT) rate, that is, the rate ΔPRS change to ΔIAP was also estimated. The best-fitting function was sigmoid logistic and linear for IAV and ΔPRS response, respectively. Increments in IAV reached a plateau at 6.0 [95%CI 5.9-6.2] L. ΔIAV for each ΔIAP decreased at IAP ranging from 9.8 [95%CI 9.7-9.9] to 12.2 [12.0-12.3] mmHg. ATT rate was 0.65 [95%CI 0.62-0.68]. One mmHg of IAP raised ΔPRS 0.88 cmH2O. During pneumoperitoneum, IAP has a nonlinear relationship with IAV and a linear one with ΔPRS. IAP should be set below the point where IAV gains diminish.NEW & NOTEWORTHY We found that intra-abdominal volume changes related to intra-abdominal pressure increase reached a plateau with diminishing gains in commonly used pneumoperitoneum pressure ranges. We also found a linear relationship between intra-abdominal pressure and respiratory driving pressure, a known marker of postoperative pulmonary complications.
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Affiliation(s)
- Guido Mazzinari
- Research Group in Perioperative Medicine, Hospital Universitario y Politécnico la Fe, Valencia, Spain.,Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Oscar Diaz-Cambronero
- Research Group in Perioperative Medicine, Hospital Universitario y Politécnico la Fe, Valencia, Spain.,Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain.,Spanish Clinical Research Network (SCReN), SCReN-IIS La Fe, Madrid, Spain
| | - Ary Serpa Neto
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Center, location "AMC." Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Pulmonary Division, Cardio-Pulmonary Department, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Antonio Cañada Martínez
- Data Science, Biostatistics and Bioinformatics Unit, Instituto de Investigacion Sanitaria la Fe, Valencia, Spain
| | - Lucas Rovira
- Department of Anaesthesiology, Consorcio Hospital General Universitario, Valencia, Spain
| | - María Pilar Argente Navarro
- Research Group in Perioperative Medicine, Hospital Universitario y Politécnico la Fe, Valencia, Spain.,Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Manu L N G Malbrain
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), Brussels, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium.,International Fluid Academy, Lovenjoel, Belgium
| | - Paolo Pelosi
- San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, Technische Universität Dresden, Dresden, Germany.,Outcomes Research Consortium, Cleveland, Ohio
| | - Markus W Hollmann
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Center, location "AMC." Amsterdam, The Netherlands.,Department of Anaesthesiology, Amsterdam University Medical Center, location "AMC," Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Center, location "AMC." Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Algera AG, Pisani L, Serpa Neto A, den Boer SS, Bosch FFH, Bruin K, Klooster PM, Van der Meer NJM, Nowitzky RO, Purmer IM, Slabbekoorn M, Spronk PE, van Vliet J, Weenink JJ, Gama de Abreu M, Pelosi P, Schultz MJ, Paulus F. Effect of a Lower vs Higher Positive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial. JAMA 2020; 324:2509-2520. [PMID: 33295981 PMCID: PMC7726701 DOI: 10.1001/jama.2020.23517] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE It is uncertain whether invasive ventilation can use lower positive end-expiratory pressure (PEEP) in critically ill patients without acute respiratory distress syndrome (ARDS). OBJECTIVE To determine whether a lower PEEP strategy is noninferior to a higher PEEP strategy regarding duration of mechanical ventilation at 28 days. DESIGN, SETTING, AND PARTICIPANTS Noninferiority randomized clinical trial conducted from October 26, 2017, through December 17, 2019, in 8 intensive care units (ICUs) in the Netherlands among 980 patients without ARDS expected not to be extubated within 24 hours after start of ventilation. Final follow-up was conducted in March 2020. INTERVENTIONS Participants were randomized to receive invasive ventilation using either lower PEEP, consisting of the lowest PEEP level between 0 and 5 cm H2O (n = 476), or higher PEEP, consisting of a PEEP level of 8 cm H2O (n = 493). MAIN OUTCOMES AND MEASURES The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for the difference in ventilator-free days at day 28 of -10%. Secondary outcomes included ICU and hospital lengths of stay; ICU, hospital, and 28- and 90-day mortality; development of ARDS, pneumonia, pneumothorax, severe atelectasis, severe hypoxemia, or need for rescue therapies for hypoxemia; and days with use of vasopressors or sedation. RESULTS Among 980 patients who were randomized, 969 (99%) completed the trial (median age, 66 [interquartile range {IQR}, 56-74] years; 246 [36%] women). At day 28, 476 patients in the lower PEEP group had a median of 18 ventilator-free days (IQR, 0-27 days) and 493 patients in the higher PEEP group had a median of 17 ventilator-free days (IQR, 0-27 days) (mean ratio, 1.04; 95% CI, 0.95-∞; P = .007 for noninferiority), and the lower boundary of the 95% CI was within the noninferiority margin. Occurrence of severe hypoxemia was 20.6% vs 17.6% (risk ratio, 1.17; 95% CI, 0.90-1.51; P = .99) and need for rescue strategy was 19.7% vs 14.6% (risk ratio, 1.35; 95% CI, 1.02-1.79; adjusted P = .54) in patients in the lower and higher PEEP groups, respectively. Mortality at 28 days was 38.4% vs 42.0% (hazard ratio, 0.89; 95% CI, 0.73-1.09; P = .99) in patients in the lower and higher PEEP groups, respectively. There were no statistically significant differences in other secondary outcomes. CONCLUSIONS AND RELEVANCE Among patients in the ICU without ARDS who were expected not to be extubated within 24 hours, a lower PEEP strategy was noninferior to a higher PEEP strategy with regard to the number of ventilator-free days at day 28. These findings support the use of lower PEEP in patients without ARDS. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03167580.
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Affiliation(s)
| | - Anna Geke Algera
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Luigi Pisani
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Sylvia S den Boer
- Department of Intensive Care, Spaarne Gasthuis, Haarlem and Hoofddorp, the Netherlands
| | - Frank F H Bosch
- Department of Intensive Care, Rijnstate Hospital, Arnhem, the Netherlands
| | - Karina Bruin
- Department of Intensive Care, Westfriesgasthuis, Hoorn, the Netherlands
| | | | | | - Ralph O Nowitzky
- Department of Intensive Care, Haga Hospital, the Hague, the Netherlands
| | - Ilse M Purmer
- Department of Intensive Care, Haga Hospital, the Hague, the Netherlands
| | | | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Jan van Vliet
- Department of Intensive Care, Rijnstate Hospital, Arnhem, the Netherlands
| | - Jan J Weenink
- Department of Intensive Care, Spaarne Gasthuis, Haarlem and Hoofddorp, the Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
- Nuffield Department of Medicine, Oxford University, Oxford, England
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Frederique Paulus
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
- ACHIEVE Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
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Scharffenberg M, Wittenstein J, Herzog M, Tauer S, Vivona L, Theilen R, Bluth T, Kiss T, Koch T, Fiorentino G, de Abreu MG, Huhle R. Continuous external negative pressure improves oxygenation and respiratory mechanics in Experimental Lung Injury in Pigs - A pilot proof-of-concept trial. Intensive Care Med Exp 2020; 8:49. [PMID: 33336263 PMCID: PMC7746426 DOI: 10.1186/s40635-020-00315-1] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous external negative pressure (CENP) during positive pressure ventilation can recruit dependent lung regions. We hypothesised that CENP applied regionally to the thorax or the abdomen only, increases the caudal end-expiratory transpulmonary pressure depending on positive end-expiratory pressure (PEEP) in lung-injured pigs. Eight pigs were anesthetised and mechanically ventilated in the supine position. Pressure sensors were placed in the left pleural space, and a lung injury was induced by saline lung lavages. A CENP shell was placed at the abdomen and thorax (randomised order), and animals were ventilated with PEEP 15, 7 and zero cmH2O (15 min each). On each PEEP level, CENP of - 40, - 30, - 20, - 10 and 0 cmH2O was applied (3 min each). Respiratory and haemodynamic variables were recorded. Electrical impedance tomography allowed assessment of centre of ventilation. RESULTS Compared to positive pressure ventilation alone, the caudal transpulmonary pressure was significantly increased by CENP of ≤ 20 cmH2O at all PEEP levels. CENP of - 20 cmH2O reduced the mean airway pressure at zero PEEP (P = 0.025). The driving pressure decreased at CENP of ≤ 10 at PEEP of 0 and 7 cmH2O (P < 0.001 each) but increased at CENP of - 30 cmH2O during the highest PEEP (P = 0.001). CENP of - 30 cmH2O reduced the mechanical power during zero PEEP (P < 0.001). Both elastance (P < 0.001) and resistance (P < 0.001) were decreased at CENP ≤ 30 at PEEP of 0 and 7 cmH2O. Oxygenation increased at CENP of ≤ 20 at PEEP of 0 and 7 cmH2O (P < 0.001 each). Applying external negative pressure significantly shifted the centre of aeration towards dorsal lung regions irrespectively of the PEEP level. Cardiac output decreased significantly at CENP -20 cmH2O at all PEEP levels (P < 0.001). Effects on caudal transpulmonary pressure, elastance and cardiac output were more pronounced when CENP was applied to the abdomen compared with the thorax. CONCLUSIONS In this lung injury model in pigs, CENP increased the end-expiratory caudal transpulmonary pressure. This lead to a shift of lung aeration towards dependent zones as well as improved respiratory mechanics and oxygenation, especially when CENP was applied to the abdomen as compared to the thorax. CENP values ≤ 20 cmH2O impaired the haemodynamics.
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Affiliation(s)
- Martin Scharffenberg
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jakob Wittenstein
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Moritz Herzog
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sebastian Tauer
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Luigi Vivona
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milano, Italia
| | - Raphael Theilen
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thomas Bluth
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thomas Kiss
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thea Koch
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | | | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Robert Huhle
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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Ball L, Serpa Neto A, Trifiletti V, Mandelli M, Firpo I, Robba C, Gama de Abreu M, Schultz MJ, Patroniti N, Rocco PRM, Pelosi P. Effects of higher PEEP and recruitment manoeuvres on mortality in patients with ARDS: a systematic review, meta-analysis, meta-regression and trial sequential analysis of randomized controlled trials. Intensive Care Med Exp 2020; 8:39. [PMID: 33336325 PMCID: PMC7746429 DOI: 10.1186/s40635-020-00322-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose In patients with acute respiratory distress syndrome (ARDS), lung recruitment could be maximised with the use of recruitment manoeuvres (RM) or applying a positive end-expiratory pressure (PEEP) higher than what is necessary to maintain minimal adequate oxygenation. We aimed to determine whether ventilation strategies using higher PEEP and/or RMs could decrease mortality in patients with ARDS. Methods We searched MEDLINE, EMBASE and CENTRAL from 1996 to December 2019, included randomized controlled trials comparing ventilation with higher PEEP and/or RMs to strategies with lower PEEP and no RMs in patients with ARDS. We computed pooled estimates with a DerSimonian-Laird mixed-effects model, assessing mortality and incidence of barotrauma, population characteristics, physiologic variables and ventilator settings. We performed a trial sequential analysis (TSA) and a meta-regression. Results Excluding two studies that used tidal volume (VT) reduction as co-intervention, we included 3870 patients from 10 trials using higher PEEP alone (n = 3), combined with RMs (n = 6) or RMs alone (n = 1). We did not observe differences in mortality (relative risk, RR 0.96, 95% confidence interval, CI [0.84–1.09], p = 0.50) nor in incidence of barotrauma (RR 1.22, 95% CI [0.93–1.61], p = 0.16). In the meta-regression, the PEEP difference between intervention and control group at day 1 and the use of RMs were not associated with increased risk of barotrauma. The TSA reached the required information size for mortality (n = 2928), and the z-line surpassed the futility boundary. Conclusions At low VT, the routine use of higher PEEP and/or RMs did not reduce mortality in unselected patients with ARDS. Trial registration PROSPERO CRD42017082035.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy. .,Anesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy. .,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
| | - Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Valeria Trifiletti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy
| | - Maura Mandelli
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy
| | - Iacopo Firpo
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicolò Patroniti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo Rosanna Benzi 8, 16131, Genova, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy
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Wittenstein J, Scharffenberg M, Ran X, Keller D, Michler P, Tauer S, Theilen R, Kiss T, Bluth T, Koch T, Gama de Abreu M, Huhle R. Comparative effects of flow vs. volume-controlled one-lung ventilation on gas exchange and respiratory system mechanics in pigs. Intensive Care Med Exp 2020; 8:24. [PMID: 33336305 PMCID: PMC7746431 DOI: 10.1186/s40635-020-00308-0] [Citation(s) in RCA: 8] [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: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 01/23/2023] Open
Abstract
Background Flow-controlled ventilation (FCV) allows expiratory flow control, reducing the collapse of the airways during expiration. The performance of FCV during one-lung ventilation (OLV) under intravascular normo- and hypovolaemia is currently unknown. In this explorative study, we hypothesised that OLV with FCV improves PaO2 and reduces mechanical power compared to volume-controlled ventilation (VCV). Sixteen juvenile pigs were randomly assigned to one of two groups: (1) intravascular normovolaemia (n = 8) and (2) intravascular hypovolaemia (n = 8). To mimic inflammation due to major thoracic surgery, a thoracotomy was performed, and 0.5 μg/kg/h lipopolysaccharides from Escherichia coli continuously administered intravenously. Animals were randomly assigned to OLV with one of two sequences (60 min per mode): (1) VCV–FCV or (2) FCV–VCV. Variables of gas exchange, haemodynamics and respiratory signals were collected 20, 40 and 60 min after initiation of OLV with each mechanical ventilation mode. The distribution of ventilation was determined using electrical impedance tomography (EIT). Results Oxygenation did not differ significantly between modes (P = 0.881). In the normovolaemia group, the corrected expired minute volume (P = 0.022) and positive end-expiratory pressure (PEEP) were lower during FCV than VCV. The minute volume (P ≤ 0.001), respiratory rate (P ≤ 0.001), total PEEP (P ≤ 0.001), resistance of the respiratory system (P ≤ 0.001), mechanical power (P ≤ 0.001) and resistive mechanical power (P ≤ 0.001) were lower during FCV than VCV irrespective of the volaemia status. The distribution of ventilation did not differ between both ventilation modes (P = 0.103). Conclusions In a model of OLV in normo- and hypovolemic pigs, mechanical power was lower during FCV compared to VCV, without significant differences in oxygenation. Furthermore, the efficacy of ventilation was higher during FCV compared to VCV during normovolaemia.
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Affiliation(s)
- Jakob Wittenstein
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Martin Scharffenberg
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Xi Ran
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Diana Keller
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Pia Michler
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sebastian Tauer
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Raphael Theilen
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thomas Kiss
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thomas Bluth
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thea Koch
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Robert Huhle
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Schmal M, Haueisen J, Männel G, Rostalski P, Kircher M, Bluth T, Gama de Abreu M, Stender B. Robust predictive control for respiratory CO 2 gas removal in closed-loop mechanical ventilation: An in-silico study. Current Directions in Biomedical Engineering 2020. [DOI: 10.1515/cdbme-2020-3080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
In this study a physiological closed-loop system for arterial CO2 partial pressure control was designed and comprehensively tested using a set of models of the respiratory CO2 gas exchange. The underlying preclinical data were collected from 12 pigs in presence of severe changes in hemodynamic and pulmonary condition. A minimally complex nonlinear state space model of CO2 gas exchange was identified post hoc in different lung conditions. The control variable was measured noninvasively using the endtidal CO2 partial pressure. For the simulation study the output signal of the controller was defined as the alveolar minute volume set value of an underlying adaptive lung protective ventilation mode. A linearisation of the two-compartment CO2 gas exchange model was used for the design of a model predictive controller (MPC). It was augmented by a tube based controller suppressing prediction errors due to model uncertainties. The controller was subject to comparative testing in interaction with each of the CO2 gas exchange models previously identified on the preclinical study data. The performance was evaluated for the system response towards the following five tests in comparison to a PID controller: recruitment maneuver, PEEP titration maneuver, stepwise change in the CO2 production, breath-hold maneuver and a step in the reference signal. A root mean square error of 2.69 mmHg between arterial CO2 partial pressure and the reference signal was achieved throughout the trial. The reference-variable response of the model predictive controller was superior regarding overshoot and settling time.
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Affiliation(s)
- Matthias Schmal
- Institute of Biomedical Engineering and Informatics, Technical University Ilmenau, Gustav-Kirchhoff Str. 2, Ilmenau , Germany
| | - Jens Haueisen
- Institute of Biomedical Engineering and Informatics, Technical University Ilmenau, Gustav-Kirchhoff Str. 2, Ilmenau , Germany
| | - Georg Männel
- Institute for Electrical Engineering in Medicine, Universität zu Lübeck, Lübeck , Germany
| | - Philipp Rostalski
- Institute for Electrical Engineering in Medicine, Universität zu Lübeck, Lübeck , Germany
| | - Michael Kircher
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe , Germany
| | - Thomas Bluth
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden , Germany
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden , Germany
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Wittenstein J, Scharffenberg M, Braune A, Huhle R, Bluth T, Herzog M, Güldner A, Ball L, Simonassi F, Zeidler-Rentzsch I, Vidal Melo MF, Koch T, Rocco PR, Pelosi P, Kotzerke J, Gama de Abreu M, Kiss T. Effects of variable versus non-variable controlled mechanical ventilation: response to comment on Br J Anaesth 2020; 124: 430–9. Br J Anaesth 2020; 124:e224-e225. [DOI: 10.1016/j.bja.2020.03.004] [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] [Received: 03/01/2020] [Accepted: 03/05/2020] [Indexed: 11/30/2022] Open
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Gama de Abreu M, Schultz MJ, Pelosi P. Atelectasis during general anaesthesia for surgery: should we treat atelectasis or the patient? Br J Anaesth 2020; 124:662-664. [DOI: 10.1016/j.bja.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 10/24/2022] Open
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Robba C, Hemmes SNT, Serpa Neto A, Bluth T, Canet J, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Putensen C, Jaber S, Schmid W, Severgnini P, Wrigge H, Battaglini D, Ball L, Gama de Abreu M, Schultz MJ, Pelosi P. Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study. BMC Anesthesiol 2020; 20:73. [PMID: 32241266 PMCID: PMC7114790 DOI: 10.1186/s12871-020-00988-x] [Citation(s) in RCA: 4] [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: 02/07/2020] [Accepted: 03/20/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. METHODS Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. RESULTS Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (VT) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH20. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. CONCLUSIONS Neurosurgical patients are ventilated with low VT and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs.
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Affiliation(s)
- Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.
| | - Sabrine N T Hemmes
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Department of Anaesthesiology, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary engineering group, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany
| | - Jaume Canet
- Department of Anaesthesiology and Postoperative Care, Hospital Universitari Germans Trials I Pujol, Barcelona, Spain
| | - Michael Hiesmayr
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - M Wiersma Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands
| | - Gary H Mills
- Operating Services, Critical Care and Anaesthesia, Sheffield Teaching Hospitals and University of Sheffield, Sheffield, UK
| | - Marcos F Vidal Melo
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachussetts General Hospital, Boston, MA, USA
| | - Christian Putensen
- Department of Anesthesiology and Intenisve Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Samir Jaber
- Department of Anaesthesia and Intensive Care, Saint Eloi Montpellier University Hospital, and PhyMedExp, University of Montpellier, Montpellier, France
| | - Werner Schmid
- Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnology and Sciences of Life, ASST-Setteleghi Ospedale di circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Denise Battaglini
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary engineering group, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location 'AMC', Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi 8, 16131, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Wittenstein J, Scharffenberg M, Braune A, Huhle R, Bluth T, Herzog M, Güldner A, Ball L, Simonassi F, Zeidler-Rentzsch I, Vidal Melo MF, Koch T, Rocco PRM, Pelosi P, Kotzerke J, Gama de Abreu M, Kiss T. Effects of variable versus nonvariable controlled mechanical ventilation on pulmonary inflammation in experimental acute respiratory distress syndrome in pigs. Br J Anaesth 2020; 124:430-439. [PMID: 32033744 PMCID: PMC8016484 DOI: 10.1016/j.bja.2019.12.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 09/30/2019] [Revised: 12/18/2019] [Accepted: 12/23/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Mechanical ventilation with variable tidal volumes (VT) may improve lung function and reduce ventilator-induced lung injury in experimental acute respiratory distress syndrome (ARDS). However, previous investigations were limited to less than 6 h, and control groups did not follow clinical standards. We hypothesised that 24 h of mechanical ventilation with variable VT reduces pulmonary inflammation (as reflected by neutrophil infiltration), compared with standard protective, nonvariable ventilation. METHODS Experimental ARDS was induced in 14 anaesthetised pigs with saline lung lavage followed by injurious mechanical ventilation. Pigs (n=7 per group) were randomly assigned to using variable VT or nonvariable VT modes of mechanical ventilation for 24 h. In both groups, ventilator settings including positive end-expiratory pressure and oxygen inspiratory fraction were adjusted according to the ARDS Network protocol. Pulmonary inflammation (primary endpoint) and perfusion were assessed by positron emission tomography using 2-deoxy-2-[18F]fluoro-d-glucose and 68Gallium (68Ga)-labelled microspheres, respectively. Gas exchange, respiratory mechanics, and haemodynamics were quantified. Lung aeration was determined using CT. RESULTS The specific global uptake rate of 18F-FDG increased to a similar extent regardless of mode of mechanical ventilation (median uptake for variable VT=0.016 min-1 [inter-quartile range, 0.012-0.029] compared with median uptake for nonvariable VT=0.037 min-1 [0.008-0.053]; P=0.406). Gas exchange, respiratory mechanics, haemodynamics, and lung aeration and perfusion were similar in both variable and nonvariable VT ventilatory modes. CONCLUSION In a porcine model of ARDS, 24 h of mechanical ventilation with variable VT did not attenuate pulmonary inflammation compared with standard protective mechanical ventilation with nonvariable VT.
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Affiliation(s)
- Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anja Braune
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thomas Bluth
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Moritz Herzog
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Francesca Simonassi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Ines Zeidler-Rentzsch
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Department of Orthodontics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcos F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Thea Koch
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Jörg Kotzerke
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Pinto EF, Santos RS, Antunes MA, Maia LA, Padilha GA, de A Machado J, Carvalho ACF, Fernandes MVS, Capelozzi VL, de Abreu MG, Pelosi P, Rocco PRM, Silva PL. Static and Dynamic Transpulmonary Driving Pressures Affect Lung and Diaphragm Injury during Pressure-controlled versus Pressure-support Ventilation in Experimental Mild Lung Injury in Rats. Anesthesiology 2020; 132:307-320. [PMID: 31939846 DOI: 10.1097/aln.0000000000003060] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 01/20/2023]
Abstract
BACKGROUND Pressure-support ventilation may worsen lung damage due to increased dynamic transpulmonary driving pressure. The authors hypothesized that, at the same tidal volume (VT) and dynamic transpulmonary driving pressure, pressure-support and pressure-controlled ventilation would yield comparable lung damage in mild lung injury. METHODS Male Wistar rats received endotoxin intratracheally and, after 24 h, were ventilated in pressure-support mode. Rats were then randomized to 2 h of pressure-controlled ventilation with VT, dynamic transpulmonary driving pressure, dynamic transpulmonary driving pressure, and inspiratory time similar to those of pressure-support ventilation. The primary outcome was the difference in dynamic transpulmonary driving pressure between pressure-support and pressure-controlled ventilation at similar VT; secondary outcomes were lung and diaphragm damage. RESULTS At VT = 6 ml/kg, dynamic transpulmonary driving pressure was higher in pressure-support than pressure-controlled ventilation (12.0 ± 2.2 vs. 8.0 ± 1.8 cm H2O), whereas static transpulmonary driving pressure did not differ (6.7 ± 0.6 vs. 7.0 ± 0.3 cm H2O). Diffuse alveolar damage score and gene expression of markers associated with lung inflammation (interleukin-6), alveolar-stretch (amphiregulin), epithelial cell damage (club cell protein 16), and fibrogenesis (metalloproteinase-9 and type III procollagen), as well as diaphragm inflammation (tumor necrosis factor-α) and proteolysis (muscle RING-finger-1) were comparable between groups. At similar dynamic transpulmonary driving pressure, as well as dynamic transpulmonary driving pressure and inspiratory time, pressure-controlled ventilation increased VT, static transpulmonary driving pressure, diffuse alveolar damage score, and gene expression of markers of lung inflammation, alveolar stretch, fibrogenesis, diaphragm inflammation, and proteolysis compared to pressure-support ventilation. CONCLUSIONS In the mild lung injury model use herein, at the same VT, pressure-support compared to pressure-controlled ventilation did not affect biologic markers. However, pressure-support ventilation was associated with a major difference between static and dynamic transpulmonary driving pressure; when the same dynamic transpulmonary driving pressure and inspiratory time were used for pressure-controlled ventilation, greater lung and diaphragm injury occurred compared to pressure-support ventilation.
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Affiliation(s)
- Eliete F Pinto
- From the Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil (E.F.P., R.S.S., M.A.A., L.A.M., G.A.P., J.D.A.M., A.C.F.C., M.V.S.F., P.R.M.R., P.L.S.) Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil (V.L.C.) Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany (M.G.D.A.) Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Genoa, Italy (P.P.) Institute of Admission and Care of a Scientific Nature, San Martino Policlinico Hospital, Genoa, Italy (P.P.)
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