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Pavlovsky B, Desprez C, Richard JC, Fage N, Lesimple A, Chean D, Courtais A, Mauri T, Mercat A, Beloncle F. Bedside personalized methods based on electrical impedance tomography or respiratory mechanics to set PEEP in ARDS and recruitment-to-inflation ratio: a physiologic study. Ann Intensive Care 2024; 14:1. [PMID: 38180544 PMCID: PMC10769993 DOI: 10.1186/s13613-023-01228-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Various Positive End-Expiratory Pressure (PEEP) titration strategies have been proposed to optimize ventilation in patients with acute respiratory distress syndrome (ARDS). We aimed to compare PEEP titration strategies based on electrical impedance tomography (EIT) to methods derived from respiratory system mechanics with or without esophageal pressure measurements, in terms of PEEP levels and association with recruitability. METHODS Nineteen patients with ARDS were enrolled. Recruitability was assessed by the estimated Recruitment-to-Inflation ratio (R/Iest) between PEEP 15 and 5 cmH2O. Then, a decremental PEEP trial from PEEP 20 to 5 cmH2O was performed. PEEP levels determined by the following strategies were studied: (1) plateau pressure 28-30 cmH2O (Express), (2) minimal positive expiratory transpulmonary pressure (Positive PLe), (3) center of ventilation closest to 0.5 (CoV) and (4) intersection of the EIT-based overdistension and lung collapse curves (Crossing Point). In addition, the PEEP levels determined by the Crossing Point strategy were assessed using different PEEP ranges during the decremental PEEP trial. RESULTS Express and CoV strategies led to higher PEEP levels than the Positive PLe and Crossing Point ones (17 [14-17], 20 [17-20], 8 [5-11], 10 [8-11] respectively, p < 0.001). For each strategy, there was no significant association between the optimal PEEP level and R/Iest (Crossing Point: r2 = 0.073, p = 0.263; CoV: r2 < 0.001, p = 0.941; Express: r2 < 0.001, p = 0.920; Positive PLe: r2 = 0.037, p = 0.461). The PEEP level obtained with the Crossing Point strategy was impacted by the PEEP range used during the decremental PEEP trial. CONCLUSIONS CoV and Express strategies led to higher PEEP levels than the Crossing Point and Positive PLe strategies. Optimal PEEP levels proposed by these four methods were not associated with recruitability. Recruitability should be specifically assessed in ARDS patients to optimize PEEP titration.
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Affiliation(s)
- Bertrand Pavlovsky
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France.
| | - Christophe Desprez
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Nicolas Fage
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Arnaud Lesimple
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Dara Chean
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Antonin Courtais
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research, Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alain Mercat
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - François Beloncle
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
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Silva PL, Scharffenberg M, Rocco PRM. Understanding the mechanisms of ventilator-induced lung injury using animal models. Intensive Care Med Exp 2023; 11:82. [PMID: 38010595 PMCID: PMC10682329 DOI: 10.1186/s40635-023-00569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Abstract
Mechanical ventilation is a life-saving therapy in several clinical situations, promoting gas exchange and providing rest to the respiratory muscles. However, mechanical ventilation may cause hemodynamic instability and pulmonary structural damage, which is known as ventilator-induced lung injury (VILI). The four main injury mechanisms associated with VILI are as follows: barotrauma/volutrauma caused by overstretching the lung tissues; atelectrauma, caused by repeated opening and closing of the alveoli resulting in shear stress; and biotrauma, the resulting biological response to tissue damage, which leads to lung and multi-organ failure. This narrative review elucidates the mechanisms underlying the pathogenesis, progression, and resolution of VILI and discusses the strategies that can mitigate VILI. Different static variables (peak, plateau, and driving pressures, positive end-expiratory pressure, and tidal volume) and dynamic variables (respiratory rate, airflow amplitude, and inspiratory time fraction) can contribute to VILI. Moreover, the potential for lung injury depends on tissue vulnerability, mechanical power (energy applied per unit of time), and the duration of that exposure. According to the current evidence based on models of acute respiratory distress syndrome and VILI, the following strategies are proposed to provide lung protection: keep the lungs partially collapsed (SaO2 > 88%), avoid opening and closing of collapsed alveoli, and gently ventilate aerated regions while keeping collapsed and consolidated areas at rest. Additional mechanisms, such as subject-ventilator asynchrony, cumulative power, and intensity, as well as the damaging threshold (stress-strain level at which tidal damage is initiated), are under experimental investigation and may enhance the understanding of VILI.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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He H, Chi Y, Long Y, Yuan S, Frerichs I, Möller K, Fu F, Zhao Z. Influence of overdistension/recruitment induced by high positive end-expiratory pressure on ventilation-perfusion matching assessed by electrical impedance tomography with saline bolus. Crit Care 2020; 24:586. [PMID: 32993811 PMCID: PMC7523261 DOI: 10.1186/s13054-020-03301-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND High positive end-expiratory pressures (PEEP) may induce overdistension/recruitment and affect ventilation-perfusion matching (VQMatch) in mechanically ventilated patients. This study aimed to investigate the association between PEEP-induced lung overdistension/recruitment and VQMatch by electrical impedance tomography (EIT). METHODS The study was conducted prospectively on 30 adult mechanically ventilated patients: 18/30 with ARDS and 12/30 with high risk for ARDS. EIT measurements were performed at zero end-expiratory pressures (ZEEP) and subsequently at high (12-15 cmH2O) PEEP. The number of overdistended pixels over the number of recruited pixels (O/R ratio) was calculated, and the patients were divided into low O/R (O/R ratio < 15%) and high O/R groups (O/R ratio ≥ 15%). The global inhomogeneity (GI) index was calculated to evaluate the ventilation distribution. Lung perfusion image was calculated from the EIT impedance-time curves caused by 10 ml 10% NaCl injection during a respiratory pause (> 8 s). DeadSpace%, Shunt%, and VQMatch% were calculated based on lung EIT perfusion and ventilation images. RESULTS Increasing PEEP resulted in recruitment mainly in dorsal regions and overdistension mainly in ventral regions. ΔVQMatch% (VQMatch% at high PEEP minus that at ZEEP) was significantly correlated with recruited pixels (r = 0.468, P = 0.009), overdistended pixels (r = - 0.666, P < 0.001), O/R ratio (r = - 0.686, P < 0.001), and ΔSpO2 (r = 0.440, P = 0.015). Patients in the low O/R ratio group (14/30) had significantly higher Shunt% and lower VQMatch% than those in the high O/R ratio group (16/30) at ZEEP but not at high PEEP. Comparable DeadSpace% was found in both groups. A high PEEP caused a significant improvement of VQMatch%, DeadSpace%, Shunt%, and GI in the low O/R ratio group, but not in the high O/R ratio group. Using O/R ratio of 15% resulted in a sensitivity of 81% and a specificity of 100% for an increase of VQMatch% > 20% in response to high PEEP. CONCLUSIONS Change of ventilation-perfusion matching was associated with regional overdistention and recruitment induced by PEEP. A low O/R ratio induced by high PEEP might indicate a more homogeneous ventilation and improvement of VQMatch. TRIAL REGISTRATION ClinicalTrials.gov, NCT04081155 . Registered on 9 September 2019-retrospectively registered.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Siyi Yuan
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein Campus kiel, Kiel 24105, Germany
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China
| | - Zhanqi Zhao
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany.
- Department of Biomedical Engineering, Fourth Military Medical University, 169 Changle Xi Rd, Xi'an, China.
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Takahashi R, Kimoto Y, Maki T, Eto M. Postinjury Bladder Overdistension Deteriorates the Lower Urinary Tract's Storage Function in Patients with Spinal Cord Injury. Urol Int 2020; 104:604-609. [PMID: 32594087 DOI: 10.1159/000508418] [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: 03/06/2020] [Accepted: 04/28/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A recent article has reported that postinjury bladder overdistension (OD) deteriorates lower urinary tract function in the mouse spinal cord injury (SCI) model. However, there have been no reports examining the effect of postinjury bladder OD on lower urinary tract function in human SCI patients. OBJECTIVE The aim of the study was to investigate the effect of postinjury bladder OD during the acute bladder-areflexia phase on the subsequent lower urinary tract storage function in patients with SCI. METHODS Thirty-one patients with OD (OD group) and 19 patients without OD (non-OD group) during the acute bladder-areflexia phase were included in the study. All patients were confirmed to be completely paralyzed. Their lower urinary tract function was retrospectively evaluated through urodynamic studies 1, 3, and 5 years after injury. Qualiveen-30 questionnaire was used for the evaluation of quality of life. RESULTS No significant difference was observed in the maximum cystometric capacity between the OD and non-OD groups in their urodynamic evaluation; however, the maximum bladder pressure was significantly higher, and the bladder compliance was significantly lower in the OD group. The incidence of detrusor overactivity tended to be higher in the OD group, but no significant difference was observed. The use of anti-muscarinics was significantly higher in the OD group. No significant differences were observed in Quali-veen-30 scores between both groups. CONCLUSIONS These results suggest that postinjury bladder OD during the acute phase deteriorates lower urinary tract storage function in patients with SCI during the later phase. Thus, it is assumed that a well-planned regular intermittent catheterization in the early spinal shock phase would be important for control of patients' subsequent storage function.
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Affiliation(s)
| | - Yasusuke Kimoto
- Department of Urology, Spinal Injuries Center, Fukuoka, Japan
| | - Tomoko Maki
- Department of Urology, Spinal Injuries Center, Fukuoka, Japan
| | - Masatoshi Eto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Wongsurakiat P, Yuangtrakul N. Performance and applications of bedside visual inspection of airway pressure-time curve profiles for estimating stress index in patients with acute respiratory distress syndrome. J Clin Monit Comput 2019; 33:281-90. [PMID: 29744774 DOI: 10.1007/s10877-018-0153-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/04/2018] [Indexed: 10/16/2022]
Abstract
To determine the performance of bedside visual inspection of airway pressure-time (Paw-t) curve profiles (VI) for estimating stress index (SI) in patients with acute respiratory distress syndrome (ARDS). A prospective study in 30 subjects with ARDS receiving mechanical ventilation at two peak inspiratory flow (PIF) settings: 60 or 40 L/min. For each study session, two physicians inspected real-time Paw-t waveforms from mechanical ventilator's monitoring screens at bedside for 30 s and interpreted which of the three patterns (tidal recruitment, noninjurious ventilation or tidal overdistension) the Paw-t curve profile was compatible with. Subsequently, the study was repeated again at the second PIF setting. SI was derived from a standardized dedicated software program and categorized into three groups: SI < 0.9, or tidal recruitment; SI = 0.9-1.05, or noninjurious ventilation; and SI > 1.05, or tidal overdistension. The lower PIF setting increased the sensitivity of VI to correctly estimate SI (75% vs. 50%; p = 0.005). At PIF 40 L/min, the likelihood ratio of a positive test was 3.6, 5.4 or 7 if the Paw-t curve profile was interpreted as noninjurious ventilation, tidal recruitment or tidal overdistension, respectively. The likelihood ratio of a negative test ranged from 0.55 for tidal recruitment to 0.32 and 0.19 for noninjurious ventilation and tidal overdistension, respectively. Experience in mechanical ventilation did not influence the accuracy. Bedside VI is moderately accurate for estimating SI and may be used to monitor injurious ventilation in patients with ARDS, in addition to plateau airway pressure.
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Eronia N, Mauri T, Maffezzini E, Gatti S, Bronco A, Alban L, Binda F, Sasso T, Marenghi C, Grasselli G, Foti G, Pesenti A, Bellani G. Bedside selection of positive end-expiratory pressure by electrical impedance tomography in hypoxemic patients: a feasibility study. Ann Intensive Care 2017; 7:76. [PMID: 28730554 PMCID: PMC5519511 DOI: 10.1186/s13613-017-0299-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/06/2017] [Indexed: 01/28/2023] Open
Abstract
Background Positive end-expiratory pressure (PEEP) is a key element of mechanical ventilation. It should optimize recruitment, without causing excessive overdistension, but controversy exists on the best method to set it. The purpose of the study was to test the feasibility of setting PEEP with electrical impedance tomography in order to prevent lung de-recruitment following a recruitment maneuver. We enrolled 16 patients undergoing mechanical ventilation with PaO2/FiO2 <300 mmHg. In all patients, under constant tidal volume (6–8 ml/kg) PEEP was set based on the PEEP/FiO2 table proposed by the ARDS network (PEEPARDSnet). We performed a recruitment maneuver and monitored the end-expiratory lung impedance (EELI) over 10 min. If the EELI signal decreased during this period, the recruitment maneuver was repeated and PEEP increased by 2 cmH2O. This procedure was repeated until the EELI maintained a stability over time (PEEPEIT). Results The procedure was feasible in 87% patients. PEEPEIT was higher than PEEPARDSnet (13 ± 3 vs. 9 ± 2 cmH2O, p < 0.001). PaO2/FiO2 improved during PEEPEIT and driving pressure decreased. Recruited volume correlated with the decrease in driving pressure but not with oxygenation improvement. Finally, regional alveolar hyperdistention and collapse was reduced in dependent lung layers and increased in non-dependent lung layers. Conclusions In hypoxemic patients, a PEEP selection strategy aimed at stabilizing alveolar recruitment guided by EIT at the bedside was feasible and safe. This strategy led, in comparison with the ARDSnet table, to higher PEEP, improved oxygenation and reduced driving pressure, allowing to estimate the relative weight of overdistension and recruitment. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0299-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nilde Eronia
- Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza, Italy
| | - Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Elisabetta Maffezzini
- Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Stefano Gatti
- Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Alfio Bronco
- Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Laura Alban
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Filippo Binda
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Tommaso Sasso
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Cristina Marenghi
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza, Italy.,Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza, Italy. .,Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy.
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