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Pupier T, Gallo É, Bonnardel E, Boisselier C, Perrier V, Repusseau B, Rozé H. Daily Evolution of Lung Dependent-Area Collapse Between Prone Position Sessions in ARDS Evaluated by Electrical Impedance Tomography. Respir Care 2024:respcare.11292. [PMID: 38471736 DOI: 10.4187/respcare.11292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Affiliation(s)
- Thomas Pupier
- CHU de Bordeaux, Service d'Anesthésie Réanimation Thoraco-Abdominale, F-33600 Pessac, France
| | - Éloïse Gallo
- CHU de Bordeaux, Service d'Anesthésie Réanimation Thoraco-Abdominale, F-33600 Pessac, France
| | - Eline Bonnardel
- CHU de Bordeaux, Service d'Anesthésie Réanimation Thoraco-Abdominale, F-33600 Pessac, France
| | - Clément Boisselier
- CHU de Bordeaux, Service d'Anesthésie Réanimation Thoraco-Abdominale, F-33600 Pessac, France
| | - Virginie Perrier
- CHU de Bordeaux, Service d'Anesthésie Réanimation Thoraco-Abdominale, F-33600 Pessac, France
| | - Benjamin Repusseau
- CHU de Bordeaux, Service d'Anesthésie Réanimation Thoraco-Abdominale, F-33600 Pessac, France
| | - Hadrien Rozé
- CHU de Bordeaux, Service d'Anesthésie Réanimation Thoraco-Abdominale, F-33600 Pessac, France; Réanimation Polyvalente, Centre Hospitalier Côte Basque, F64100 Bayonne, Centre Hospitalier Côte Basque, F64100 Bayonne, France; Université de Bordeaux, F-33400 Talence, France.
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Nieman GF, Herrmann J, Satalin J, Kollisch-Singule M, Andrews PL, Habashi NM, Tingay DG, Gaver DP, Bates JHT, Kaczka DW. Ratchet recruitment in the acute respiratory distress syndrome: lessons from the newborn cry. Front Physiol 2023; 14:1287416. [PMID: 38028774 PMCID: PMC10646689 DOI: 10.3389/fphys.2023.1287416] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Patients with acute respiratory distress syndrome (ARDS) have few treatment options other than supportive mechanical ventilation. The mortality associated with ARDS remains unacceptably high, and mechanical ventilation itself has the potential to increase mortality further by unintended ventilator-induced lung injury (VILI). Thus, there is motivation to improve management of ventilation in patients with ARDS. The immediate goal of mechanical ventilation in ARDS should be to prevent atelectrauma resulting from repetitive alveolar collapse and reopening. However, a long-term goal should be to re-open collapsed and edematous regions of the lung and reduce regions of high mechanical stress that lead to regional volutrauma. In this paper, we consider the proposed strategy used by the full-term newborn to open the fluid-filled lung during the initial breaths of life, by ratcheting tissues opened over a series of initial breaths with brief expirations. The newborn's cry after birth shares key similarities with the Airway Pressure Release Ventilation (APRV) modality, in which the expiratory duration is sufficiently short to minimize end-expiratory derecruitment. Using a simple computational model of the injured lung, we demonstrate that APRV can slowly open even the most recalcitrant alveoli with extended periods of high inspiratory pressure, while reducing alveolar re-collapse with brief expirations. These processes together comprise a ratchet mechanism by which the lung is progressively recruited, similar to the manner in which the newborn lung is aerated during a series of cries, albeit over longer time scales.
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Affiliation(s)
- Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical Center, Syracuse, NY, United States
| | - Jacob Herrmann
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical Center, Syracuse, NY, United States
| | | | - Penny L. Andrews
- Department of Medicine, University of Maryland, Baltimore, MD, United States
| | - Nader M. Habashi
- Department of Medicine, University of Maryland, Baltimore, MD, United States
| | - David G. Tingay
- Neonatal Research, Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, VIC, Australia
| | - Donald P. Gaver
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, United States
| | - Jason H. T. Bates
- Department of Medicine, University of Vermont, Burlington, VT, United States
| | - David W. Kaczka
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA, United States
- Departments of Anesthesia and Radiology, University of Iowa, Iowa City, IA, United States
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3
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Zheng M. Respiratory Mechanics: Revisiting the Appraisement of Lung Recruitment. Respir Care 2023; 68:1262-1270. [PMID: 37072160 PMCID: PMC10468170 DOI: 10.4187/respcare.10601] [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] [Indexed: 04/20/2023]
Abstract
Mechanical ventilation has long been recognized as the most vital therapy for patients with ARDS. Compared with lung-protective ventilation, debates that involve the open lung strategy, which consists primarily of the lung recruitment maneuver and higher PEEP, have never been resolved. In terms of the beneficial and detrimental effects of this aggressive maneuver, appraisal of lung recruitment is essential for intensivists to make clinical decisions. This review aimed to clarify how to assess the potential for lung recruitment based on respiratory mechanics when using the pressure-volume curve or loop method and end-expiratory lung volume-static compliance of the respiratory system method. However, their limitations related to excessive generalization, accuracy, and identification of cutoff values cannot be omitted. Finally, future studies are warranted to combine these classic methods with newly invented techniques to achieve safer and more effective lung recruitment.
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Affiliation(s)
- Mingjia Zheng
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Wuxing, Huzhou, Zhejiang, People's Republic of China.
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4
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Schranc Á, Diaper J, Südy R, Peták F, Habre W, Albu G. Lung recruitment by continuous negative extra-thoracic pressure support following one-lung ventilation: an experimental study. Front Physiol 2023; 14:1160731. [PMID: 37256073 PMCID: PMC10225513 DOI: 10.3389/fphys.2023.1160731] [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: 02/07/2023] [Accepted: 05/03/2023] [Indexed: 06/01/2023] Open
Abstract
Lung recruitment maneuvers following one-lung ventilation (OLV) increase the risk for the development of acute lung injury. The application of continuous negative extrathoracic pressure (CNEP) is gaining interest both in intubated and non-intubated patients. However, there is still a lack of knowledge on the ability of CNEP support to recruit whole lung atelectasis following OLV. We investigated the effects of CNEP following OLV on lung expansion, gas exchange, and hemodynamics. Ten pigs were anesthetized and mechanically ventilated with pressure-regulated volume control mode (PRVC; FiO2: 0.5, Fr: 30-35/min, VT: 7 mL/kg, PEEP: 5 cmH2O) for 1 hour, then baseline (BL) data for gas exchange (arterial partial pressure of oxygen, PaO2; and carbon dioxide, PaCO2), ventilation and hemodynamical parameters and lung aeration by electrical impedance tomography were recorded. Subsequently, an endobronchial blocker was inserted, and OLV was applied with a reduced VT of 5 mL/kg. Following a new set of measurements after 1 h of OLV, two-lung ventilation was re-established, combining PRVC (VT: 7 mL/kg) and CNEP (-15 cmH2O) without any hyperinflation maneuver and data collection was then repeated at 5 min and 1 h. Compared to OLV, significant increases in PaO2 (154.1 ± 13.3 vs. 173.8 ± 22.1) and decreases in PaCO2 (52.6 ± 11.7 vs. 40.3 ± 4.5 mmHg, p < 0.05 for both) were observed 5 minutes following initiation of CNEP, and these benefits in gas exchange remained after an hour of CNEP. Gradual improvements in lung aeration in the non-collapsed lung were also detected by electrical impedance tomography (p < 0.05) after 5 and 60 min of CNEP. Hemodynamics and ventilation parameters remained stable under CNEP. Application of CNEP in the presence of whole lung atelectasis proved to be efficient in improving gas exchange via recruiting the lung without excessive airway pressures. These benefits of combined CNEP and positive pressure ventilation may have particular value in relieving atelectasis in the postoperative period of surgical procedures requiring OLV.
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Affiliation(s)
- Álmos Schranc
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - John Diaper
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Roberta Südy
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Ferenc Peták
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Walid Habre
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Gergely Albu
- Unit for Anesthesiological Investigations, Department of Anesthesiology Pharmacology, Intensive Care and Emergency Medicine, University of Geneva, Geneva, Switzerland
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Protić A, Bura M, Šustić A, Brusić J, Sotošek V. Segmental Lung Recruitment in Patients with Bilateral COVID-19 Pneumonia Complicated by Acute Respiratory Distress Syndrome: A Case Report. Medicina (B Aires) 2023; 59. [PMID: 36676766 DOI: 10.3390/medicina59010142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/12/2023] Open
Abstract
Bilateral COVID-19 pneumonia is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and usually leads to life-threatening acute respiratory distress syndrome (ARDS). Treatment of patients with ARDS is difficult and usually involves protective mechanical ventilation and various types of recruitment maneuvers. A segmental lung recruitment maneuver by independent lung ventilation has been described as a successful recruitment maneuver in patients with lobar pneumonia, and may, therefore, be useful for the treatment of patients with bilateral COVID-19 pneumonia complicated by ARDS in the critical phase of the disease when all other therapeutic options have been exhausted. The aim of this case series was to present a case report of four mechanically ventilated patients with severe bilateral COVID-19 pneumonia complicated by ARDS using the segmental lung recruitment maneuver. The effect of the segmental lung recruitment maneuver was assessed by the increase in PaO2/FiO2 ratio and the lung ultrasound (LUS) scoring system (0 points-presence of sliding lungs with A-lines or one or two isolated B-lines; 1 point-moderate loss of lung ventilation with three to five B lines; 2 points-severe loss of lung ventilation with more than five B lines (B pattern); and 3 points-lung consolidation) determined 12, 24, and 48 h after segmental lung recruitment. In three of four patients with bilateral COVID-19 pneumonia complicated by ARDS, an increase in the PaO2/FiO2 ratio and an improvement in the LUS scoring system were observed 48 h after segmental lung recruitment. In conclusion, the segmental lung recruitment maneuver in patients with bilateral COVID-19 complicated by ARDS is an effective method of lung recruitment and may be a useful treatment method.
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Rosner EA, L Parker J, Vandenberg C, Bridges BC, Kilbaugh TJ, Bembea MM, Chima RS, Potera RM, Sandhu HS, Barbaro RP, Tarquinio KM, Cheifetz IM, Friedman ML. Flexible Bronchoscopy in Pediatric Venovenous Extracorporeal Membrane Oxygenation. Respir Care 2022; 67:688-693. [PMID: 35351825 PMCID: PMC9994196 DOI: 10.4187/respcare.09243] [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] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pediatric patients with ARDS will on occasion need venovenous extracorporeal membrane oxygenation (VV-ECMO) for organ support. As these patients recover, they may benefit from lung recruitment maneuvers including flexible bronchoscopy (FB). The objective of this study was to assess the clinical course of patients who underwent FB while on VV-ECMO for ARDS. METHODS This was a secondary analysis of a retrospective multi-center cohort at 10 United States pediatric academic quaternary care centers. Data were collected on 204 subjects age 14 d-18 y on VV-ECMO. RESULTS 271 FBs were performed on 129 (63%) subjects. Pre-FB tidal volume was 1.8 mL/kg compared to 2.22 mL/kg following FB (P = .007). Dynamic compliance also improved from pre-FB to post-FB (2.23 vs 3.04 mL/cm H2O, P = .005). There was a low incidence of complications following FB (3.1%). Subjects in the FB group had fewer ECMO-free days (EFDs) (17.9 vs 22.1 d, P < .001), fewer ventilator-free days (VFDs) (40.0 vs 46.5 d, P = .001), and longer ICU length of stay (LOS) (18 vs 32 d, P < .001). Subjects in the early versus late FB group had more EFDs (19.4 vs 15.2 d, P = .003), more VFDs (43.0 vs 34.0 d, P = .004), and shorter ICU LOS (27.5 vs 35.5 d, P = .045). Mortality in the subjects who had at least one FB was 27.1% compared to 40% in the subjects who did not have a FB while on VV-ECMO (P = .057). CONCLUSIONS FB can be performed on patients while anticoagulated on VV-ECMO with a low incidence of complications. FB may be beneficial especially when performed early in the course of VV-ECMO.
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Affiliation(s)
| | | | | | - Brian C Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ranjit S Chima
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Renee M Potera
- Department of Pediatrics UT Southwestern Medical Center, Dallas, Texas
| | - Hitesh S Sandhu
- Division of Pediatric Critical Care, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Ryan P Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan; and Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Keiko M Tarquinio
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ira M Cheifetz
- Division of Pediatric Critical Care, Duke Children's, Durham, North Carolina
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana
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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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Liaqat A, Mason M, Foster BJ, Kulkarni S, Barlas A, Farooq AM, Patak P, Liaqat H, Basso RG, Zaman MS, Pau D. Evidence-Based Mechanical Ventilatory Strategies in ARDS. J Clin Med 2022; 11:319. [PMID: 35054013 DOI: 10.3390/jcm11020319] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 02/01/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) remains one of the leading causes of morbidity and mortality in critically ill patients despite advancements in the field. Mechanical ventilatory strategies are a vital component of ARDS management to prevent secondary lung injury and improve patient outcomes. Multiple strategies including utilization of low tidal volumes, targeting low plateau pressures to minimize barotrauma, using low FiO2 (fraction of inspired oxygen) to prevent injury related to oxygen free radicals, optimization of positive end expiratory pressure (PEEP) to maintain or improve lung recruitment, and utilization of prone ventilation have been shown to decrease morbidity and mortality. The role of other mechanical ventilatory strategies like non-invasive ventilation, recruitment maneuvers, esophageal pressure monitoring, determination of optimal PEEP, and appropriate patient selection for extracorporeal support is not clear. In this article, we review evidence-based mechanical ventilatory strategies and ventilatory adjuncts for ARDS.
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Deng B, Xu F, Li J, Mai M, Chen Q, Liao J, He X, Li N. Case Report: Lung Ultrasound in Critically Ill Neonates With Lung Diseases: Experience From Several Typical Cases. Front Pediatr 2022; 10:846279. [PMID: 35664870 PMCID: PMC9161147 DOI: 10.3389/fped.2022.846279] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Lung ultrasound (LUS) can be used to diagnose various neonatal lung diseases. It more sensitively diagnoses pulmonary edema, pneumothorax, pulmonary consolidation, and atelectasis than traditional X-ray and quickly determines the cause of dyspnea. As a component of severe ultrasound, LUS enables rapid bedside visualization of lung diseases and plays a major role in guiding the differential diagnosis of disease, ventilator treatment, and lung recruitment. This study introduced the application of LUS in the diagnosis and treatment of critically ill neonates with lung diseases.
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Affiliation(s)
- Biying Deng
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
| | - Fengdan Xu
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
| | - Jinfeng Li
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
| | - Minling Mai
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
| | - Qin Chen
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
| | - Jinfeng Liao
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
| | - Xiaoguang He
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
| | - Ning Li
- Department of Neonatal Intensive Care Unit, Guangdong Medical University Affiliated Dongguan Children's Hospital, Dongguan, China
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Adler AC, von Ungern-Sternberg BS, Matava CT. Lung ultrasound and atelectasis-The devil is in the details. Paediatr Anaesth 2021; 31:1269-1270. [PMID: 34750922 DOI: 10.1111/pan.14286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Britta S von Ungern-Sternberg
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kid's Institute, Perth, WA, Australia
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, ON, Canada
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Brault C, Zerbib Y, Kontar L, Maizel J, Slama M. Transoesophageal Ultrasound Assessment of Lung Aeration in Patients With Acute Respiratory Distress Syndrome. Front Physiol 2021; 12:716949. [PMID: 34566682 PMCID: PMC8458769 DOI: 10.3389/fphys.2021.716949] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The effect of positive end-expiratory pressure (PEEP) depends closely on the potential for lung recruitment. Bedside assessment of lung recruitability is crucial for personalized lung-protective mechanical ventilation in acute respiratory distress syndrome (ARDS) patients. Methods: We developed a transoesophageal lung ultrasound (TE-LUS) method in which a quantitative (computer-assisted) grayscale determination served as a guide to PEEP-induced lung recruitment. The method is based on the following hypothesis: when the PEEP increases, inflation of the recruited alveoli leads to significant changes in the air/water ratio. Normally ventilated areas are hypoechoic because the ultrasound waves are weakly reflected while poorly aerated areas or non-aerated areas are hyperechoic. We calculated the TE-LUS re-aeration score (RAS) as the ratio of the mean gray scale level at low PEEP to that value at high PEEP for the lower and upper lobes. A RAS > 1 indicated an increase in ventilated area. We used this new method to detect changes in ventilation in patients with a low (<0.5) vs. high (≥0.5) recruitment-to-inflation (R/I) ratio (i.e., the ratio between the recruited lung compliance and the respiratory system compliance at low PEEP). Results: We included 30 patients with moderate-to-severe ARDS. In patients with a high R/I ratio, the TE-LUS RAS was significantly higher in the lower lobes than in the upper lobes (1.20 [1.12-1.63] vs. 1.05 [0.89-1.38]; p = 0.05). Likewise, the TE-LUS RAS in the lower lobes was significantly higher in the high R/I group than in the low R/I group (1.20 [1.12-1.63] vs. 1.07 [1.00-1.20]; p = 0.04). Conclusion: The increase in PEEP induces a substantial gain in the ventilation detected by TE-LUS of poorly or non-aerated lower lobes (dependent lung regions), especially in patients with a high R/I ratio.
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Affiliation(s)
- Clément Brault
- Intensive Care Department, CHU Amiens-Picardie, Amiens, France
| | - Yoann Zerbib
- Intensive Care Department, CHU Amiens-Picardie, Amiens, France
| | - Loay Kontar
- Intensive Care Department, CHU Amiens-Picardie, Amiens, France
| | - Julien Maizel
- Intensive Care Department, CHU Amiens-Picardie, Amiens, France
| | - Michel Slama
- Intensive Care Department, CHU Amiens-Picardie, Amiens, France
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Liu T, Qiao H, Xu L, Li D, Fan Y. [Estimation of lung recruitment characteristics using the static pressure-volume curve of lungs]. Sheng Wu Yi Xue Gong Cheng Xue Za Zhi 2021; 38:326-332. [PMID: 33913293 DOI: 10.7507/1001-5515.202008061] [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] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Mechanical ventilation is an importmant life-sustaining treatment for patients with acute respiratory distress syndrome. Its clinical outcomes depend on patients' characteristics of lung recruitment. Estimation of lung recruitment characteristics is valuable for the determination of ventilatory maneurvers and ventilator parameters. There is no easily-used, bedside method to assess lung recruitment characteristics. The present paper proposed a method to estimate lung recruitment characteristics from the static pressure-volume curve of lungs. The method was evaluated by comparing with published experimental data. Results of lung recruitment derived from the presented method were in high agreement with the published data, suggesting that the proposed method is capable to estimate lung recruitment characteristics. Since some advanced ventilators are capable to measure the static pressure-volume curve automatedly, the presented method is potential to be used at bedside, and it is helpful for clinicians to individualize ventilatory manuevers and the correpsonding ventilator parameters.
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Affiliation(s)
- Tianya Liu
- Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, P.R. China
| | - Huiting Qiao
- Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, P.R. China
| | - Liqiang Xu
- Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, P.R. China
| | - Deyu Li
- Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, P.R. China
| | - Yubo Fan
- Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, P.R. China.,School of Medical Science and Engineering, Beihang University, Beijing 100083, P.R. China
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Bernal-Utrera C, Anarte-Lazo E, Gonzalez-Gerez JJ, De-La-Barrera-Aranda E, Saavedra-Hernandez M, Rodriguez-Blanco C. Could Physical Therapy Interventions Be Adopted in the Management of Critically Ill Patients with COVID-19? A Scoping Review. Int J Environ Res Public Health 2021; 18:ijerph18041627. [PMID: 33567748 PMCID: PMC7915254 DOI: 10.3390/ijerph18041627] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 02/06/2023]
Abstract
As part of COVID-19 consequences, it has been estimated that 5% of patients affected by this disease will require admission to the intensive care unit (ICU), and physical therapy techniques have been implemented in patients with other conditions admitted to ICU. The aim of the present study is to summarize all the available information about the implementation of physical therapy management in critically ill patients. From three clinical guidelines already published, we performed a search in PubMed, Scopus, ScienceDirect, and CINAHL, including systematic reviews, clinical guidelines, and randomized controlled trials, among others. Data extraction was performed independently by two reviewers. Quality assessment was developed through the AMSTAR-2 tool and PEDro Scale. A narrative synthesis was performed and 29 studies were included. The information extracted has been classified into four folders: ICU environment in COVID-19 (security aspects and management of the patient), respiratory physiotherapy (general indications and contraindications, spontaneously breathing and mechanically ventilated patient approaches), positional treatment, and exercise therapy (safety aspects and progression). The implementation of physiotherapy in patients affected with COVID-19 admitted to the ICU is a necessary strategy that prevents complications and contributes to the stabilization of patients in critical periods, facilitating their recovery.
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Affiliation(s)
- Carlos Bernal-Utrera
- Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain;
- Fisiosur I+D Research Institute, 04630 Almería, Spain; (J.J.G.-G.); (E.D.-L.-B.-A.); (M.S.-H.)
- Correspondence: ; Tel.: +34-639616829
| | - Ernesto Anarte-Lazo
- Doctoral Program in Health Sciences, University of Seville, 41009 Seville, Spain;
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Juan Jose Gonzalez-Gerez
- Fisiosur I+D Research Institute, 04630 Almería, Spain; (J.J.G.-G.); (E.D.-L.-B.-A.); (M.S.-H.)
- Department Nursing, Physiotherapy and Medicine, University of Almeria, 04120 Almería, Spain
| | - Elena De-La-Barrera-Aranda
- Fisiosur I+D Research Institute, 04630 Almería, Spain; (J.J.G.-G.); (E.D.-L.-B.-A.); (M.S.-H.)
- Morphological and Socio-Health Sciences Department, University of Cordoba, 14071 Cordoba, Spain
| | - Manuel Saavedra-Hernandez
- Fisiosur I+D Research Institute, 04630 Almería, Spain; (J.J.G.-G.); (E.D.-L.-B.-A.); (M.S.-H.)
- Department Nursing, Physiotherapy and Medicine, University of Almeria, 04120 Almería, Spain
| | - Cleofas Rodriguez-Blanco
- Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain;
- Fisiosur I+D Research Institute, 04630 Almería, Spain; (J.J.G.-G.); (E.D.-L.-B.-A.); (M.S.-H.)
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14
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Tana M, Paladini A, Tirone C, Aurilia C, Lio A, Bottoni A, Costa S, Tiberi E, Pastorino R, Vento G. Effects of High-Frequency Oscillatory Ventilation With Volume Guarantee During Surfactant Treatment in Extremely Low Gestational Age Newborns With Respiratory Distress Syndrome: An Observational Study. Front Pediatr 2021; 9:804807. [PMID: 35310140 PMCID: PMC8927884 DOI: 10.3389/fped.2021.804807] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/28/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the effect of volume guarantee (VG) combined with high-frequency oscillatory ventilation (HFOV) on respiratory and other physiological parameters immediately after lung recruitment and surfactant administration in HFOV elective ventilated extremely low gestational age newborns (ELGAN) with respiratory distress syndrome (RDS). DESIGN Observational study. SETTING Tertiary neonatal intensive care unit. PATIENTS Twenty-two ELGANs of 25.5 ± 1.1 weeks of gestational age requiring invasive mechanical ventilation and surfactant administration for RDS during the first 6 h of life. INTERVENTIONS All infants intubated in delivery room, were managed with elective HFOV and received surfactant after a lung recruitment manoeuver. Eleven infants received HFOV + VG and were compared with a control group of 11 infants receiving HFOV alone. HFOV was delivered in both groups by Dräger Babylog VN500 ventilator (Dräger, Lubeck, Germany). MAIN OUTCOME MEASURES Variations and fluctuations of delivered high-frequency tidal volume (VThf), fluctuation of pressure amplitude (ΔP) and partial pressure of CO2 (pCO2) levels after recruitment manoeuver and immediately after surfactant administration, in HFOV + VG vs. HFOV ventilated infants. RESULTS There were no significant differences in the two groups at starting ventilation with or without VG. The mean applied VThf per kg was 1.7 ± 0.3 ml/kg in the HFOV group and 1.7 ± 0.1 ml/kg in the HFOV + VG group. Thirty minutes after surfactant administration, HFOV group had a significant higher VThf/Kg than HFOV + VG (2.1 ± 0.3 vs. 1.6 ± 0.1 ml/kg, p < 0.0001) with significantly lower pCO2 levels (43.1 ± 3.8 vs. 46.8 ± 1.5 mmHg, p = 0.01), 54.4% of patients having pCO2 below 45 mmHg. Measured post-surfactant ΔP values were higher in HFOV group (17 ± 3 cmH2O) than in HFOV + VG group (13 ± 3 cmH2O, p = 0.01). CONCLUSION HFOV + VG maintains pCO2 levels within target range and reduces VThf delivered variations more consistently than HFOV alone after surfactant administration.
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Affiliation(s)
- Milena Tana
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Angela Paladini
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Chiara Tirone
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Aurilia
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandra Lio
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Anthea Bottoni
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simonetta Costa
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Eloisa Tiberi
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberta Pastorino
- Section of Hygiene, Institute of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Vento
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
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15
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Rodríguez Sánchez de la Blanca A, Sánchez Luna M, González Pacheco N, Ramos Navarro C, Santos González M, Tendillo Cortijo F. New indicators for optimal lung recruitment during high frequency oscillator ventilation. Pediatr Pulmonol 2020; 55:3525-3531. [PMID: 32965770 DOI: 10.1002/ppul.25084] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 08/26/2020] [Accepted: 09/15/2020] [Indexed: 11/09/2022]
Abstract
UNLABELLED Previous research has demonstrated the potential benefit derived from the combination of high frequency oscillatory ventilation and volume guarantee mode (HFOV-VG), a procedure that allows us to explore and control very low tidal volumes. We hypothesized that secondary spontaneous change in oscillation pressure amplitude (∆Phf), while increasing the mean airway pressure (MAP) using HFOV-VG can target the lung recruitment. METHODS A two-step animal distress model study was designed; in the first-step (ex vivo model), the animal's lungs were isolated to visually check lung recruitment and, in the second one (in vivo model), they were checked through arterial oxygen partial pressure improvement. Baseline measurements were performed, ventilation was set for 10 min and followed by bronchoalveolar lavage with isotonic saline to induce depletion of surfactant and thereby achieve a low compliance lung model. The high-frequency tidal volume and frequency remained constant and the MAP was increased by 2 cmH2 O (ex vivo) and 3 cmH2 O steps (in vivo) every 2 min. Changes in ΔPhf to achieve the fixed volume were recorded at the end of each interval to describe the maximum drop point as the recruitment point. RESULTS Fourteen Wistar Han rats were included, seven on each sub-study described. After gradual MAP increments, a progressive decrease in ΔPhf related to recruited lung regions was visually demonstrated. In the in vivo model we detected a significant comparative decrease of ΔPhf, when measured against the previous value, after reaching a MAP of 11 cmH2 O up to 17 cmH2 O, correlating with a significant improvement in oxygenation. CONCLUSION The changes in ∆Phf, linked to a progressive increase in MAP during HFOV-VG, might identify optimal lung recruitment and could potentially be used as an additional lung recruitment marker.
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Affiliation(s)
| | - Manuel Sánchez Luna
- Division of Neonatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Martín Santos González
- Medical and Surgical Research Unit, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
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16
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Tuzun F, Deliloglu B, Cengiz MM, Iscan B, Duman N, Ozkan H. Volume Guarantee High-Frequency Oscillatory Ventilation in Preterm Infants With RDS: Tidal Volume and DCO 2 Levels for Optimal Ventilation Using Open-Lung Strategies. Front Pediatr 2020; 8:105. [PMID: 32266185 PMCID: PMC7105735 DOI: 10.3389/fped.2020.00105] [Citation(s) in RCA: 12] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/28/2020] [Indexed: 11/19/2022] Open
Abstract
High frequency oscillatory ventilation with volume-guarantee (HFOV-VG) is a promising lung protective ventilator mode for the treatment of respiratory failure in newborns. However, indicators of optimal ventilation during HFOV-VG mode are not identified yet. In this study, we aimed to evaluate optimal high-frequency tidal volume (VThf) and the dissociation coefficient of CO2 (DCO2) levels to achieve normocapnia during HFOV-VG after lung recruitment in very low birthweight infants with respiratory distress syndrome (RDS). Preterm babies under the 32nd postmenstrual week with severe RDS that received HFOV-VG using open-lung strategy between January 2014 and January 2019 were retrospectively evaluated. All included patients were treated with the Dräger Babylog VN500 ventilator in the HFOV-VG mode. In total, 53 infants with a mean gestational age of 26.8 ± 2.3 weeks were evaluated. HFOV mean optimal airway pressure (MAPhf) level after lung recruitment was found to be 10.2 ± 1.7 mbar. Overall, the mean applied VThf per kg was 1.64 ± 0.25 mL/kg in the study sample. To provide normocapnia, the mean VThf was 1.61 ± 0.25 mL/kg and the mean DCO2corr was 29.84 ± 7.88 [mL/kg]2/s. No significant correlation was found between pCO2 levels with VThf (per kg) or DCO2corr levels. VThf levels to maintain normocarbia were significantly lower with 12 Hz frequency compared to 10 Hz frequency (1.50 ± 0.24 vs. 1.65 ± 0.25 mL/ kg, p < 0.001, respectively). A weak but significant positive correlation was found between mean airway pressure (MAPhf) and VThf levels. To our knowledge, this is the largest study to evaluate the optimal HFOV-VG settings in premature infants with RDS, using the open-lung strategy. According to the results, a specific set of numbers could not be recommended to achieve normocarbia. Following the trend of each patient and small adjustments according to the closely monitored pCO2 levels seems logical.
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Affiliation(s)
- Funda Tuzun
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Burak Deliloglu
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Merve Meryem Cengiz
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Burcin Iscan
- Division of Neonatology, Department of Pediatrics, Tinaztepe University Faculty of Medicine, Izmir, Turkey
| | - Nuray Duman
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Hasan Ozkan
- Division of Neonatology, Department of Pediatrics, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
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17
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Haase J, Buchloh DC, Hammermüller S, Salz P, Mrongowius J, Carvalho NC, Beda A, Rau A, Starke H, Spieth PM, Gittel C, Muders T, Wrigge H, Reske AW. Mechanical Ventilation Strategies Targeting Different Magnitudes of Collapse and Tidal Recruitment in Porcine Acid Aspiration-Induced Lung Injury. J Clin Med 2019; 8:jcm8081250. [PMID: 31426607 PMCID: PMC6722815 DOI: 10.3390/jcm8081250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 06/25/2019] [Revised: 08/06/2019] [Accepted: 08/14/2019] [Indexed: 12/29/2022] Open
Abstract
Reducing ventilator-associated lung injury by individualized mechanical ventilation (MV) in patients with Acute Respiratory Distress Syndrome (ARDS) remains a matter of research. We randomly assigned 27 pigs with acid aspiration-induced ARDS to three different MV protocols for 24 h, targeting different magnitudes of collapse and tidal recruitment (collapse&TR): the ARDS-network (ARDSnet) group with low positive end-expiratory pressure (PEEP) protocol (permissive collapse&TR); the Open Lung Concept (OLC) group, PaO2/FiO2 >400 mmHg, indicating collapse&TR <10%; and the minimized collapse&TR monitored by Electrical Impedance Tomography (EIT) group, standard deviation of regional ventilation delay, SDRVD. We analyzed cardiorespiratory parameters, computed tomography (CT), EIT, and post-mortem histology. Mean PEEP over post-randomization measurements was significantly lower in the ARDSnet group at 6.8 ± 1.0 cmH2O compared to the EIT (21.1 ± 2.6 cmH2O) and OLC (18.7 ± 3.2 cmH2O) groups (general linear model (GLM) p < 0.001). Collapse&TR and SDRVD, averaged over all post-randomization measurements, were significantly lower in the EIT and OLC groups than in the ARDSnet group (collapse p < 0.001, TR p = 0.006, SDRVDp < 0.004). Global histological diffuse alveolar damage (DAD) scores in the ARDSnet group (10.1 ± 4.3) exceeded those in the EIT (8.4 ± 3.7) and OLC groups (6.3 ± 3.3) (p = 0.16). Sub-scores for edema and inflammation differed significantly (ANOVA p < 0.05). In a clinically realistic model of early ARDS with recruitable and nonrecruitable collapse, mechanical ventilation involving recruitment and high-PEEP reduced collapse&TR and resulted in improved hemodynamic and physiological conditions with a tendency to reduced histologic lung damage.
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Affiliation(s)
- Juliane Haase
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103 Leipzig, Germany
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, St. Georg Hospital, 04129 Leipzig, Germany
| | - Dorina C Buchloh
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103 Leipzig, Germany
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Sören Hammermüller
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Peter Salz
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Medical Faculty, 04103 Leipzig, Germany
| | - Julia Mrongowius
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Medical Faculty, 04103 Leipzig, Germany
| | - Nadja C Carvalho
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103 Leipzig, Germany
- Laboratory of Pneumology LIM09, Medical Faculty, São Paulo University, São Paulo 05508-060, Brazil
| | - Alessandro Beda
- Department of Electronic Engineering, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Anna Rau
- Department of Anesthesiology, University Medicine Göttingen, University of Göttingen, 37075 Göttingen, Germany
| | - Henning Starke
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Peter M Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Dresden, Technische Universität Dresden, 01307 Dresden, Germany
| | - Claudia Gittel
- Department for Horses, University of Leipzig, 04103 Leipzig, Germany
| | - Thomas Muders
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103 Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, 06112 Halle, Germany
| | - Andreas W Reske
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, 04103 Leipzig, Germany.
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Medical Faculty, 04103 Leipzig, Germany.
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy Heinrich-Braun-Hospital Zwickau, 08060 Zwickau, Germany.
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18
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Abdel‐Ghaffar HS, Youseff HA, Abdelal FA, Osman MA, Sayed JA, Riad MAF, Abdel‐Rady MM. Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial. Acta Anaesthesiol Scand 2019; 63:620-629. [PMID: 30761530 DOI: 10.1111/aas.13324] [Citation(s) in RCA: 5] [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] [Received: 01/17/2018] [Revised: 08/28/2018] [Accepted: 09/05/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO2 ] after pediatric laparoscopic surgery. METHODS Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO2 ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events. RESULTS At 1 hour postoperatively, mean [(A-a) DO2 ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO2 (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO2 ] and PaO2 were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups. CONCLUSIONS An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.
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Affiliation(s)
- Hala S. Abdel‐Ghaffar
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Hamdy A. Youseff
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Fatma A. Abdelal
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Mohamed A. Osman
- Pediatric Surgery Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Jehan A. Sayed
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | | | - Marwa M. Abdel‐Rady
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
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Abstract
Dead space is the portion of each tidal volume that does not take part in gas exchange and represents a good global index of the efficiency of the lung function. Dead space is not routinely measured in critical care practice, because the difficulties in in interpreting capnograms and the different methods of calculations. Different dead space indices can provide useful information in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) patients, where changes in microvasculature are the main determinants for the increase in dead space and consequently a worsening of the outcome. Lung recruitment is a dynamic process that combines recruitment manoeuvres (RMs) with positive end expiratory pressure (PEEP) and low Vt to recruit collapsed alveoli. Dead space guided recruitment allows avoiding regional overdistension or reduction in cardiac output in critical care patients with ALI or ARDS. Different patterns of ventilation affect also CO2 elimination; in fact, end-inspiratory pause prolongation reduces dead space, increasing respiratory system compliance; plateau pressure and consequently driving pressure increase accordingly. Dead space measurement is a reliable method that provides important clinical and prognostic information. Different capnographic indices can be useful to evaluate therapeutic interventions or setting mechanical ventilation.
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Affiliation(s)
- Massimo Ferluga
- Emergency and Urgency Department, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Umberto Lucangelo
- Emergency and Urgency Department, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Lluis Blanch
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
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20
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Chen WM, Lu GP. [ Lung recruitment maneuvers and positive end-expiratory pressure titration in children with acute respiratory distress syndrome]. Zhongguo Dang Dai Er Ke Za Zhi 2018; 20:706-712. [PMID: 30210020 PMCID: PMC7389168 DOI: 10.7499/j.issn.1008-8830.2018.09.003] [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] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/26/2018] [Indexed: 06/08/2023]
Abstract
The application of small tidal volume and the limitation of airway pressure during mechanical ventilation in acute respiratory distress syndrome (ARDS) are well accepted. Lung recruitment and positive end-expiratory pressure (PEEP) titration can improve oxygenation and protect the lungs. However, the approaches of lung recruitment and PEEP titration remain controversial. This article reviews the lung recruitment maneuvers and PEEP titration in children with ARDS.
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Affiliation(s)
- Wei-Ming Chen
- Department of Pediatric Emergency and Critical Care Medicine, Children's Hospital of Fudan University, Shanghai 201102, China.
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21
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Goligher EC, Hodgson CL, Adhikari NKJ, Meade MO, Wunsch H, Uleryk E, Gajic O, Amato MPB, Ferguson ND, Rubenfeld GD, Fan E. Lung Recruitment Maneuvers for Adult Patients with Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2017; 14:S304-11. [PMID: 29043837 DOI: 10.1513/AnnalsATS.201704-340OT] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE In patients with acute respiratory distress syndrome (ARDS), lung recruitment maneuvers (LRMs) may prevent ventilator-induced lung injury and improve survival. OBJECTIVES To summarize the current evidence in support of the use of LRMs in adult patients with ARDS and to inform the recently published American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline on mechanical ventilation in ARDS. METHODS We conducted a systematic review and meta-analysis of randomized trials comparing mechanical ventilation strategies with and without LRMs. Eligible trials were identified from among previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapy were collected, and results were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS We screened 430 citations and previous systematic reviews and found six trials eligible for inclusion (n = 1,423 patients in total). The type of LRM varied widely between trials, and five of the trials involved a cointervention with a higher positive end-expiratory pressure (PEEP) ventilation strategy. Risk of bias was deemed high in one trial. In the primary analysis, the only trial without a cointervention showed that LRMs were associated with reduced mortality (one trial; risk ratio [RR], 0.62; 95% confidence interval [CI], 0.39-0.98; evidence grade = low). Meta-analysis of all six trials also suggested a significant mortality reduction (six trials; RR, 0.81; 95% CI, 0.69-0.95; evidence grade = moderate), and the use of a higher PEEP cointervention did not significantly modify the mortality effect (P = 0.27 for heterogeneity). LRMs were also associated with improved oxygenation after 24 hours (six trials; mean increase, 52 mm Hg; 95% CI, 23-81 mm Hg) and less frequent requirement for rescue therapy (three trials; RR, 0.65; 95% CI, 0.45-0.94). LRMs were not associated with an increased rate of barotrauma (four trials; RR, 0.84; 95% CI, 0.46-1.55). The rate of hemodynamic compromise was not significantly increased with LRMs (three trials; RR, 1.30; 95% CI, 0.92-1.78). CONCLUSIONS Randomized trials suggest that LRMs in combination with a higher PEEP ventilation strategy reduce mortality, but confidence in this finding is limited. Further trials are required to confirm benefit from LRMs in adults with ARDS.
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Goligher EC, Munshi L, Adhikari NKJ, Meade MO, Hodgson CL, Wunsch H, Uleryk E, Gajic O, Amato MPB, Ferguson ND, Rubenfeld GD, Fan E. High-Frequency Oscillation for Adult Patients with Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Ann Am Thorac Soc 2017; 14:S289-96. [PMID: 29043832 DOI: 10.1513/AnnalsATS.201704-341OT] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE By minimizing tidal lung strain and maintaining alveolar recruitment, high-frequency oscillatory ventilation (HFOV) may protect against ventilator-induced lung injury. OBJECTIVES To summarize the current evidence in support of the use of HFOV in adult patients with acute respiratory distress syndrome. METHODS We conducted a systematic review and meta-analysis of randomized trials comparing mortality rates with the use of HFOV versus conventional mechanical ventilation for adult patients with acute respiratory distress syndrome. Eligible trials were identified from previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapies were collected; effects were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS Six trials were eligible for inclusion (total n = 1,715 patients). Four trials mandated lung-protective ventilation in the control group and one trial applied a higher positive end-expiratory pressure (PEEP) ventilation strategy in the control group. None of the trials were judged to be at high risk of bias, though all were unblinded. In trials that did not systematically employ any cointerventions with HFOV and that targeted low tidal volumes in the patients randomized to conventional ventilation (primary analysis), HFOV had no significant effect on mortality (three trials; risk ratio [RR], 1.14; 95% confidence interval [CI], 0.88 to 1.48; evidence grade = high). Pooled analysis of all six trials also did not suggest a significant mortality reduction (RR, 0.94; 95% CI, 0.71 to 1.24; evidence grade = low). The single trial that employed a conventional ventilation strategy with both lower tidal volumes and higher PEEP as control reported higher mortality in patients receiving HFOV (RR, 1.41; 95% CI, 1.12 to 1.79). HFOV was not associated with improved oxygenation after 24 hours (five trials; mean increase of 10 mm Hg; 95% CI, -16 to 37 mm Hg). Rates of barotrauma were not different between HFOV and conventional ventilation, although significant benefit or harm could not be excluded (RR, 1.15; 95% CI, 0.61 to 2.17). CONCLUSIONS Published randomized trials suggest that HFOV is not associated with a mortality benefit, and may even be harmful in comparison to ventilation with low tidal volumes and higher levels of PEEP.
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Gattinoni L, Collino F, Maiolo G, Rapetti F, Romitti F, Tonetti T, Vasques F, Quintel M. Positive end-expiratory pressure: how to set it at the individual level. Ann Transl Med 2017; 5:288. [PMID: 28828363 DOI: 10.21037/atm.2017.06.64] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The positive end-expiratory pressure (PEEP), since its introduction in the treatment of acute respiratory failure, up to the 1980s was uniquely aimed to provide a viable oxygenation. Since the first application, a large debate about the criteria for selecting the PEEP levels arose within the scientific community. Lung mechanics, oxygen transport, venous admixture thresholds were all proposed, leading to PEEP recommendations from 5 up to 25 cmH2O. Throughout this period, the main concern was the hemodynamics. This paradigm changed during the 1980s after the wide acceptance of atelectrauma as one of the leading causes of ventilator induced lung injury. Accordingly, the PEEP aim shifted from oxygenation to lung protection. In this framework, the prevention of lung opening and closing became an almost unquestioned dogma. Consequently, as PEEP keeps open the pulmonary units opened during the previous inspiratory phase, new methods were designed to identify the 'optimal' PEEP during the expiratory phase. The open lung approach requires that every collapsed unit potentially openable is opened and maintained open. The methods to assess the recruitment are based on imaging (computed tomography, electric impedance tomography, ultrasound) or mechanically-driven gas exchange modifications. All the latest assume that whatever change in respiratory system compliance is due to changes in lung compliance, which in turn is uniquely function of the recruitment. Comparative studies, however, showed that the only possible approach to measure the amount of collapsed tissue regaining inflation is the CT scan. In fact, all the other methods estimate as recruitment the gas entry in pulmonary units already open at lower PEEP, but increasing their compliance at higher PEEP. Since higher PEEP is usually more indicated (also for oxygenation) when the recruitability is higher, as occurs with increasing severity, a meaningful PEEP selection requires the assessment of recruitment. The Berlin definition may help in this assessment.
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Francesca Collino
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Giorgia Maiolo
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Francesca Rapetti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Tommaso Tonetti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Francesco Vasques
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
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Abstract
OBJECTIVE To determine the strength of the evidence evaluating the effectiveness of intrapulmonary percussive ventilation (IPV) as a safe alternative or adjunctive therapy to traditional chest physiotherapy (CPT) among potential organ donors. DATA SOURCES Literature search conducted from February 2015 to November 2015 using PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and bibliographies of pertinent articles. Search Terms: Intrapulmonary percussive ventilation, chest physiotherapy, chest wall oscillation, organ donors, and ventilation. STUDY SELECTION Articles in English from 1994 to present directly compared IPV to CPT or conventional (no) therapy. DATA EXTRACTION Association of Critical-Care Nurses Levels of Evidence was used to determine the strength of evidence. Level B and level C articles were reviewed. DATA SYNTHESIS No studies were found using IPV in the donor population. Results from studies using IPV in other populations indicated IPV had no adverse effects, improved sputum clearance and oxygenation, and reduced atelectasis and pneumonia in patients with artificial airways. CONCLUSION Intrapulmonary percussive ventilation may be a safe and effective alternative or adjunctive to CPT therapy and improve the number of lungs available for transplantation. Clinical research is essential to determine the effectiveness of this therapy for lung recruitment in the donor population.
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Affiliation(s)
- Geralyn Lerg
- 1 College of Nursing and Professional Disciplines, University of North Dakota, Grand Forks, ND, USA
| | - Linda Shanta
- 1 College of Nursing and Professional Disciplines, University of North Dakota, Grand Forks, ND, USA
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Santini A, Protti A, Langer T, Comini B, Monti M, Sparacino CC, Dondossola D, Gattinoni L. Prone position ameliorates lung elastance and increases functional residual capacity independently from lung recruitment. Intensive Care Med Exp 2015; 3:55. [PMID: 26215819 PMCID: PMC4480350 DOI: 10.1186/s40635-015-0055-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [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: 04/15/2015] [Accepted: 05/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prone position is used to recruit collapsed dependent lung regions during severe acute respiratory distress syndrome, improving lung elastance and lung gas content. We hypothesised that, in the absence of recruitment, prone position would not result in any improvement in lung mechanical properties or gas content compared to supine position. METHODS Ten healthy pigs under general anaesthesia and paralysis underwent a pressure-volume curve of the respiratory system, chest wall and lung in supine and prone positions; the respective elastances were measured. A lung computed tomography (CT) scan was performed in the two positions to compute gas content (i.e. functional residual capacity (FRC)) and the distribution of aeration. Recruitment was defined as a percentage change in non-aerated lung tissue compared to the total lung weight. RESULTS Non-aerated (recruitable) lung tissue was a small percentage of the total lung tissue weight in both positions (4 ± 3 vs 1 ± 1 %, supine vs prone, p = 0.004). Lung elastance decreased (20.5 ± 1.8 vs 15.5 ± 1.6 cmH2O/l, supine vs prone, p < 0.001) and functional residual capacity increased (380 ± 82 vs 459 ± 60 ml, supine vs prone, p = 0.025) in prone position; specific lung elastance did not change (7.0 ± 0.5 vs 6.5 ± 0.5 cmH2O, supine vs prone, p = 0.24). Lung recruitment was low (3 ± 2 %) and was not correlated to increases in functional residual capacity (R (2) 0.2, p = 0.19). A higher amount of well-aerated and a lower amount of poorly aerated lung tissue were found in prone position. CONCLUSIONS In healthy pigs, prone position ameliorates lung mechanical properties and increases functional residual capacity independently from lung recruitment, through a redistribution of lung aeration.
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Affiliation(s)
- Alessandro Santini
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Alessandro Protti
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Thomas Langer
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Beatrice Comini
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Massimo Monti
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Cristina Carin Sparacino
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Daniele Dondossola
- />Centro di Ricerche Chirurgiche Precliniche, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luciano Gattinoni
- />Dipartimento di Fisiopatologica Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Francesco Sforza 35, 20122 Milan, Italy
- />Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico di Milano, Milan, Italy
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Li DK, Liu DW, Long Y, Wang XT. Use of Lung Ultrasound to Assess the Efficacy of an Alveolar Recruitment Maneuver in Rabbits With Acute Respiratory Distress Syndrome. J Ultrasound Med 2015; 34:2209-2215. [PMID: 26543168 DOI: 10.7863/ultra.14.11051] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/17/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To investigate the application of lung ultrasound (US) in the evaluation and implementation of alveolar recruitment maneuvers in acute respiratory distress syndrome (ARDS). METHODS Twelve rabbits with saline lavage-induced lung injury were randomly divided into 2 groups: one with alveolar recruitment guided by lung US and the other with alveolar recruitment guided by maximal oxygenation. Recruitment maneuvers were applied according to a stepwise incremental positive end-expiratory pressure method in both groups. In the oxygenation group, a sum of the partial pressures of oxygen and carbon dioxide exceeding 400 mm Hg was used to define adequate recruitment. In the lung US group, a new protocol for reaeration in US-guided lung recruitment was used to guide treatment. Evaluation by lung US, respiratory mechanical parameters, the Smith pathologic score (Crit Care Med 1997; 25:1888-1897), and wet-to-dry ratio were compared between the groups. RESULTS Opening pressure was significantly higher in the lung US group (mean ± SD, 23.4 ± 3.4 cm H2O) than the oxygenation group (18.7 ± 2.1 cm H2O; P < .05). The reaeration score in the lung US group significantly increased during alveolar recruitment (6.5 ± 1.6 points at baseline versus 13.8 ± 3.0 points after completion; P < .05). Lung compliance, dead space shunts, the Smith pathologic score, and tissue wet-to-dry ratio, however, were not significantly different between the groups. CONCLUSIONS Lung US is an effective means of evaluating and guiding alveolar recruitment in ARDS. Compared with the maximal oxygenation-guided method, the protocol for reaeration in US-guided lung recruitment achieved a higher opening pressure, resulted in greater improvements in lung aeration, and substantially reduced lung heterogeneity in ARDS.
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Affiliation(s)
- Dong-kai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Da-wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Lovas A, Németh MF, Trásy D, Molnár Z. Lung recruitment can improve oxygenation in patients ventilated in continuous positive airway pressure/pressure support mode. Front Med (Lausanne) 2015; 2:25. [PMID: 25954744 PMCID: PMC4404945 DOI: 10.3389/fmed.2015.00025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 02/13/2015] [Accepted: 04/05/2015] [Indexed: 11/28/2022] Open
Abstract
Background Recruitment maneuvers are often used in critical care patients with hypoxemic respiratory failure. Although continuous positive airway pressure/pressure support (CPAP/PS) ventilation is a frequently used approach, but whether lung recruitment also improves oxygenation in spontaneously breathing patients has not been investigated yet. The primary objective was to analyze the effect of recruitment maneuver on oxygenation in patients ventilated in CPAP/PS mode. Methods Following baseline measurements PEEP was increased by 5 cmH2O. Recruitment maneuver was applied for 40 s with 40 cmH2O of PS. Measurements of the difference in PaO2/FiO2 and airway parameters measured by the ventilator were recorded immediately after recruitment then 15 and 30 min later. Thirty patients ventilated in CPAP/PS mode with a PEEP ≥5 cmH2O were enrolled in this prospective, observational study if their PaO2/FiO2 ratio was <300 mmHg or required an FiO2 >0.5. Results Following recruitment maneuver patients were considered as non-responders (NR, n = 15) if difference of PaO2/FiO2 <20% and responders (R, n = 15) if difference of PaO2/FiO2 ≥20%. In the NR-group, PaO2/FiO2 decreased non-significantly from baseline: median [interquartile], PaO2/FiO2 = 176 [120–186] vs. after recruitment: 169 [121–182] mmHg, P = 0.307 while in the R-group there was significant improvement: 139 [117–164] vs. 230 [211–323] mmHg, P = 0.01. At the same time points, dead space to tidal volume ratio (Vds/Vte) significantly increased in the NR-group Vds/Vte = 32 [27–37] vs. 36 [25–42]%, P = 0.013 but no significant change was observed in the R-group: 26 [22–34] vs. 27 [24–33]%, P = 0.386. Conclusion Recruitment maneuver improved PaO2/FiO2 ratio by ≥20% in 50% of patients ventilated in CPAP/PS mode.
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Affiliation(s)
- András Lovas
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
| | - Márton Ferenc Németh
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
| | - Domonkos Trásy
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
| | - Zsolt Molnár
- Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged , Szeged , Hungary
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Tingay DG, Polglase GR, Bhatia R, Berry CA, Kopotic RJ, Kopotic CP, Song Y, Szyld E, Jobe AH, Pillow JJ. Pressure-limited sustained inflation vs. gradual tidal inflations for resuscitation in preterm lambs. J Appl Physiol (1985) 2015; 118:890-7. [PMID: 25635005 DOI: 10.1152/japplphysiol.00985.2014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [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: 11/05/2014] [Accepted: 01/26/2015] [Indexed: 01/09/2023] Open
Abstract
Support of the mechanically complex preterm lung needs to facilitate aeration while avoiding ventilation heterogeneities: whether to achieve this gradually or quickly remains unclear. We compared the effect of gradual vs. constant tidal inflations and a pressure-limited sustained inflation (SI) at birth on gas exchange, lung mechanics, gravity-dependent lung volume distribution, and lung injury in 131-day gestation preterm lambs. Lambs were resuscitated with either 1) a 20-s, 40-cmH2O pressure-limited SI (PressSI), 2) a gradual increase in tidal volume (Vt) over 5-min from 3 ml/kg to 7 ml/kg (IncrVt), or 3) 7 ml/kg Vt from birth. All lambs were subsequently ventilated for 15 min with 7 ml/kg Vt with the same end-expiratory pressure. Lung mechanics, gas exchange and spatial distribution of end-expiratory volume (EEV), and tidal ventilation (electrical impedance tomography) were recorded regularly. At 15 min, early mRNA tissue markers of lung injury were assessed. The IncrVt group resulted in greater tissue hysteresivity at 5 min (P = 0.017; two-way ANOVA), higher alveolar-arterial oxygen difference from 10 min (P < 0.01), and least uniform gravity-dependent distribution of EEV. There were no other differences in lung mechanics between groups, and the PressSI and 7 ml/kg Vt groups behaved similarly throughout. EEV was more uniformly distributed, but Vt least so, in the PressSI group. There were no differences in mRNA markers of lung injury. A gradual increase in Vt from birth resulted in less recruitment of the gravity-dependent lung with worse oxygenation. There was no benefit of a SI at birth over mechanical ventilation with 7 ml/kg Vt.
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Affiliation(s)
- David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Neonatology, The Royal Children's Hospital, Melbourne, Victoria, Australia; Neonatal Research, The Royal Women's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, MIMR-PHI Institute of Medical Research, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Risha Bhatia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Neonatology, The Royal Children's Hospital, Melbourne, Victoria, Australia; Neonatal Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Clare A Berry
- Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | | | | | - Yong Song
- Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, Australia; School of Anatomy, Physiology and Human Biology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Edgardo Szyld
- Universidad Abierta Interamericana (UAI), Buenos Aires, Argentina; Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Alan H Jobe
- Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio
| | - J Jane Pillow
- Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, Australia; School of Anatomy, Physiology and Human Biology, The University of Western Australia, Crawley, Western Australia, Australia;
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Abstract
Previous studies have shown that lung recruitment maneuvers are important means of treating ARDS. Although computed tomography (CT) scans and pressure-volume curves are the most common ways to evaluate lung recruitment, there are still many disadvantages. Not only do the scans have to take place in a CT room, but the patient is exposed to large doses of radiation through the multiple scans necessary to define the optimal PEEP. Pressure-volume curves require deep sedation and muscle relaxation. Thus, bedside lung ultrasound may be considered to be a safer and easier alternative to CT scans or pressure-volume curves. In our case, we evaluated the effectiveness of lung recruitment with a bedside ultrasound on a patient who was suffering from life-threatening hypoxemia. Bedside ultrasound is a faster and more convenient imaging method because it reduces the need for patient transport compared with CT scan and requires no muscle relaxation. This case supports that ultrasound may become an alternative imaging tool to guide and evaluate alveolar recruitment in patients with ARDS. Additionally, we have also included a brief review of lung recruitment evaluation by ultrasound to supplement this case study.
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Affiliation(s)
- Jiang Du
- Department of Critical Care Medicine, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jiuting Tan
- Department of Critical Care Medicine, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Kanglong Yu
- Department of Critical Care Medicine, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ruilan Wang
- Department of Critical Care Medicine, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China.
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Hanson A, Göthberg S, Nilsson K, Hedenstierna G. Recruitment and PEEP level influences long-time aeration in saline-lavaged piglets: an experimental model. Paediatr Anaesth 2012; 22:1072-9. [PMID: 22340954 DOI: 10.1111/j.1460-9592.2012.03817.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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate aeration/ventilation in saline-lavaged piglets during a 3-h follow-up after a recruitment maneuver (RM)/PEEP titration compared with PEEP 10 cmH2O without a RM. BACKGROUND Lung recruitment and PEEP titration are used to find a PEEP preventing repetitive opening/collapsing of lung. METHODS Twenty-one lung-lavaged piglets, mean age 7 weeks and mean weight 10 kg; a RM-group and a PEEP10-group, were ventilated at PEEP 5 cmH2O (baseline) followed by zero PEEP ventilation. In the RM-group, tidal elimination of CO2 and dynamic compliance (Cdyn) guided recruitment and PEEP titration, respectively. A final 3-h ventilation followed using PEEP 2 cmH2O above the first decline of Cdyn and end-inspiratory pressure (EIP) for a target tidal volume (VT) of 10 ml · kg(-1). In the PEEP10-group, PEEP 10 cmH2O without a RM was used during the final 3-h ventilation. CT scans and blood gases were repeated every 30 min. Airway pressures, Cdyn and hemodynamics were continuously recorded. RESULTS Aeration improved without differences between groups. The RM-group PEEP level of 10 ± 0.6 cmH2O did not differ from the PEEP10-group. Compared to baseline EIP was lower in the RM-group after 3-h ventilation. In both groups, driving pressure (DP) was lower and Cdyn higher than baseline. In the RM-group, final EIP and DP were lower and Cdyn higher than in the PEEP10-group. CONCLUSIONS Both RM/PEEP titration and PEEP elevation resulted in improved aeration without differences between groups at the end point. Lung aeration was achieved at lower EIP and DP and higher Cdyn in the RM-group than in the PEEP10-group.
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Affiliation(s)
- Angela Hanson
- The Department of Paediatric Anaesthesia and Intensive Care, The Queen Silvia Children's Hospital, University of Gothenburg, Göteborg, Sweden.
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