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Tonna JE, Selzman CH, Bartos JA, Presson AP, Ou Z, Jo Y, Becker LB, Youngquist ST, Thiagarajan RR, Austin Johnson M, Cho SM, Rycus P, Keenan HT. The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest. Resuscitation 2022; 174:53-61. [PMID: 35331803 PMCID: PMC9050917 DOI: 10.1016/j.resuscitation.2022.03.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 01/19/2023]
Abstract
RESEARCH QUESTION Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival? METHODS Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival. RESULTS Hospital survival was decreased with higher PaO2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume. CONCLUSION Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA. https://twitter.com/JoeTonnaMD
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Yeonjung Jo
- Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Lance B Becker
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA
| | - Scott T Youngquist
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Ravi R Thiagarajan
- Division of Cardiac Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Austin Johnson
- Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Department of Neurology, Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Heather T Keenan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
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Chiumello D, Coppola S, Formenti P, Ciabattoni A, Lucenteforte M, Liu G, Mao W, Pozzi T. A validation study of a continuous automatic measurement of the mechanical power in ARDS patients. J Crit Care 2021; 67:21-25. [PMID: 34624699 DOI: 10.1016/j.jcrc.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 01/18/2023]
Abstract
The mechanical power (MP) is the energy delivered into the respiratory system over time. It can be computed as a direct measurement of the inspiratory area of the airway pressure and volume loop during the respiratory cycle or calculated by "power equations". The absence of a bedside computation limited its widespread use. Recently, it has been developed an automatic monitoring system inside of a mechanical ventilator. PURPOSE Our aim was to investigate the repeatability and the accuracy of the measured MP at different PEEP values and tidal volume compared with the calculated MP. MATERIAL AND METHODS MP was measured and calculated in sedated and paralyzed ARDS patients at low and high tidal volume, at 5-10-15 cmH2O of PEEP both in volume and pressure-controlled ventilation. The same measurements were performed twice. RESULTS Fifty ARDS patients were enrolled. MP was measured and calculated for a total of 300 measurements. The bias and limits of agreement were 0.38 from -1.31 to 2.0 J/min. The measured and calculated MP were similar in each ventilatory condition. CONCLUSIONS The mechanical power measured by a new automatic real time system implemented in a mechanical ventilator was repeatable and accurate compared with the computed one.
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Affiliation(s)
- D Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy; Department of Health Sciences, University of Milan, Milano, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - S Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
| | - P Formenti
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
| | - A Ciabattoni
- Department of Health Sciences, University of Milan, Milano, Italy
| | - M Lucenteforte
- Department of Health Sciences, University of Milan, Milano, Italy
| | - G Liu
- Department of Emergency and Intensive Care, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - W Mao
- Department of Emergency and Intensive Care, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - T Pozzi
- Department of Health Sciences, University of Milan, Milano, Italy
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Apostel HJCL, Duval ELIM, De Dooy J, Jorens PG, Schepens T. Respiratory support in the absence of abdominal muscles: A case study of ventilatory management in prune belly syndrome. Paediatr Respir Rev 2021; 37:44-47. [PMID: 33349558 DOI: 10.1016/j.prrv.2020.07.002] [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] [Received: 06/01/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
Prune belly syndrome (PBS) results in a total lack of abdominal musculature. Abdominal muscles have an important function during inspiration and expiration. This puts the patient at risk for respiratory complications since they have a very limited ability to cough up secretions. Patients in an intensive care unit (ICU) with PBS who receive mechanical ventilation are at even greater risk for respiratory complications. We review the function of the abdominal muscles in breathing and delineate why they are important in the ICU. We include an illustrative case of a long-term ventilated patient with PBS and offer respiratory management options.
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Affiliation(s)
- Heleen J C L Apostel
- Departement of Anesthesiology and Pain Management, Maastricht Universitair Medisch Centrm, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.
| | - Els L I M Duval
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Jozef De Dooy
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Philippe G Jorens
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Tom Schepens
- Departement of Critical Care, Universitair Ziekenhuis Antwerpen, Wilrijkstraat 10, 2650 Edegem, Belgium
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Murakami T, Yamaji H, Numa K, Kawamura H, Murakami M, Higashiya S, Kamikawa S, Hina K, Hirohata S, Kusachi S. Adaptive-servo ventilation combined with deep sedation is an effective strategy during pulmonary vein isolation. Europace 2013; 15:951-6. [PMID: 23419657 DOI: 10.1093/europace/eut007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS Pulmonary vein isolation (PVI) by catheter ablation for atrial fibrillation (AF) requires suppression of patient restlessness by sufficient sedation in addition to maintaining stable respiration. We applied adaptive-servo ventilation (ASV) and examined the effects of ASV combined with deep propofol sedation on PVI using a NavX. METHODS AND RESULTS We analysed 75 paroxysmal AF (PAF) patients (62 ± 11 years; 53 men and 22 women) who underwent PVI for treatment of PAF using an ASV system combined with deep sedation (ASV group). Control patients included 75 consecutive PAF patients (62 ± 11 years; 51 men and 24 women) who underwent PVI just before introduction of the ASV system. Deep sedation was defined as a Ramsay sedation score of 6. The ASV group had a lower frequency of restless body movements compared with the control group during PVI (1.5 ± 0.7 vs. 7.8 ± 1.4 times, P < 0.01). The frequency of respiratory compensation and EnGuide alignment of catheter position by the NavX was lower in the ASV (4.2 ± 3.3 and 8.8 ± 7.1 times) than control group (7.1 ± 5.1 and 15.2 ± 10.0 times, P < 0.05 and <0.01, respectively). Consequently, significantly lower total electrical energy supply (48.7 ± 6.0 KJ) was required in the ASV than control group (64.5 ± 24.9 KJ, P < 0.01). Further, significantly shorter fluoroscopy and procedural times were observed in the ASV (28 ± 5 and 109 ± 25 min) than the control group (33 ± 6 and 141 ± 38 min, respectively, P < 0.01) and the AF recurrence rate was significantly lower in the ASV than the control group (12 vs. 25%, P < 0.01). CONCLUSION ASV combined with deep sedation is an effective strategy during PVI using the NavX in patients with PAF.
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