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Beauchamp FO, Thériault J, Sauthier M. Tailoring ventilation and respiratory management in pediatric critical care: optimizing care with precision medicine. Curr Opin Pediatr 2025; 37:223-232. [PMID: 40327352 DOI: 10.1097/mop.0000000000001449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2025]
Abstract
PURPOSE OF REVIEW Critically ill children admitted to the intensive care unit frequently need respiratory care to support the lung function. Mechanical ventilation is a complex field with multiples parameters to set. The development of precision medicine will allow clinicians to personalize respiratory care and improve patients' outcomes. RECENT FINDINGS Lung and diaphragmatic ultrasound, electrical impedance tomography, neurally adjusted ventilatory assist ventilation, as well as the use of monitoring data in machine learning models are increasingly used to tailor care. Each modality offers insights into different aspects of the patient's respiratory system function and enables the adjustment of treatment to better support the patient's physiology. Precision medicine in respiratory care has been associated with decreased ventilation time, increased extubation and ventilation wean success and increased ability to identify phenotypes to guide treatment and predict outcomes. This review will focus on the use of precision medicine in the setting of pediatric acute respiratory distress syndrome, asthma, bronchiolitis, extubation readiness trials and ventilation weaning, ventilation acquired pneumonia and other respiratory tract infections. SUMMARY Precision medicine is revolutionizing respiratory care and will decrease complications associated with ventilation. More research is needed to standardize its use and better evaluate its impact on patient outcomes.
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Affiliation(s)
- Francis-Olivier Beauchamp
- CHU Sainte-Justine, Université de Montréal, Chemin de la Côte-Sainte-Catherine, Montréal, QC, Canada
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Maia IS, Cavalcanti AB, Tramujas L, Veiga VC, Oliveira JS, Sady ERR, Barbante LG, Nicola ML, Gurgel RM, Damiani LP, Negrelli KL, Miranda TA, Laranjeira LN, Tomazzini B, Zandonai C, Pincelli MP, Westphal GA, Fernandes RP, Figueiredo R, Sartori Bustamante CL, Norbin LF, Boschi E, Lessa R, Romano MP, Miura MC, Soares de Alencar Filho M, Cés de Souza Dantas V, Barreto PA, Hernandes ME, Grion C, Laranjeira AS, Mezzaroba AL, Bahl M, Starke AC, Biondi R, Dal-Pizzol F, Caser E, Thompson MM, Padial AA, Leite RT, Araújo G, Guimarães M, Aquino P, Lacerda F, Hoffmann Filho CR, Melro L, Pacheco E, Ospina-Táscon G, Ferreira JC, Calado Freires FJ, Machado FR, Zampieri FG. Effect of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome secondary to community-acquired pneumonia: the STAMINA randomised clinical trial. Br J Anaesth 2025; 134:693-702. [PMID: 39592365 PMCID: PMC11867071 DOI: 10.1016/j.bja.2024.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 10/22/2024] [Accepted: 10/22/2024] [Indexed: 11/28/2024] Open
Abstract
BACKGROUND This study aimed to assess whether a driving pressure-limiting strategy based on positive end-expiratory pressure (PEEP) titration according to best respiratory system compliance and tidal volume adjustment increases the number of ventilator-free days within 28 days in patients with moderate to severe acute respiratory distress syndrome (ARDS). METHODS This is a multi-centre, randomised trial, enrolling adults with moderate to severe ARDS secondary to community-acquired pneumonia. Patients were randomised to a driving pressure-limiting strategy or low PEEP strategy based on a PEEP:FiO2 table. All patients received volume assist-control mode until day 3 or when considered ready for spontaneous modes of ventilation. The primary outcome was ventilator-free days within 28 days. Secondary outcomes were in-hospital and intensive care unit mortality at 90 days. RESULTS The trial was stopped because of recruitment fatigue after 214 patients were randomised. In total, 198 patients (n=96 intervention group, n=102 control group) were available for analysis (median age 63 yr, [interquartile range 47-73 yr]; 36% were women). The mean difference in driving pressure up to day 3 between the intervention and control groups was -0.7 cm H2O (95% confidence interval -1.4 to -0.1 cm H2O). Mean ventilator-free days were 6 (sd 9) in the driving pressure-limiting strategy group and 7 (9) in the control group (proportional odds ratio 0.72, 95% confidence interval 0.39-1.32; P=0.28). There were no significant differences regarding secondary outcomes. CONCLUSIONS In patients with moderate to severe ARDS secondary to community-acquired pneumonia, a driving pressure-limiting strategy did not increase the number of ventilator-free days compared with a standard low PEEP strategy within 28 days. CLINICAL TRIAL REGISTRATION NCT04972318.
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Affiliation(s)
- Israel Silva Maia
- Instituto de Pesquisa Hcor, São Paulo, Brazil; Divisão de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Nereu Ramos, Florianópolis, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - Alexandre Biasi Cavalcanti
- Instituto de Pesquisa Hcor, São Paulo, Brazil; Divisão de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | | | - Viviane Cordeiro Veiga
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | | | | | | | | | - Bruno Tomazzini
- Instituto de Pesquisa Hcor, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | | | | | - Glauco Adrieno Westphal
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Centro Hospitalar Unimed Joinville, Joinville, Brazil
| | | | - Rodrigo Figueiredo
- Hospital e Maternidade São José, Colatina, Brazil; Linhares Medical Centre, Linhares, Brazil
| | | | | | | | - Rafael Lessa
- Hospital Geral de Caxias do Sul, Caxias do Sul, Brazil
| | | | | | | | | | | | | | - Cintia Grion
- Hospital Universitário da Universidade Estadual de Londrina, Londrina, Brazil; Hospital Araucária de Londrina, Londrina, Brazil
| | | | | | - Marina Bahl
- Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Ana Carolina Starke
- Hospital Universitário da Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Rodrigo Biondi
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Hospital Brasília, Brasília, Brazil
| | - Felipe Dal-Pizzol
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Hospital São José, Criciúma, Brazil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Juliana Carvalho Ferreira
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Flávia Ribeiro Machado
- Divisão de Anestesiologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Departamento de Anestesiologia, Dor e Medicina Intensiva, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Fernando Godinho Zampieri
- Instituto de Pesquisa Hcor, São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Service, Edmonton, AB, Canada.
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Fiedler-Kalenka MO, Brenner T, Bernhard M, Reuß CJ, Beynon C, Hecker A, Jungk C, Nusshag C, Michalski D, Weigand MA, Dietrich M. [Focus on ventilation, oxygen therapy and weaning 2022-2024 : Summary of selected intensive care studies]. DIE ANAESTHESIOLOGIE 2024; 73:698-711. [PMID: 39210065 DOI: 10.1007/s00101-024-01455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/04/2024]
Affiliation(s)
- M O Fiedler-Kalenka
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
- Translationales Lungenforschungszentrum Heidelberg (TLRC-H), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine Universität, Düsseldorf, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - A Hecker
- Klinik für Allgemein- Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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Boesing C, Rocco PRM, Luecke T, Krebs J. Positive end-expiratory pressure management in patients with severe ARDS: implications of prone positioning and extracorporeal membrane oxygenation. Crit Care 2024; 28:277. [PMID: 39187853 PMCID: PMC11348554 DOI: 10.1186/s13054-024-05059-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024] Open
Abstract
The optimal strategy for positive end-expiratory pressure (PEEP) titration in the management of severe acute respiratory distress syndrome (ARDS) patients remains unclear. Current guidelines emphasize the importance of a careful risk-benefit assessment for PEEP titration in terms of cardiopulmonary function in these patients. Over the last few decades, the primary goal of PEEP usage has shifted from merely improving oxygenation to emphasizing lung protection, with a growing focus on the individual pattern of lung injury, lung and chest wall mechanics, and the hemodynamic consequences of PEEP. In moderate-to-severe ARDS patients, prone positioning (PP) is recommended as part of a lung protective ventilation strategy to reduce mortality. However, the physiologic changes in respiratory mechanics and hemodynamics during PP may require careful re-assessment of the ventilation strategy, including PEEP. For the most severe ARDS patients with refractory gas exchange impairment, where lung protective ventilation is not possible, veno-venous extracorporeal membrane oxygenation (V-V ECMO) facilitates gas exchange and allows for a "lung rest" strategy using "ultraprotective" ventilation. Consequently, the importance of lung recruitment to improve oxygenation and homogenize ventilation with adequate PEEP may differ in severe ARDS patients treated with V-V ECMO compared to those managed conservatively. This review discusses PEEP management in severe ARDS patients and the implications of management with PP or V-V ECMO with respect to respiratory mechanics and hemodynamic function.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Zaidi SF, Shaikh A, Khan DA, Surani S, Ratnani I. Driving pressure in mechanical ventilation: A review. World J Crit Care Med 2024; 13:88385. [PMID: 38633474 PMCID: PMC11019631 DOI: 10.5492/wjccm.v13.i1.88385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024] Open
Abstract
Driving pressure (∆P) is a core therapeutic component of mechanical ventilation (MV). Varying levels of ∆P have been employed during MV depending on the type of underlying pathology and severity of injury. However, ∆P levels have also been shown to closely impact hard endpoints such as mortality. Considering this, conducting an in-depth review of ∆P as a unique, outcome-impacting therapeutic modality is extremely important. There is a need to understand the subtleties involved in making sure ∆P levels are optimized to enhance outcomes and minimize harm. We performed this narrative review to further explore the various uses of ∆P, the different parameters that can affect its use, and how outcomes vary in different patient populations at different pressure levels. To better utilize ∆P in MV-requiring patients, additional large-scale clinical studies are needed.
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Affiliation(s)
- Syeda Farheen Zaidi
- Department of Medicine, Queen Mary University, London E1 4NS, United Kingdom
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Sindh, Karachi 74500, Pakistan
| | - Daniyal Aziz Khan
- Department of Medicine, Jinnah Postgraduate Medical Center, Sindh, Karachi 75510, Pakistan
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A and M University, College Station, TX 77843, United States
| | - Iqbal Ratnani
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, TX 77030, United States
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Boesing C, Schaefer L, Graf PT, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies on mechanical power during ultraprotective ventilation in ARDS patients treated with veno-venous extracorporeal membrane oxygenation: A prospective interventional study. J Crit Care 2024; 79:154406. [PMID: 37690365 DOI: 10.1016/j.jcrc.2023.154406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 05/13/2023] [Accepted: 07/09/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Ultraprotective ventilation in acute respiratory distress syndrome (ARDS) patients with veno-venous extracorporeal membrane oxygenation (VV ECMO) reduces mechanical power (MP) through changes in positive end-expiratory pressure (PEEP); however, the optimal approach to titrate PEEP is unknown. This study assesses the effects of three PEEP titration strategies on MP, hemodynamic parameters, and oxygen delivery in twenty ARDS patients with VV ECMO. MATERIAL AND METHODS PEEP was titrated according to: (A) a PEEP of 10 cmH2O representing the lowest recommendation by the Extracorporeal Life Support Organization (PEEPELSO), (B) the highest static compliance of the respiratory system (PEEPCstat,RS), and (C) a target end-expiratory transpulmonary pressure of 0 cmH2O (PEEPPtpexp). RESULTS PEEPELSO was lower compared to PEEPCstat,RS and PEEPPtpexp (10.0 ± 0.0 vs. 16.2 ± 4.7 cmH2O and 17.3 ± 4.0 cmH2O, p < 0.001 each, respectively). PEEPELSO reduced MP compared to PEEPCstat,RS and PEEPPtpexp (5.3 ± 1.3 vs. 6.8 ± 2.0 and 6.9 ± 2.3 J/min, p < 0.001 each, respectively). PEEPELSO resulted in less lung stress compared to PEEPCstat,RS (p = 0.011) and PEEPPtpexp (p < 0.001) and increased cardiac output and oxygen delivery (p < 0.001 each). CONCLUSIONS An empirical PEEP of 10 cmH2O minimized MP, provided favorable hemodynamics, and increased oxygen delivery in ARDS patients treated with VV ECMO. TRIAL REGISTRATION German Clinical Trials Register (DRKS00013967). Registered 02/09/2018https://drks.de/search/en/trial/DRKS00013967.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Peter T Graf
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil.
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
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Roca O, Goligher EC, Amato MBP. Driving pressure: applying the concept at the bedside. Intensive Care Med 2023; 49:991-995. [PMID: 37191695 DOI: 10.1007/s00134-023-07071-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Oriol Roca
- Servei de Medicina Intensiva, Parc Taulí Hospital Universitari, Institut de Recerca Part Taulí-I3PT, Parc del Taulí 1, 08028, Sabadell, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain.
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute Toronto, Toronto, ON, Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Rali AS, Tran LE, Auvil B, Xu M, Huang S, Labrada L, Schlendorf KH, Bacchetta MD, Shah AS, Hernandez A, Lindenfeld J. Modifiable Mechanical Ventilation Targets Are Associated With Improved Survival in Ventilated VA-ECLS Patients. JACC. HEART FAILURE 2023; 11:961-968. [PMID: 37178085 PMCID: PMC10171237 DOI: 10.1016/j.jchf.2023.03.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/29/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In acute respiratory distress syndrome (ARDS), lung protective ventilation (LPV) improves patient outcomes by minimizing ventilator-induced lung injury. The value of LPV in ventilated patients with cardiogenic shock (CS) requiring venoarterial extracorporeal life support (VA-ECLS) is not known, but the extracorporeal circuit provides a unique opportunity to modify ventilatory parameters to improve outcomes. OBJECTIVES The authors hypothesized that CS patients on VA-ECLS who require mechanical ventilation (MV) may benefit from low intrapulmonary pressure ventilation (LPPV), which has the same end goals as LPV. METHODS The authors queried the ELSO (Extracorporeal Life Support Organization) registry for hospital admissions between 2009 and 2019 for CS patients on VA-ECLS and MV. They defined LPPV as peak inspiratory pressure at 24 hours on ECLS of <30 cm H2O. Positive end-expiration pressure and dynamic driving pressure (DDP) at 24 hours were also studied as continuous variables. Their primary outcome was survival to discharge. Multivariable analyses were performed that adjusted for baseline Survival After Venoarterial Extracorporeal Membrane Oxygenation score, chronic lung conditions, and center extracorporeal membrane oxygenation volume. RESULTS A total of 2,226 CS patients on VA-ECLS were included: 1,904 received LPPV. The primary outcome was higher in the LPPV group vs the no-LPPV group (47.4% vs 32.6%; P < 0.001). Median peak inspiratory pressure (22 vs 24 cm H2O; P < 0.001) as well as DDP (14.5 vs 16 cm H2O; P < 0.001) were also significantly lower in those surviving to discharge. The adjusted OR for the primary outcome with LPPV was 1.69 (95% CI: 1.21-2.37; P = 0.0021). CONCLUSIONS LPPV is associated with improved outcomes in CS patients on VA-ECLS requiring MV.
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Affiliation(s)
- Aniket S Rali
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Auvil
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Lyana Labrada
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abstract
PURPOSE OF REVIEW Recent studies have focused on identifying optimal targets and strategies of mechanical ventilation in patients with acute brain injury (ABI). The present review will summarize these findings and provide practical guidance to titrate ventilatory settings at the bedside, with a focus on managing potential brain-lung conflicts. RECENT FINDINGS Physiologic studies have elucidated the impact of low tidal volume ventilation and varying levels of positive end expiratory pressure on intracranial pressure and cerebral perfusion. Epidemiologic studies have reported the association of different thresholds of tidal volume, plateau pressure, driving pressure, mechanical power, and arterial oxygen and carbon dioxide concentrations with mortality and neurologic outcomes in patients with ABI. The data collectively make clear that injurious ventilation in this population is associated with worse outcomes; however, optimal ventilatory targets remain poorly defined. SUMMARY Although direct data to guide mechanical ventilation in brain-injured patients is accumulating, the current evidence base remains limited. Ventilatory considerations in this population should be extrapolated from high-quality evidence in patients without brain injury - keeping in mind relevant effects on intracranial pressure and cerebral perfusion in patients with ABI and individualizing the chosen strategy to manage brain-lung conflicts where necessary.
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Affiliation(s)
- Shaurya Taran
- Department of Neurology, Massachusetts General Hospital, Harvard University, Boston, MA, USA
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Wahlster
- Department of Neurology
- Department of Neurological Surgery
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Chiara Robba
- IRCCS, Policlinico San Martino
- Department of Surgical Sciences and Diagnostic Integrated, University of Genoa, Genoa, Italy
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Battaglini D, Fazzini B, Silva PL, Cruz FF, Ball L, Robba C, Rocco PRM, Pelosi P. Challenges in ARDS Definition, Management, and Identification of Effective Personalized Therapies. J Clin Med 2023; 12:1381. [PMID: 36835919 PMCID: PMC9967510 DOI: 10.3390/jcm12041381] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Over the last decade, the management of acute respiratory distress syndrome (ARDS) has made considerable progress both regarding supportive and pharmacologic therapies. Lung protective mechanical ventilation is the cornerstone of ARDS management. Current recommendations on mechanical ventilation in ARDS include the use of low tidal volume (VT) 4-6 mL/kg of predicted body weight, plateau pressure (PPLAT) < 30 cmH2O, and driving pressure (∆P) < 14 cmH2O. Moreover, positive end-expiratory pressure should be individualized. Recently, variables such as mechanical power and transpulmonary pressure seem promising for limiting ventilator-induced lung injury and optimizing ventilator settings. Rescue therapies such as recruitment maneuvers, vasodilators, prone positioning, extracorporeal membrane oxygenation, and extracorporeal carbon dioxide removal have been considered for patients with severe ARDS. Regarding pharmacotherapies, despite more than 50 years of research, no effective treatment has yet been found. However, the identification of ARDS sub-phenotypes has revealed that some pharmacologic therapies that have failed to provide benefits when considering all patients with ARDS can show beneficial effects when these patients were stratified into specific sub-populations; for example, those with hyperinflammation/hypoinflammation. The aim of this narrative review is to provide an overview on current advances in the management of ARDS from mechanical ventilation to pharmacological treatments, including personalized therapy.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
| | - Brigitta Fazzini
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London E1 1BB, UK
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Fernanda Ferreira Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 15145 Genoa, Italy
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Boesing C, Graf PT, Schmitt F, Thiel M, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study. Crit Care 2022; 26:82. [PMID: 35346325 PMCID: PMC8962042 DOI: 10.1186/s13054-022-03956-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/19/2022] [Indexed: 01/01/2023] Open
Abstract
Background Prone positioning in combination with the application of low tidal volume and adequate positive end-expiratory pressure (PEEP) improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the effects of PEEP on end-expiratory transpulmonary pressure (Ptpexp) during prone positioning require clarification. For this purpose, the effects of three different PEEP titration strategies on Ptpexp, respiratory mechanics, mechanical power, gas exchange, and hemodynamics were evaluated comparing supine and prone positioning. Methods In forty consecutive patients with moderate to severe ARDS protective ventilation with PEEP titrated according to three different titration strategies was evaluated during supine and prone positioning: (A) ARDS Network recommendations (PEEPARDSNetwork), (B) the lowest static elastance of the respiratory system (PEEPEstat,RS), and (C) targeting a positive Ptpexp (PEEPPtpexp). The primary endpoint was to analyze whether Ptpexp differed significantly according to PEEP titration strategy during supine and prone positioning. Results Ptpexp increased progressively with prone positioning compared with supine positioning as well as with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork (positioning effect p < 0.001, PEEP strategy effect p < 0.001). PEEP was lower during prone positioning with PEEPEstat,RS and PEEPPtpexp (positioning effect p < 0.001, PEEP strategy effect p < 0.001). During supine positioning, mechanical power increased progressively with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork, and prone positioning attenuated this effect (positioning effect p < 0.001, PEEP strategy effect p < 0.001). Prone compared with supine positioning significantly improved oxygenation (positioning effect p < 0.001, PEEP strategy effect p < 0.001) while hemodynamics remained stable in both positions. Conclusions Prone positioning increased transpulmonary pressures while improving oxygenation and hemodynamics in patients with moderate to severe ARDS when PEEP was titrated according to the ARDS Network lower PEEP table. This PEEP titration strategy minimized parameters associated with ventilator-induced lung injury induction, such as transpulmonary driving pressure and mechanical power. We propose that a lower PEEP strategy (PEEPARDSNetwork) in combination with prone positioning may be part of a lung protective ventilation strategy in patients with moderate to severe ARDS. Trial registration German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03956-8.
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12
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Pelosi P, Ball L, Barbas CSV, Bellomo R, Burns KEA, Einav S, Gattinoni L, Laffey JG, Marini JJ, Myatra SN, Schultz MJ, Teboul JL, Rocco PRM. Personalized mechanical ventilation in acute respiratory distress syndrome. Crit Care 2021; 25:250. [PMID: 34271958 PMCID: PMC8284184 DOI: 10.1186/s13054-021-03686-3] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 01/22/2023] Open
Abstract
A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (VT) is a standard of care, further individualization of VT may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust VT and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.
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Affiliation(s)
- Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Carmen S V Barbas
- Pneumology and Intensive Care Medicine, University of São Paulo, São Paulo, Brazil
- Adult Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto-St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Sharon Einav
- Intensive Care Unit of the Shaare Zedek Medical Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Luciano Gattinoni
- Department of Anaesthesiology, Emergency, and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, University Hospital Galway, and School of Medicine, National University of Ireland, Galway, Ireland
| | - John J Marini
- University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jean Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Inserm UMR S_999, AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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