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Zhang JC, Li T. Awake extracorporeal membrane oxygenation support for a critically ill COVID-19 patient: A case report. World J Clin Cases 2021; 9:5963-5971. [PMID: 34368315 PMCID: PMC8316967 DOI: 10.12998/wjcc.v9.i21.5963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/30/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A critically ill coronavirus disease 2019 (COVID-19) patient complicated by acute respiratory distress syndrome is reported. The patient survived following treatment with awake veno-venous extracorporeal membrane oxygenation (ECMO). CASE SUMMARY A 53-year-old male patient attended our hospital following a cough for 11 d and fever for 9 d. According to his computed tomography (CT) scan and real-time reverse transcription-polymerase chain reaction assay of a throat swab, nucleic acid was positive, confirming that he had COVID-19. He was subsequently transferred to the intensive care unit due to respiratory failure. The patient received antiviral drugs, a small dose of glucocorticoid, and respiratory support, including mechanical ventilation, but the treatment effect was poor. On the 28th day after admission, veno-venous ECMO and prone position ventilation (PPV) were performed, combined with awake ECMO and other comprehensive rehabilitation measures. On the 17th day of ECMO, the patient started to improve and his chest CT and lung compliance improved. ECMO was discontinued after 27 days, and mechanical ventilation was also discontinued after 9 days. The patient was then transferred to the rehabilitation department. CONCLUSION COVID-19 can damage lung tissues and cause evident inflammatory exudation, thus affecting oxygenation function. Awake ECMO, PPV, and comprehensive rehabilitation are effective in patients with critical COVID-19 and respiratory failure.
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Affiliation(s)
- Jing-Chen Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Tong Li
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Prone Ventilation for Patients with Mild or Moderate Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2021; 17:24-29. [PMID: 31532692 DOI: 10.1513/annalsats.201906-456ip] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Gattinoni L, Marini JJ, Collino F, Maiolo G, Rapetti F, Tonetti T, Vasques F, Quintel M. The future of mechanical ventilation: lessons from the present and the past. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:183. [PMID: 28701178 PMCID: PMC5508674 DOI: 10.1186/s13054-017-1750-x] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/31/2017] [Indexed: 02/07/2023]
Abstract
The adverse effects of mechanical ventilation in acute respiratory distress syndrome (ARDS) arise from two main causes: unphysiological increases of transpulmonary pressure and unphysiological increases/decreases of pleural pressure during positive or negative pressure ventilation. The transpulmonary pressure-related side effects primarily account for ventilator-induced lung injury (VILI) while the pleural pressure-related side effects primarily account for hemodynamic alterations. The changes of transpulmonary pressure and pleural pressure resulting from a given applied driving pressure depend on the relative elastances of the lung and chest wall. The term ‘volutrauma’ should refer to excessive strain, while ‘barotrauma’ should refer to excessive stress. Strains exceeding 1.5, corresponding to a stress above ~20 cmH2O in humans, are severely damaging in experimental animals. Apart from high tidal volumes and high transpulmonary pressures, the respiratory rate and inspiratory flow may also play roles in the genesis of VILI. We do not know which fraction of mortality is attributable to VILI with ventilation comparable to that reported in recent clinical practice surveys (tidal volume ~7.5 ml/kg, positive end-expiratory pressure (PEEP) ~8 cmH2O, rate ~20 bpm, associated mortality ~35%). Therefore, a more complete and individually personalized understanding of ARDS lung mechanics and its interaction with the ventilator is needed to improve future care. Knowledge of functional lung size would allow the quantitative estimation of strain. The determination of lung inhomogeneity/stress raisers would help assess local stresses; the measurement of lung recruitability would guide PEEP selection to optimize lung size and homogeneity. Finding a safety threshold for mechanical power, normalized to functional lung volume and tissue heterogeneity, may help precisely define the safety limits of ventilating the individual in question. When a mechanical ventilation set cannot be found to avoid an excessive risk of VILI, alternative methods (such as the artificial lung) should be considered.
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Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - John J Marini
- University of Minnesota, Minneapolis/Saint Paul, MN, USA
| | - Francesca Collino
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Giorgia Maiolo
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Francesca Rapetti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Tommaso Tonetti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Francesco Vasques
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
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Abstract
BACKGROUND Mechanical ventilation worsens acute respiratory distress syndrome, but this secondary "ventilator-associated" injury is variable and difficult to predict. The authors aimed to visualize the propagation of such ventilator-induced injury, in the presence (and absence) of a primary underlying lung injury, and to determine the predictors of propagation. METHODS Anesthetized rats (n = 20) received acid aspiration (hydrochloric acid) followed by ventilation with moderate tidal volume (V(T)). In animals surviving ventilation for at least 2 h, propagation of injury was quantified by using serial computed tomography. Baseline lung status was assessed by oxygenation, lung weight, and lung strain (V(T)/expiratory lung volume). Separate groups of rats without hydrochloric acid aspiration were ventilated with large (n = 10) or moderate (n = 6) V(T). RESULTS In 15 rats surviving longer than 2 h, computed tomography opacities spread outward from the initial site of injury. Propagation was associated with higher baseline strain (propagation vs. no propagation [mean ± SD]: 1.52 ± 0.13 vs. 1.16 ± 0.20, P < 0.01) but similar oxygenation and lung weight. Propagation did not occur where baseline strain was less than 1.29. In healthy animals, large V(T) caused injury that was propagated inward from the lung periphery; in the absence of preexisting injury, propagation did not occur where strain was less than 2.0. CONCLUSIONS Compared with healthy lungs, underlying injury causes propagation to occur at a lower strain threshold and it originates at the site of injury; this suggests that tissue around the primary lesion is more sensitive. Understanding how injury is propagated may ultimately facilitate a more individualized monitoring or management.
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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: 2.0] [Reference Citation Analysis] [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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Vendettuoli V, Veneroni C, Zannin E, Mercadante D, Matassa P, Pedotti A, Colnaghi M, Dellacà RL, Mosca F. Positional effects on lung mechanics of ventilated preterm infants with acute and chronic lung disease. Pediatr Pulmonol 2015; 50:798-804. [PMID: 24706414 DOI: 10.1002/ppul.23049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 03/07/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The role of prone position in preterm infants has not been completely clarified. We investigated prone versus supine posture-related changes in respiratory system resistance (Rrs) and reactance (Xrs) measured by the Forced Oscillation Technique (FOT) in mechanically ventilated preterm newborns. METHODS Patients were studied in the supine versus prone positions in random order. Oxygen saturation, transcutaneous partial pressure of oxygen (ptcO2 ), carbon dioxide (ptcCO2 ), Rrs and Xrs were measured in each position. RESULTS Nine patients with respiratory distress syndrome (RDS) and nine with evolving broncho-pulmonary dysplasia (BPD) were studied. Rrs was, on average, 9.8 (1.3, 18.3 as 95%CI) cmH2 O*s/l lower in the prone compared to the supine position (P = 0.02), while no differences in Xrs, ptcO2 , ptcCO2 , and breathing pattern were observed between postures. Only patients with evolving BPD showed a significant reduction of Rrs from 69.0 ± 27.4 to 53.0 ± 16.7 cmH2 O*s/l, P = 0.01. No significant correlations were found between changes in lung mechanics and ptcO2 , ptcCO2 , or breathing pattern. CONCLUSIONS On short-term basis, prone positioning does not offer significant advantages in lung mechanics in mechanically ventilated infants with RDS, while it is associated with lower Rrs values in patients with evolving BPD.
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Affiliation(s)
- V Vendettuoli
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - C Veneroni
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - E Zannin
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - D Mercadante
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - P Matassa
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - A Pedotti
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - M Colnaghi
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
| | - R L Dellacà
- TBMLab, Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano University, Milan, Italy
| | - F Mosca
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università Degli Studi di Milano, Milan, Italy
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Yehya N, Xin Y, Oquendo Y, Cereda M, Rizi RR, Margulies SS. Cecal ligation and puncture accelerates development of ventilator-induced lung injury. Am J Physiol Lung Cell Mol Physiol 2014; 308:L443-51. [PMID: 25550313 DOI: 10.1152/ajplung.00312.2014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Sepsis is a leading cause of respiratory failure requiring mechanical ventilation, but the interaction between sepsis and ventilation is unclear. While prior studies demonstrated a priming role with endotoxin, actual septic animal models have yielded conflicting results regarding the role of preceding sepsis on development of subsequent ventilator-induced lung injury (VILI). Using a rat cecal ligation and puncture (CLP) model of sepsis and subsequent injurious ventilation, we sought to determine if sepsis affects development of VILI. Adult male Sprague-Dawley rats were subject to CLP or sham operation and, after 12 h, underwent injurious mechanical ventilation (tidal volume 30 ml/kg, positive end-expiratory pressure 0 cmH2O) for either 0, 60, or 120 min. Biochemical and physiological measurements, as well as computed tomography, were used to assess injury at 0, 60, and 120 min of ventilation. Before ventilation, CLP rats had higher levels of alveolar neutrophils and interleukin-1β. After 60 min of ventilation, CLP rats had worse injury as evidenced by increased alveolar inflammation, permeability, respiratory static compliance, edema, oxygenation, and computed tomography. By 120 min, CLP and sham rats had comparable levels of lung injury as assessed by many, but not all, of these metrics. CLP rats had an accelerated and worse loss of end-expiratory lung volume relative to sham, and consistently higher levels of alveolar interleukin-1β. Loss of aeration and progression of edema was more pronounced in dependent lung regions. We conclude that CLP initiated pulmonary inflammation in rats, and accelerated the development of subsequent VILI.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Yi Xin
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Yousi Oquendo
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maurizio Cereda
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rahim R Rizi
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Susan S Margulies
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
Multiple animal and human studies have shown that prone positioning improves oxygenation and reduces ventilator-induced lung injury (VILI) in the setting of acute lung injury or acute respiratory distress syndrome (ARDS). In this article, the physiologic changes explaining the improvement in oxygenation are reviewed, how prone positioning reduces VILI is described, randomized controlled trials of prone ventilation in patients with ARDS are evaluated, the complications associated with prone ventilation are summarized, suggestions are made as to how these might be reduced or avoided, and when prone ventilation should start and stop and for what duration it should be used are discussed.
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Affiliation(s)
- Alexander B Benson
- University of Colorado, 12605 E, 16th avenue, Aurora, CO 80045, USA; Department of Medicine, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204-4507, USA
| | - Richard K Albert
- University of Colorado, 12605 E, 16th avenue, Aurora, CO 80045, USA; Department of Medicine, Denver Health, 777 Bannock, MC 4000, Denver, CO 80204-4507, USA.
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Gattinoni L, Pesenti A, Carlesso E. Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure: impact and clinical fallout through the following 20 years. Intensive Care Med 2013; 39:1909-15. [PMID: 24026295 DOI: 10.1007/s00134-013-3066-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/06/2013] [Indexed: 12/15/2022]
Abstract
In patients with acute respiratory distress syndrome (ARDS), in supine position, there is a decrease of inflation along the sternum vertebral axis, up to lung collapse. In 1991 we published a report showing that, in ARDS patients, shifting from supine to prone position led immediately to the inversion of the inflation gradient and to a redistribution of densities from dorsal to ventral lung regions. This led to a "sponge model" as a wet sponge, similar to a heavy edematous lung, squeezes out the gas in the most dependent regions, due to the weight-related increase of the compressive forces. The sponge model accounts for density distribution in prone position, for which the unloaded dorsal regions are recruited, while the loaded ventral region, collapses. In addition, the sponge model accounts for the mechanism through which the positive end-expiratory pressure acts as counterforce to oppose the collapsing, compressing forces. The final result of proning was that the inversion of gravitational forces, together with other factors such as lung-chest wall shape-matching and the heart weight led to a more homogeneous distribution of inflation throughout the lung parenchyma. This is associated with oxygenation improvement as the dorsal recruitment, for anatomical reasons, prevails on the ventral de-recruitment. The more homogeneous distribution of inflation (i.e. of stress and strain) decreases/prevents the ventilator-induced lung injury, as consistently shown in animal experiments. Finally, and a series of clinical trials led to the conclusion that in patients with severe ARDS, the prone position provides a significant survival advantage.
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Affiliation(s)
- Luciano Gattinoni
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy,
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Abstract
Optimal management of the acute respiratory distress syndrome (ARDS) requires prompt recognition, treatment of the underlying cause and the prevention of secondary injury. Ventilator-associated lung injury (VALI) is one of the several iatrogenic factors that can exacerbate lung injury and ARDS. Reduction of VALI by protective low tidal volume ventilation is one of the only interventions with a proven survival benefit in ARDS. There are, however, several factors inhibiting the widespread use of this technique in patients with established lung injury. Prevention of ARDS and VALI by detecting at-risk patients and implementing protective ventilation early is a feasible strategy. Detection of injurious ventilation itself is possible, and potential biological markers of VALI have been investigated. Finally, facilitation of protective ventilation, including techniques such as extracorporeal support, can mitigate VALI.
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Affiliation(s)
- David Salman
- Adult Intensive Care Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom
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Rocco PRM, Pelosi P, de Abreu MG. Pros and cons of recruitment maneuvers in acute lung injury and acute respiratory distress syndrome. Expert Rev Respir Med 2010; 4:479-89. [PMID: 20658909 DOI: 10.1586/ers.10.43] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In patients with acute lung injury and acute respiratory distress syndrome, a protective mechanical ventilation strategy characterized by low tidal volumes has been associated with reduced mortality. However, such a strategy may result in alveolar collapse, leading to cyclic opening and closing of atelectatic alveoli and distal airways. Thus, recruitment maneuvers (RMs) have been used to open up collapsed lungs, while adequate positive end-expiratory pressure (PEEP) levels may counteract alveolar derecruitment during low tidal volume ventilation, improving respiratory function and minimizing ventilator-associated lung injury. Nevertheless, considerable uncertainty remains regarding the appropriateness of RMs. The most commonly used RM is conventional sustained inflation, associated with respiratory and cardiovascular side effects, which may be minimized by newly proposed strategies: prolonged or incremental PEEP elevation; pressure-controlled ventilation with fixed PEEP and increased driving pressure; pressure-controlled ventilation applied with escalating PEEP and constant driving pressure; and long and slow increase in pressure. The efficiency of RMs may be affected by different factors, including the nature and extent of lung injury, capability of increasing inspiratory transpulmonary pressures, patient positioning and cardiac preload. Current evidence suggests that RMs can be used before setting PEEP, after ventilator circuit disconnection or as a rescue maneuver to overcome severe hypoxemia; however, their routine use does not seem to be justified at present. The development of new lung recruitment strategies that have fewer hemodynamic and biological effects on the lungs, as well as randomized clinical trials analyzing the impact of RMs on morbidity and mortality of acute lung injury/acute respiratory distress syndrome patients, are warranted.
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Affiliation(s)
- Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute of Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão-21941-902, Rio de Janeiro, RJ, Brazil.
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Santana MCE, Garcia CSNB, Xisto DG, Nagato LKS, Lassance RM, Prota LFM, Ornellas FM, Capelozzi VL, Morales MM, Zin WA, Pelosi P, Rocco PRM. Prone position prevents regional alveolar hyperinflation and mechanical stress and strain in mild experimental acute lung injury. Respir Physiol Neurobiol 2009; 167:181-8. [PMID: 19505674 DOI: 10.1016/j.resp.2009.04.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 04/03/2009] [Accepted: 04/06/2009] [Indexed: 02/06/2023]
Abstract
Prone position may delay the development of ventilator-induced lung injury (VILI), but the mechanisms require better elucidation. In experimental mild acute lung injury (ALI), arterial oxygen partial pressure (Pa O2), lung mechanics and histology, inflammatory markers [interleukin (IL)-6 and IL-1 beta], and type III procollagen (PCIII) mRNA expressions were analysed in supine and prone position. Wistar rats were randomly divided into two groups. In controls, saline was intraperitoneally injected while ALI was induced by paraquat. After 24-h, the animals were mechanically ventilated for 1-h in supine or prone positions. In ALI, prone position led to a better blood flow/tissue ratio both in ventral and dorsal regions and was associated with a more homogeneous distribution of alveolar aeration/tissue ratio reducing lung static elastance and viscoelastic pressure, and increasing end-expiratory lung volume and Pa O2. PCIII expression was higher in the ventral than dorsal region in supine position, with no regional changes in inflammatory markers. In conclusion, prone position may protect the lungs against VILI, thus reducing pulmonary stress and strain.
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Affiliation(s)
- Maria Cristina E Santana
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, RJ, Brazil
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Gattinoni L, Carlesso E, Caironi P. Mechanical Ventilation in Acute Respiratory Distress Syndrome. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50013-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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de Carvalho MEP, Dolhnikoff M, Meireles SI, Reis LFL, Martins MA, Deheinzelin D. Effects of overinflation on procollagen type III expression in experimental acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 11:R23. [PMID: 17313668 PMCID: PMC2151905 DOI: 10.1186/cc5702] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 01/10/2007] [Accepted: 02/21/2007] [Indexed: 11/19/2022]
Abstract
Introduction In acute lung injury (ALI), elevation of procollagen type III (PC III) occurs early and has an adverse impact on outcome. We examined whether different high-inflation strategies of mechanical ventilation (MV) in oleic acid (OA) ALI alter regional expression of PC III. Methods We designed an experimental, randomized, and controlled protocol in which rats were allocated to two control groups (no injury, recruited [alveolar recruitment maneuver after tracheotomy without MV; n = 4 rats] and control [n = 5 rats]) or four injured groups (one exposed to OA only [n = 10 rats] and three OA-injured and ventilated). The three OA-injured groups were ventilated for 1 hour according to the following strategies: LVHP-S (low volume-high positive end-expiratory pressure [PEEP], supine; n = 10 rats, tidal volume [VT] = 8 ml/kg, PEEP = 12 cm H2O), HVLP-S (high volume-low PEEP, supine; n = 10 rats, VT = 20 ml/kg, PEEP = 5 cm H2O), and HVLP-P (high volume-low PEEP, prone; n = 10 rats). Northern blot analysis for PC III and interleukin-1-beta (IL-1β) and polymorphonuclear infiltration index (PMI) counting were performed in nondependent and dependent regions. Regional differences between groups were assessed by two-way analysis of variance after logarithmic transformation and post hoc tests. Results A significant interaction for group and region effects was observed for PC III (p = 0.012) with higher expression in the nondependent region for HVLP-S and LVHP-S, intermediate for OA and HVLP-P, and lower for control (group effect, p < 0.00001, partial η2 = 0.767; region effect, p = 0.0007, partial η2 = 0.091). We found high expression of IL-1β (group effect, p < 0.00001, partial η2 = 0.944) in the OA, HVLP-S, and HVLP-P groups without regional differences (p = 0.16). PMI behaved similarly (group effect, p < 0.00001, partial η2 = 0.832). Conclusion PC III expression is higher in nondependent regions and in ventilatory strategies that caused overdistension. This response was partially attenuated by prone positioning.
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Affiliation(s)
- Maria-Eudóxia Pilotto de Carvalho
- Intensive Care Unit, Centro de Tratamento e Pesquisa, Hospital do Câncer, Fundação Antônio Prudente; Rua Prof. Antônio Prudente, 211; São Paulo; CEP: 01509-010; Brazil
| | - Marisa Dolhnikoff
- Department of Pathology, School of Medicine, University of São Paulo; Avenida Dr. Arnaldo, 455; São Paulo; CEP: 01246-000; Brazil
| | - Sibele Inácio Meireles
- Ludwig Institute of Cancer Research, Centro de Tratamento e Pesquisa, Hospital do Câncer; Rua Prof. Antônio Prudente, 211; São Paulo; CEP: 01509-010; Brazil
| | - Luiz Fernando Lima Reis
- Ludwig Institute of Cancer Research, Centro de Tratamento e Pesquisa, Hospital do Câncer; Rua Prof. Antônio Prudente, 211; São Paulo; CEP: 01509-010; Brazil
| | - Milton Arruda Martins
- Laboratório de Investigação Médica 20, School of Medicine, University of São Paulo; Avenida Dr. Arnaldo, 455; São Paulo; CEP: 01246-000; Brazil
| | - Daniel Deheinzelin
- Intensive Care Unit, Centro de Tratamento e Pesquisa, Hospital do Câncer, Fundação Antônio Prudente; Rua Prof. Antônio Prudente, 211; São Paulo; CEP: 01509-010; Brazil
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Pavone L, Albert S, DiRocco J, Gatto L, Nieman G. Alveolar instability caused by mechanical ventilation initially damages the nondependent normal lung. Crit Care 2007; 11:R104. [PMID: 17877789 PMCID: PMC2556747 DOI: 10.1186/cc6122] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 09/06/2007] [Accepted: 09/18/2007] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Septic shock is often associated with acute respiratory distress syndrome, a serious clinical problem exacerbated by improper mechanical ventilation. Ventilator-induced lung injury (VILI) can exacerbate the lung injury caused by acute respiratory distress syndrome, significantly increasing the morbidity and mortality. In this study, we asked the following questions: what is the effect of the lung position (dependent lung versus nondependent lung) on the rate at which VILI occurs in the normal lung? Will positive end-expiratory pressure (PEEP) slow the progression of lung injury in either the dependent lung or the nondependent lung? MATERIALS AND METHODS Sprague-Dawley rats (n = 19) were placed on mechanical ventilation, and the subpleural alveolar mechanics were measured with an in vivo microscope. Animals were placed in the lateral decubitus position, left lung up to measure nondependent alveolar mechanics and left lung down to film dependent alveolar mechanics. Animals were ventilated with a high peak inspiratory pressure of 45 cmH2O and either a low PEEP of 3 cmH2O or a high PEEP of 10 cmH2O for 90 minutes. Animals were separated into four groups based on the lung position and the amount of PEEP: Group I, dependent + low PEEP (n = 5); Group II, nondependent + low PEEP (n = 4); Group III, dependent + high PEEP (n = 5); and Group IV, nondependent + high PEEP (n = 5). Hemodynamic and lung function parameters were recorded concomitant with the filming of alveolar mechanics. Histological assessment was performed at necropsy to determine the presence of lung edema. RESULTS VILI occurred earliest (60 min) in Group II. Alveolar instability eventually developed in Groups I and II at 75 minutes. Alveoli in both the high PEEP groups were stable for the entire experiment. There were no significant differences in arterial PO2 or in the degree of edema measured histologically among experimental groups. CONCLUSION This open-chest animal model demonstrates that the position of the normal lung (dependent or nondependent) plays a role on the rate of VILI.
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Affiliation(s)
- Lucio Pavone
- Upstate Medical University, Department of Surgery, 750 E Adams Street, Syracuse, NY 13210 USA
| | - Scott Albert
- Upstate Medical University, Department of Surgery, 750 E Adams Street, Syracuse, NY 13210 USA
| | - Joseph DiRocco
- Upstate Medical University, Department of Surgery, 750 E Adams Street, Syracuse, NY 13210 USA
| | - Louis Gatto
- Department of Biology, Cortland College, P.O. Box 2000 Cortland, NY 13045 USA
| | - Gary Nieman
- Upstate Medical University, Department of Surgery, 750 E Adams Street, Syracuse, NY 13210 USA
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García-Delgado M, Navarrete-Sánchez I, Colmenero M, Touma-Fernández A, López-Cuervo JE, Hassan-Montero L, Fernández-Mondéjar E. Intermittent alveolar overdistension for 30 or 240 minutes does not produce acute lung injury in normal pig lung. J Surg Res 2006; 131:233-40. [PMID: 16427087 DOI: 10.1016/j.jss.2005.11.575] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Revised: 10/27/2005] [Accepted: 11/03/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective is to study whether alveolar overdistension can induce acute lung injury in pigs as assessed by analysis of respiratory and histological parameters and inflammatory markers. MATERIALS AND METHODS Experimental study, using mixed-breed pigs. Animals were assigned to one of the following groups: Control Group (CG) (n = 5), applying mechanical ventilation with tidal volume (Vt) of 10 ml/kg, respiratory rate (RR) of 18 bpm, and FiO2 of 1 for 240 min; High Vt for 30 min (HVt-30) Group (n = 5), applying ventilation with Vt of 50 ml/kg and RR of 8 bpm and FiO2 of 1 for 30 min, followed by ventilation as in the CG for a further 210 min; and HVt-240 Group (n = 5), applying ventilation with Vt of 50 ml/kg, RR of 8 bpm, and FiO2 of 1 for 240 min. Hemodynamic parameters, airway pressures, arterial blood gases, extravascular lung water (EVLW), and cytokines (IL-2, IL-4, IL-6, IL-10, TNF-alpha, and ITF-gamma) in plasma and bronchoalveolar lavage (BAL) were determined. Lungs were fixed with 10% formalin for histological analysis. Results are expressed as mean +/- standard deviation. The ANOVA test was used to compare measurements among the three groups. RESULTS At 30 min, airway pressures and oxygenation of HVt-30 and HVt-240 groups were higher than those of controls [Pplateau: 39.2 +/- 5.6 and 33.0+/- 5.1 versus 12.2 +/- 1.3 (P < 0.01); PaO2/FiO2: 443.8 +/- 55 and 430.6 +/- 34 versus 194.4 +/- 77 (P < 0.01)]. In HVt-240 group, these parameters were also higher than in the other two groups at the subsequent measurement times. There were no differences among the groups in EVLW values. Cytokines were undetected or negligible in plasma and BAL in all of the groups. The histological analysis showed no changes suggestive of acute lung injury. CONCLUSIONS In this animal model, ventilation for 4 h with large tidal volume did not cause ventilator-induced lung injury.
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Affiliation(s)
- Manuel García-Delgado
- Department of Emergency and Critical Care, Universitary Hospital Virgen de las Nieves, Granada, Spain.
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Fujita Y, Maeda Y, Fujino Y, Uchiyama A, Mashimo T, Nishimura M. Effect of peak inspiratory flow on gas exchange, pulmonary mechanics, and lung histology in rabbits with injured lungs. J Anesth 2006; 20:96-101. [PMID: 16633765 DOI: 10.1007/s00540-005-0374-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Accepted: 12/01/2005] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to evaluate, using a rabbit model, the little-known effect of different levels of peak inspiratory flow on acutely injured lungs. METHODS Fourteen male rabbits (body weight, 2,711 +/- 146 g) were anesthetized and their lungs were injured by alveolar overstretch with mechanical ventilation until Pa(O(2)) was reduced below 300 mmHg. Injured animals were randomly assigned to: the P group-to receive pressure-regulated volume-control ventilation (PRVCV; n = 7); and the V group-to receive volume-control ventilation (VCV; n = 7). Other ventilator settings were: fraction of inspired oxygen (FI(O(2)), 1.0; tidal volume, 20 ml x kg(-1); positive end-expiratory pressure (PEEP) 5 cmH(2)O; and respiratory rate, 20 min(-1). The animals were thus ventilated for 4 h. Throughout the protocol, ventilatory parameters and blood gas were measured every 30 min. After the protocol, the lung wet-to-dry ratio and histological lung injury score were evaluated in the excised lungs. RESULTS Throughout the protocol, peak inspiratory flow and mean inspiratory flow values in the P group were significantly higher than those in the V group (26.7 +/- 5.0 l x min(-1) vs 1.2 +/- 0.2 l x min(-1), and 4.3 +/- 0.3 l x min(-1) vs 1.1 +/- 0.1 l x min(-1); P < 0.05). The wet-to-dry ratio in the P group was also significantly higher than that in the V group (7.7 +/- 0.9 vs 6.3 +/- 0.5; P < 0.05). More animals in the P group than in the V group had end-of-protocol Pa(O(2))/FI(O(2)) ratios below 200 mmHg (43% vs 0%; P = 0.06). CONCLUSION In rabbits with injured lungs, high peak inspiratory flow with high tidal volume (V(T)) reduces the Pa(O(2))/FI(O(2)) ratio and increases the lung wet-to-dry ratio.
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Affiliation(s)
- Yasuki Fujita
- Intensive Care Unit, Osaka University Hospital, 2-15 Yamadaoka, Suita 565-0871, Japan
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Prone to Survive. Crit Care Med 2005. [DOI: 10.1097/01.ccm.0000179034.85196.2f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gattinoni L, Chiumello D, Biondetti P, Carlesso E. CT Ventilation Imaging. FUNCTIONAL LUNG IMAGING 2005. [DOI: 10.1201/b14155-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Valenza F, Guglielmi M, Maffioletti M, Tedesco C, Maccagni P, Fossali T, Aletti G, Porro GA, Irace M, Carlesso E, Carboni N, Lazzerini M, Gattinoni L. Prone position delays the progression of ventilator-induced lung injury in rats: Does lung strain distribution play a role?*. Crit Care Med 2005; 33:361-7. [PMID: 15699840 DOI: 10.1097/01.ccm.0000150660.45376.7c] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate if prone position delays the progression of experimental ventilator-induced lung injury, possibly due to a more homogeneous distribution of strain within lung parenchyma. DESIGN Prospective, randomized, controlled trial. SETTING Animal laboratory of a university hospital. SUBJECTS Thirty-five Sprague Dawley male rats (weight 257 +/- 45 g). INTERVENTIONS Mechanical ventilation in either supine or prone position and computed tomography scan analysis. MEASUREMENTS : Animals were ventilated in supine (n = 15) or prone (n = 15) position until a similar ventilator-induced lung injury was reached. To do so, experiments were interrupted when respiratory system elastance was 150% of baseline. Ventilator-induced lung injury was assessed as lung wet-to-dry ratio and histology. Time to reach lung injury was considered as a main outcome measure. In five additional animals, computed tomography scans (GE Light Speed QX/I, thickness 1.25 mm, interval 0.6 mm, 100 MA, 100 Kv) were randomly taken at end-expiration and end-inspiration in both positions, and quantitative analysis was performed. Data are shown as mean +/- sd. MEASUREMENTS AND MAIN RESULTS Similar ventilator-induced lung injury was reached (respiratory system elastance, wet-to-dry ratio, and histology). The time taken to achieve the target ventilator-induced lung injury was longer with prone position (73 +/- 37 mins vs. 112 +/- 42, supine vs. prone, p = .011). Computed tomography scan analysis performed before lung injury revealed that at end-expiration, the lung was wider in prone position (p = .004) and somewhat shorter (p = .09), despite similar lung volumes (p = .455). Lung density along the vertical axis increased significantly only in supine position (p = .002). Lung strain was greater in supine as opposed to prone position (width strain, 7.8 +/- 1.8% vs. 5.6 +/- 0.9, supine vs. prone, p = .029). CONCLUSIONS Prone position delays the progression of ventilator-induced lung injury. Computed tomography scan analysis suggests that a more homogeneous distribution of strain may be implicated in the protective role of prone position against ventilator-induced lung injury.
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Affiliation(s)
- Franco Valenza
- Università degli Studi di Milano, Istituto di Anestesia e Rianimazione, Ospedale Maggiore di Milano-IRCCS, Via F. Sforza 35, 20122 Milano, Italy.
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Gattinoni L, Carlesso E, Valenza F, Chiumello D, Caspani ML. Acute respiratory distress syndrome, the critical care paradigm: what we learned and what we forgot. Curr Opin Crit Care 2004; 10:272-8. [PMID: 15258499 DOI: 10.1097/01.ccx.0000135511.75998.22] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the last several years, we definitely learned that the acute respiratory distress syndrome lung is small, nonhomogeneous, and that mechanical ventilation in this baby lung may cause physical damage as well as inflammatory reaction. The clinical benefit of the gentle lung treatment, based on a decrease of global/regional stress and strain into the lung, has been finally proved. However, we forgot the importance of lung perfusion and its distribution in this syndrome and, besides a low tidal volume, we still do not know how to handle the other variables of mechanical ventilation. Measurements of variables as transpulmonary pressure and end expiratory lung volume, for a rational setting of mechanical ventilation, should be introduced in routine clinical practice.
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Affiliation(s)
- Luciano Gattinoni
- Istituto di Anestesia e Rianimazione, Universita' degli Studi di Milano, Ospedale Policlinico IRCCS, Milano, Italy.
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