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American Journal of Respiratory and... Feb 2017Mechanical ventilation is used to sustain life in patients with acute respiratory failure. A major concern in mechanically ventilated patients is the risk of...
Mechanical ventilation is used to sustain life in patients with acute respiratory failure. A major concern in mechanically ventilated patients is the risk of ventilator-induced lung injury, which is partially prevented by lung-protective ventilation. Spontaneously breathing, nonintubated patients with acute respiratory failure may have a high respiratory drive and breathe with large tidal volumes and potentially injurious transpulmonary pressure swings. In patients with existing lung injury, regional forces generated by the respiratory muscles may lead to injurious effects on a regional level. In addition, the increase in transmural pulmonary vascular pressure swings caused by inspiratory effort may worsen vascular leakage. Recent data suggest that these patients may develop lung injury that is similar to the ventilator-induced lung injury observed in mechanically ventilated patients. As such, we argue that application of a lung-protective ventilation, today best applied with sedation and endotracheal intubation, might be considered a prophylactic therapy, rather than just a supportive therapy, to minimize the progression of lung injury from a form of patient self-inflicted lung injury. This has important implications for the management of these patients.
Topics: Disease Progression; Humans; Respiration, Artificial; Respiratory Distress Syndrome; Ventilator-Induced Lung Injury
PubMed: 27626833
DOI: 10.1164/rccm.201605-1081CP -
Swiss Medical Weekly 2017Critically ill patients with the need for mechanical ventilation show complex interactions between respiratory and cardiovascular physiology. These interactions are... (Review)
Review
Critically ill patients with the need for mechanical ventilation show complex interactions between respiratory and cardiovascular physiology. These interactions are important as they may guide the clinician's therapeutic decisions and, possibly, affect patient outcome. The aim of the present review is to provide the practicing physician with an overview of the concepts of heart-lung interactions during mechanical ventilation. We outline the basic cardiac and respiratory physiology during spontaneous breathing and under mechanical ventilation. The main focus is on the interaction between positive pressure ventilation and its effects on right and left ventricular pre- and afterload and ventricular interdependence. Further we discuss different modalities to assess volume responsiveness, such as pulse pressure variation. We aim to familiarise the reader with cardiovascular side effects of mechanical ventilation when experiencing weaning problems or right heart failure.
Topics: Blood Pressure; Cardiovascular System; Heart; Heart Rate; Hemodynamics; Humans; Lung; Respiration, Artificial
PubMed: 28944931
DOI: 10.4414/smw.2017.14491 -
Critical Care (London, England) Mar 2020This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at... (Review)
Review
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
Topics: Diaphragm; Humans; Intensive Care Units; Lung; Monitoring, Physiologic; Protective Agents; Respiration, Artificial; Respiratory Physiological Phenomena
PubMed: 32204729
DOI: 10.1186/s13054-020-2777-y -
Anesthesiology Jul 2019The physiological concept, pathophysiological implications and clinical relevance and application of driving pressure and transpulmonary pressure to prevent... (Review)
Review
The physiological concept, pathophysiological implications and clinical relevance and application of driving pressure and transpulmonary pressure to prevent ventilator-induced lung injury are discussed.
Topics: Humans; Positive-Pressure Respiration; Respiration, Artificial; Respiratory Mechanics; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 31094753
DOI: 10.1097/ALN.0000000000002731 -
Respiratory Care Jun 2020The estimation of pleural pressure with esophageal manometry has been used for decades, and it has been a fertile area of physiology research in healthy subject as well... (Review)
Review
The estimation of pleural pressure with esophageal manometry has been used for decades, and it has been a fertile area of physiology research in healthy subject as well as during mechanical ventilation in patients with lung injury. However, its scarce adoption in clinical practice takes its roots from the (false) ideas that it requires expertise with years of training, that the values obtained are not reliable due to technical challenges or discrepant methods of calculation, and that measurement of esophageal pressure has not proved to benefit patient outcomes. Despites these criticisms, esophageal manometry could contribute to better monitoring, optimization, and personalization of mechanical ventilation from the acute initial phase to the weaning period. This review aims to provide a comprehensive but comprehensible guide addressing the technical aspects of esophageal catheter use, its application in different clinical situations and conditions, and an update on the state of the art with recent studies on this topic and on remaining questions and ways for improvement.
Topics: Catheters; Esophagus; Humans; Manometry; Monitoring, Physiologic; Respiration, Artificial; Respiratory Mechanics
PubMed: 32457170
DOI: 10.4187/respcare.07425 -
European Respiratory Review : An... Jun 2023There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement... (Review)
Review
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure ( ) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of -guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
Topics: Humans; Respiration, Artificial; Lung; Respiratory Mechanics; Ventilators, Mechanical; Monitoring, Physiologic
PubMed: 37197768
DOI: 10.1183/16000617.0186-2022 -
Anesthesiology Sep 2015Postoperative pulmonary complications are associated with increased morbidity, length of hospital stay, and mortality after major surgery. Intraoperative lung-protective... (Review)
Review
Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers.
Postoperative pulmonary complications are associated with increased morbidity, length of hospital stay, and mortality after major surgery. Intraoperative lung-protective mechanical ventilation has the potential to reduce the incidence of postoperative pulmonary complications. This review discusses the relevant literature on definition and methods to predict the occurrence of postoperative pulmonary complication, the pathophysiology of ventilator-induced lung injury with emphasis on the noninjured lung, and protective ventilation strategies, including the respective roles of tidal volumes, positive end-expiratory pressure, and recruitment maneuvers. The authors propose an algorithm for protective intraoperative mechanical ventilation based on evidence from recent randomized controlled trials.
Topics: Animals; Humans; Intraoperative Care; Lung; Positive-Pressure Respiration; Postoperative Complications; Respiration, Artificial; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 26120769
DOI: 10.1097/ALN.0000000000000754 -
Critical Care (London, England) Mar 2020This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at... (Review)
Review
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
Topics: Breathing Exercises; Humans; Intensive Care Units; Respiration, Artificial; Respiratory Muscles
PubMed: 32204719
DOI: 10.1186/s13054-020-2783-0 -
Respiratory Care Feb 2021The unifying goal of lung-protective ventilation strategies in ARDS is to minimize the strain and stress applied by mechanical ventilation to the lung to reduce...
BACKGROUND
The unifying goal of lung-protective ventilation strategies in ARDS is to minimize the strain and stress applied by mechanical ventilation to the lung to reduce ventilator-induced lung injury (VILI). The relative contributions of the magnitude and frequency of mechanical stress and the end-expiratory pressure to the development of VILI is unknown. Consequently, it is uncertain whether the risk of VILI is best quantified in terms of tidal volume (V), driving pressure (ΔP), or mechanical power.
METHODS
The correlation between differences in V, ΔP, and mechanical power and the magnitude of mortality benefit in trials of lung-protective ventilation strategies in adult subjects with ARDS was assessed by meta-regression. Modified mechanical power was computed including PEEP (Power), excluding PEEP (Power), and using ΔP (Power). The primary analysis incorporated all included trials. A secondary subgroup analysis was restricted to trials of lower versus higher PEEP strategies.
RESULTS
We included 9 trials involving 4,731 subjects in the analysis. Odds ratios for moderation derived from meta-regression showed that variations in V, ΔP, and Power were associated with increased mortality with odds ratios of 1.24 (95% CI 1.03-1.49), 1.31 (95% CI 1.03-1.66), and 1.37 (95% CI 1.05-1.78), respectively. In trials comparing higher versus lower PEEP strategies, Power was increased in the higher PEEP arm (24 ± 1.7 vs 20 ± 1.5 J/min, respectively), whereas the other parameters were not affected on average by a higher PEEP ventilation strategy.
CONCLUSIONS
In trials of lung-protective ventilation strategies, V, ΔP, Power, Power, and Power exhibited similar moderation of treatment effect on mortality. In this study, modified mechanical power did not add important information on the risk of death from VILI in comparison to V or ΔP.
Topics: Adult; Humans; Lung; Positive-Pressure Respiration; Respiration, Artificial; Respiratory Distress Syndrome; Tidal Volume
PubMed: 32843513
DOI: 10.4187/respcare.07876 -
Critical Care (London, England) May 2019The optimal securement method of endotracheal tubes is unknown but should prevent dislodgement while minimizing complications. The use of an endotracheal tube fastener...
BACKGROUND
The optimal securement method of endotracheal tubes is unknown but should prevent dislodgement while minimizing complications. The use of an endotracheal tube fastener might reduce complications among critically ill adults undergoing endotracheal intubation.
METHODS
In this pragmatic, single-center, randomized trial, critically ill adults admitted to the medical intensive care unit (MICU) and expected to require invasive mechanical ventilation for greater than 24 h were randomized to adhesive tape or endotracheal tube fastener at the time of intubation. The primary endpoint was a composite of any of the following: presence of lip ulcer, endotracheal tube dislodgement (defined as moving at least 2 cm), ventilator-associated pneumonia, or facial skin tears anytime between randomization and the earlier of death or 48 h after extubation. Secondary endpoints included duration of mechanical ventilation and ICU and in-hospital mortality.
RESULTS
Of 500 patients randomized over a 12-month period, 162 had a duration of mechanical ventilation less than 24 h and 40 had missing outcome data, leaving 153 evaluable patients randomized to tube fastener and 145 evaluable patients randomized to adhesive tape. Baseline characteristics were similar between the groups. The primary endpoint occurred 13 times in 12 (7.8%) patients in the tube fastener group and 30 times in 25 (17.2%) patients in the adhesive tape group (p = 0.014) for an overall incidence of 22.0 versus 52.6 per 1000 ventilator days, respectively (p = 0.020). Lip ulcers occurred in 4 (2.6%) versus 11 (7.3%) patients, or an incidence rate of 6.5 versus 19.5 per 1000 patient ventilator days (p = 0.053) in the fastener and tape groups, respectively. The endotracheal tube was dislodged 7 times in 6 (3.9%) patients in the tube fastener group and 16 times in 15 (10.3%) patients in the tape group (p = 0.03), reflecting incidences of 11.9 and 28.1 per 1000 ventilator days, respectively. Facial skin tears were similar between the groups. Mechanical ventilation duration and ICU and hospital mortality did not differ.
CONCLUSION
The use of the endotracheal tube fastener to secure the endotracheal tubes reduces the rate of a composite outcome that included lip ulcers, facial skin tears, or endotracheal tube dislodgement compared to adhesive tape.
TRIAL REGISTRATION
ClinicalTrials.gov NCT03760510. Retrospectively registered on November 30, 2018.
Topics: Adult; Aged; Airway Extubation; Chi-Square Distribution; Critical Illness; Female; Humans; Intensive Care Units; Intubation, Intratracheal; Male; Middle Aged; Pressure Ulcer; Respiration, Artificial; Retrospective Studies; Statistics, Nonparametric; Surgical Tape
PubMed: 31064406
DOI: 10.1186/s13054-019-2440-7