Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial

by Jose Victor Jimenez, Elizabeth Munroe, Andrew J. Weirauch, Kelly Fiorino, Christopher A. Culter, Kristine Nelson, Wassim W. Labaki, Philip J. Choi, Ivan Co, Theodore J. Standiford, Hallie C. Prescott and Robert C. Hyzy 

Critical Care volume 27, Article number: 21 Published: 17 January 2023

Background

In patients with acute respiratory distress syndrome undergoing mechanical ventilation, positive end-expiratory pressure (PEEP) can lead to recruitment or overdistension. Current strategies utilized for PEEP titration do not permit the distinction. Electric impedance tomography (EIT) detects and quantifies the presence of both collapse and overdistension. We investigated whether using EIT-guided PEEP titration leads to decreased mechanical power compared to high-PEEP/FiO2 tables.

Methods

A single-center, randomized crossover pilot trial comparing EIT-guided PEEP selection versus PEEP selection using the High-PEEP/FiO2 table in patients with moderate–severe acute respiratory distress syndrome. The primary outcome was the change in mechanical power after each PEEP selection strategy. Secondary outcomes included changes in the 4 × driving pressure + respiratory rate (4 ΔP, + RR index) index, driving pressure, plateau pressure, PaO2/FiO2 ratio, and static compliance.

Results

EIT was consistently associated with a decrease in mechanical power compared to PEEP/FiO2 tables (mean difference − 4.36 J/min, 95% CI − 6.7, − 1.95, p = 0.002) and led to lower values in the 4ΔP + RR index (− 11.42 J/min, 95% CI − 19.01, − 3.82, p = 0.007) mainly driven by a decrease in the elastic–dynamic power (− 1.61 J/min, − 2.99, − 0.22, p = 0.027). The elastic–static and resistive powers were unchanged. Similarly, EIT led to a statistically significant change in set PEEP (− 2 cmH2O, p = 0.046), driving pressure, (− 2.92 cmH2O, p = 0.003), peak pressure (− 6.25 cmH2O, p = 0.003), plateau pressure (− 4.53 cmH2O, p = 0.006), and static respiratory system compliance (+ 7.93 ml/cmH2O, p = 0.008).

Conclusions

In patients with moderate–severe acute respiratory distress syndrome, EIT-guided PEEP titration reduces mechanical power mainly through a reduction in elastic–dynamic power.

 

The Use of IV Vasoactive Intestinal Peptide (Aviptadil) in Patients With Critical COVID-19 Respiratory Failure: Results of a 60-Day Randomized Controlled Trial

 

by Youssef, Jihad Georges; Lavin, Philip; Schoenfeld, David A.; Lee, Richard A.; Lenhardt, Rainer; Park, David J.; Fernandez, Javier Perez; Morganroth, Melvin L.; Javitt, Jonathan C.; Jayaweera, Dushyantha 

 

Critical Care Medicine: August 31, 2022 - Volume - Issue - 10.1097

 

Objectives: 

Respiratory failure is a lethal complication of COVID-19 that has remained resistant to drug therapy. Vasoactive intestinal peptide (VIP) is shown in nonclinical studies to upregulate surfactant production, inhibit cytokine synthesis, prevent cytopathy, and block replication of the severe acute respiratory syndrome coronavirus 2 virus in pulmonary cells. The study aims to determine whether Aviptadil (synthetic VIP) can improve survival and recovery in patients with COVID-19 respiratory failure compared with placebo and demonstrate biological effects in such patients.

Design: 

A multicenter, placebo-controlled trial.

Setting: 

Ten U.S. hospitals: six tertiary-care hospitals and four community hospitals.

Patients: 

A total of 196 patients with COVID-19 respiratory failure.

Interventions: 

Participants were randomized 2:1 to receive 3 days of IV Aviptadil or placebo.

Measurements and Main Results: 

The primary end point (alive and free from respiratory failure at day 60) did not reach statistical significance (odds ratio [OR], 1.6; 95% CI, 0.86–3.11) for patients treated with Aviptadil when controlling for baseline ventilation status as prespecified in the protocol. There was, however, a statistically significant two-fold odds of improved survival (OR, 2.0; 95% CI, 1.1–3.9) at 60 days (p = 0.035). There was significant improvement in respiratory distress ratio and reduced interleukin 6 cytokine release (p = 0.02) by day 3.

Subgroup analysis identified a statistically significant likelihood of achieving primary end point among those treated with high-flow nasal oxygen at baseline (p = 0.039). Subjects on mechanical ventilation also experienced a 10-fold increased odds of survival with drug versus placebo (p = 0.031).

Conclusions: 

The primary end point did not reach statistical significance, indicating that there was no difference between Aviptadil versus placebo. However, Aviptadil improves the likelihood of survival from respiratory failure at day 60 in critical COVID-19 across all sites of care. Given the absence of drug-related serious adverse events and acceptable safety profile, we believe the benefit versus risk for the use of Aviptadil is favorable for patient treatment.

 

Electrical Impedance Tomography in Acute Respiratory Distress Syndrome Management

 

by Jimenez, Jose Victor; Weirauch, Andrew J.; Culter, Christopher A.; Choi, Philip J.; Hyzy, Robert C.

 

Critical Care Medicine: August 2022 - Volume 50 - Issue 8 - p 1210-1223

 

OBJECTIVE: To describe, through a narrative review, the physiologic principles underlying electrical impedance tomography, and its potential applications in managing 

acute respiratory distress syndrome (ARDS). To address the current evidence supporting its use in different clinical scenarios along the ARDS management continuum.

DATA SOURCES: We performed an online search in Pubmed to review articles. We searched MEDLINE, Cochrane Central Register, and clinicaltrials.gov for controlled trials databases.

STUDY SELECTION: Selected publications included case series, pilot-physiologic studies, observational cohorts, and randomized controlled trials. To describe the rationale underlying physiologic principles, we included experimental studies.

DATA EXTRACTION: Data from relevant publications were reviewed, analyzed, and its content summarized.

DATA SYNTHESIS: Electrical impedance tomography is an imaging technique that has aided in understanding the mechanisms underlying multiple interventions used in ARDS management. It has the potential to monitor and predict the response to prone positioning, aid in the dosage of flow rate in high-flow nasal cannula, and guide the titration of positive-end expiratory pressure during invasive mechanical ventilation. The latter has been demonstrated to improve physiologic and mechanical parameters correlating with lung recruitment. Similarly, its use in detecting pneumothorax and harmful patient-ventilator interactions such as pendelluft has been proven effective. Nonetheless, its impact on clinically meaningful outcomes remains to be determined.

CONCLUSIONS: Electrical impedance tomography is a potential tool for the individualized management of ARDS throughout its different stages. Clinical trials should aim to determine whether a specific approach can improve clinical outcomes in ARDS management.

 

 

Important issues in the design and reporting of clinical trials in severe sepsis and acute lung injury.

pp. 493-499
Important issues in the design and reporting of clinical trials in severe sepsis and acute lung injury.
Dellinger, R. P.; Vincent, J. L.; Marshall, J.; Reinhart, K.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN241197898&field=zid

The effect of intensive care unit staffing model on tidal volume in patients with acute lung injury

Bibliographic export Print Select
Colin R Cooke ; Timothy R Watkins ; Jeremy M Kahn ; Miriam M Treggiari ; Ellen Caldwell ; Leonard D Hudson and Gordon D Rubenfeld
BioMed Central PDF Abstract
Free Medical Journals . com (/1997 - / Embargo: 2 years)
UK PubMed Central (/1997 - /2008)
Page: R134 Vol/Issue: 2008 ; VOL 12 Date: 2008-07-16
ISSN Print: 1364-8535 E-ISSN: 1466-609X
Search Google: Article Author(s)

Nebulised heparin: a new approach to the treatment of acute lung injury ?

Nebulised heparin: a new approach to the treatment of acute lung injury ?
Author(s): Peter M Suter
ISSUE: 2008 ; VOL 12 (2008-01-03)
Access: From BioMed Central [PDF] [Abstract]

From Free Medical Journals . com (/1997 - /Embargo: 2 years)

From UK PubMed Central (/1997 - /2008)
Page: 170
Search the Web: [article] [author(s)]