Mechanical power of ventilation and driving pressure: two undervalued parameters for pre extracorporeal membrane oxygenation ventilation and during daily management?

by K. Hoppe, E. Khan, P. Meybohm and T. Riese 

Critical Care volume 27, Article number: 111 (2023) Published: 14 March 2023

Abstract

The current ARDS guidelines highly recommend lung protective ventilation which include plateau pressure (Pplat < 30 cm H2O), positive end expiratory pressure (PEEP > 5 cm H2O) and tidal volume (Vt of 6 ml/kg) of predicted body weight. In contrast, the ELSO guidelines suggest the evaluation of an indication of veno-venous extracorporeal membrane oxygenation (ECMO) due to hypoxemic or hypercapnic respiratory failure or as bridge to lung transplantation. Finally, these recommendations remain a wide range of scope of interpretation. However, particularly patients with moderate-severe to severe ARDS might benefit from strict adherence to lung protective ventilation strategies. Subsequently, we discuss whether extended physiological ventilation parameter analysis might be relevant for indication of ECMO support and can be implemented during the daily routine evaluation of ARDS patients. Particularly, this viewpoint focus on driving pressure and mechanical power.

 

Dead space ventilation-related indices: bedside tools to evaluate the ventilation and perfusion relationship in patients with acute respiratory distress syndrome

 

by Mingjia Zheng 

 

Critical Care volume 27, Article number: 46 (2023) 

 

Abstract

Cumulative evidence has demonstrated that the ventilatory ratio closely correlates with mortality in acute respiratory distress syndrome (ARDS), and a primary feature in coronavirus disease 2019 (COVID-19)-ARDS is increased dead space that has been reported recently. Thus, new attention has been given to this group of dead space ventilation-related indices, such as physiological dead space fraction, ventilatory ratio, and end-tidal-to-arterial PCO2 ratio, which, albeit distinctive, are all global indices with which to assess the relationship between ventilation and perfusion. These parameters have already been applied to positive end expiratory pressure titration, prediction of responses to the prone position and the field of extracorporeal life support for patients suffering from ARDS. Dead space ventilation-related indices remain hampered by several deflects; notwithstanding, for this catastrophic syndrome, they may facilitate better stratifications and identifications of subphenotypes, thereby providing therapy tailored to individual needs.

 

Refractory ineffective triggering during pressure support ventilation: effect of proportional assist ventilation with load-adjustable gain factors

 

by Anne-Fleur Haudebourg, Tommaso Maraffi, Samuel Tuffet, François Perier, Nicolas de Prost, Keyvan Razazi, Armand Mekontso Dessap and Guillaume Carteaux 

 

Annals of Intensive Care volume 11, Article number: 147 (2021) 

Background

Ineffective triggering is frequent during pressure support ventilation (PSV) and may persist despite ventilator adjustment, leading to refractory asynchrony. We aimed to assess the effect of proportional assist ventilation with load-adjustable gain factors (PAV+) on the occurrence of refractory ineffective triggering.

Design

Observational assessment followed by prospective cross-over physiological study.

Setting

Academic medical ICU.

Patients

Ineffective triggering was detected during PSV by a twice-daily inspection of the ventilator’s screen. The impact of pressure support level (PSL) adjustments on the occurrence of asynchrony was recorded. Patients experiencing refractory ineffective triggering, defined as persisting asynchrony at the lowest tolerated PSL, were included in the physiological study.

Interventions

Physiological study: Flow, airway, and esophageal pressures were continuously recorded during 10 min under PSV with the lowest tolerated PSL, and then under PAV+ with the gain adjusted to target a muscle pressure between 5 and 10 cmH2O.

Measurements

Primary endpoint was the comparison of asynchrony index between PSV and PAV+ after PSL and gain adjustments.

Results

Among 36 patients identified having ineffective triggering under PSV, 21 (58%) exhibited refractory ineffective triggering. The lowest tolerated PSL was higher in patients with refractory asynchrony as compared to patients with non-refractory ineffective triggering. Twelve out of the 21 patients with refractory ineffective triggering were included in the physiological study. The median lowest tolerated PSL was 17 cmH2O [12–18] with a PEEP of 7 cmH2O [5–8] and FiO2 of 40% [39–42]. The median gain during PAV+ was 73% [65–80]. The asynchrony index was significantly lower during PAV+ than PSV (2.7% [1.0–5.4] vs. 22.7% [10.3–40.1], p < 0.001) and consistently decreased in every patient with PAV+. Esophageal pressure–time product (PTPes) did not significantly differ between the two modes (107 cmH2O/s/min [79–131] under PSV vs. 149 cmH2O/s/min [129–170] under PAV+, p = 0.092), but the proportion of PTPes lost in ineffective triggering was significantly lower with PAV+ (2 cmH2O/s/min [1–6] vs. 8 cmH2O/s/min [3–30], p = 0.012).

Conclusions

Among patients with ineffective triggering under PSV, PSL adjustment failed to eliminate asynchrony in 58% of them (21 of 36 patients). In these patients with refractory ineffective triggering, switching from PSV to PAV+ significantly reduced or even suppressed the incidence of asynchrony.

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

by Gaetano Florio, Matteo Ferrari, Edward A. Bittner, Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi, Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai…

Critical Care volume 24, Article number: 4 (2020) Published: 15 January 2020

Background

Limited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS.

Methods

In this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012–2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015–2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring.

Results

The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13–0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16–0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16–0.74).

Conclusion

Individualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.

Subglottic Secretion Drainage and Objective Outcomes: A Systematic Review and Meta-Analysis

Critical Care Medicine: April 2016 - Volume 44 - Issue 4 - p 830–840
Caroff, D

Objective: Current guidelines recommend endotracheal tubes with subglottic secretion drainage to prevent ventilator-associated pneumonia. Subglottic secretion drainage is associated with fewer ventilator-associated pneumonia diagnoses, but it is unclear to what extent this reflects fewer invasive pneumonias versus fewer false-positive diagnoses due to less secretions and/or less microbial colonization of the oropharynx. We, therefore, undertook a systematic review and meta-analysis of the impact of subglottic secretion drainage on duration of mechanical ventilation, ICU and hospital length of stay, ventilator-associated events, mortality, antibiotic utilization, stridor, and reintubations to better understand the net benefits and limitations of this intervention. Data Sources: We searched Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, and PubMed from inception through February 22, 2015, without language restrictions. Study Selection: Randomized controlled trials comparing subglottic secretion drainage versus no subglottic secretion drainage in adult patients on mechanical ventilation. Data Extraction: Eligible trials were abstracted and assessed for risk of bias by two reviewers. Data Synthesis: We identified 17 eligible trials with a total of 3,369 patients. Subglottic secretion drainage was associated with lower ventilator-associated pneumonia rates (risk ratio, 0.58; 95% CI, 0.51–0.67; I2 = 0%), but there were no significant differences between groups in duration of mechanical ventilation (weighted mean difference, −0.16 d; 95% CI, −0.64 to 0.33; I2 = 0%), ICU length of stay (weighted mean difference, +0.17 d; 95% CI, −0.62 to 0.95; I2 = 0%), hospital length of stay (weighted mean difference, −0.57 d; 95% CI, −2.44 to 1.30; I2 = 0%), ventilator-associated events (risk ratio, 0.97; 95% CI, 0.65–1.43), or mortality (risk ratio, 0.93; 95% CI, 0.84–1.03; I2 = 0%). Two studies observed significantly less antibiotic use with subglottic secretion drainage whereas a third did not. There were no significant differences between groups in stridor or reintubations. Conclusions: Subglottic secretion drainage is associated with lower ventilator-associated pneumonia rates but does not clearly decrease duration of mechanical ventilation, length of stay, ventilator-associated events, mortality, or antibiotic usage. Further data are required to demonstrate the benefits of subglottic secretion drainage.

Lung-Protective Ventilation With Low Tidal Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data Analysis

Critical Care Medicine: October 2015 - Volume 43 - Issue 10 - p 2155–2163

Neto, AS et al

Objective: Protective mechanical ventilation with low tidal volumes is standard of care for patients with acute respiratory distress syndrome. The aim of this individual patient data analysis was to determine the association between tidal volume and the occurrence of pulmonary complications in ICU patients without acute respiratory distress syndrome and the association between occurrence of pulmonary complications and outcome in these patients. Design: Individual patient data analysis. Patients: ICU patients not fulfilling the consensus criteria for acute respiratory distress syndrome at the onset of ventilation. Interventions: Mechanical ventilation with low tidal volume. Measurements and Main Results: The primary endpoint was development of a composite of acute respiratory distress syndrome and pneumonia during hospital stay. Based on the tertiles of tidal volume size in the first 2 days of ventilation, patients were assigned to a “low tidal volume group” (tidal volumes≤ 7 mL/kg predicted body weight), an “intermediate tidal volume group” (> 7 and < 10 mL/kg predicted body weight), and a “high tidal volume group” (≥ 10 mL/kg predicted body weight). Seven investigations (2,184 patients) were included. Acute respiratory distress syndrome or pneumonia occurred in 23% of patients in the low tidal volume group, in 28% of patients in the intermediate tidal volume group, and in 31% of the patients in the high tidal volume group (adjusted odds ratio [low vs high tidal volume group], 0.72; 95% CI, 0.52–0.98; p = 0.042). Occurrence of pulmonary complications was associated with a lower number of ICU-free and hospital-free days and alive at day 28 (10.0 ± 10.9 vs 13.8 ± 11.6 d; p < 0.01 and 6.1 ± 8.1 vs 8.9 ± 9.4 d; p < 0.01) and an increased hospital mortality (49.5% vs 35.6%; p < 0.01). Conclusions: Ventilation with low tidal volumes is associated with a lower risk of development of pulmonary complications in patients without acute respiratory distress syndrome.

Comparative Effectiveness of Noninvasive and Invasive Ventilation in Critically Ill Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Comparative Effectiveness of Noninvasive and Invasive Ventilation in Critically Ill Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Critical Care Medicine: July 2015 - Volume 43 - Issue 7 - p 1386–1394 doi: 10.1097/CCM.0000000000000945

Stefan, MS. Et al

http://journals.lww.com/ccmjournal/Fulltext/2015/07000/Comparative_Effectiveness_of_Noninvasive_and.6.aspx

Objectives: To compare the characteristics and hospital outcomes of patients with an acute exacerbation of chronic obstructive pulmonary disease treated in the ICU with initial noninvasive ventilation or invasive mechanical ventilation.
Design: Retrospective, multicenter cohort study of prospectively collected data. We used propensity matching to compare the outcomes of patients treated with noninvasive ventilation to those treated with invasive mechanical ventilation. We also assessed predictors for noninvasive ventilation failure. 

Noninvasive ventilation and survival in acute care settings

Noninvasive ventilation and survival in acute care settings: A comprehensive systematic review and metanalysis of randomized controlled trials. Critical Care Medicine, April 2015, Vol. 43(4), p.880-88.

Cabrini, L., et al.

http://journals.lww.com/ccmjournal/Abstract/2015/04000/Noninvasive_Ventilation_and_Survival_in_Acute_Care.20.aspx

Noninvasive ventilation is increasingly applied to prevent or treat acute respiratory failure, but its benefit on survival is still controversial for many indications. We performed a metaanalysis of randomized controlled trials focused on the effect of noninvasive ventilation on mortality.

Do heart rate and respiratory rate variability improve prediction of extubation outcomes in critically ill patients?

Do heart rate and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? Critical Care, 2014, 18:R65

Seely, AJE, et al.

http://ccforum.com/content/pdf/cc13822.pdf

Prolonged ventilation and failed extubation are associated with increased harm and cost. The 
added value of heart and respiratory rate variability (HRV and RRV) during spontaneous 
breathing trials (SBTs) to predict extubation failure remains unknown. 

Acute post-traumatic stress in survivors of critical illness who were mechanically ventilated

Acute post-traumatic stress in survivors of critcal illness who were mechanically ventilated: A mixed methods study. Intensive & critical care nursing, Dec. 2011, Vol. 27(6), p. 338-346.

Talisayon, R., et al.

http://www.intensivecriticalcarenursing.com/article/PIIS0964339711000942/abstract?rss=yes

This study investigated the severity of post-traumatic stress (PTS) symptoms, the relationships between PTS symptoms and clinical and demographic characteristics and the subjective experiences of patients who were critically ill and mechanically ventilated in intensive care.

Delirium duration and mortality in lightly sedated, mechanicaly ventilated intensive care patients

Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Critical Care Medicine, Vol 38(12), December 2010, p. 2311-2318.

Shehabi, Y., et al.

http://journals.lww.com/ccmjournal/Abstract/2010/12000/Delirium_duration_and_mortality_in_lightly.7.aspx

To determine the relationship between the number of delirium days experienced by intensive care patients and mortality, ventilation time, and intensive care unit stay.

Weaning from ventilation: Does a care bundle approach work?

Weaning from ventilation: Does a care bundle approach work? Intensive and critical care nursing, 2008, vol. 24(3), p. 180-186

Crocker, C. and Kinnear, W.

http://www.intensivecriticalcarenursing.com/article/S0964-3397(07)00120-6/abstract

A care bundle is a small but critical set of processes that when implemented together improve outcome. One critical care network has written a weaning care bundle. This is an example of a service improvement initiative the aim of which was to improve weaning from mechanical ventilation.

Outcomes of patients ventilated with synchronized intermittent mandatory ventilation with pressure support

Outcomes of patients ventilated with synchronized intermittent mandatory ventilation with pressure support. CHEST, June 2010 Vol. 137(6), p. 1265-1277.

Ortiz, G., et al.

http://chestjournal.chestpubs.org/content/137/6/1265.short?rss=1

Few data are available regarding the benefits of one mode over another for ventilatory support. We set out to compare clinical outcomes of patients receiving synchronized intermittent mandatory ventilation with pressure support (SIMV-PS) compared with assist-control (A/C) ventilation as their primary mode of ventilatory support.

Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. New England Journal of Medicine, vol. 349(12), Sept. 2003. [journal article]

Cook, D., et al.

http://content.nejm.org/cgi/reprint/349/12/1123.pdf

In critically ill patients who are receiving mechanical ventilation, the factors associated with physicians’ decisions to withdraw ventilation in anticipation of death are unclear. The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation.

Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation

BMC Emergency Medicine, published between 30-Jan-2009 and 13-Mar-2009

Research article
Smaller self-inflating bags produce greater guideline consistent ventilation in simulated cardiopulmonary resuscitation
Nehme Z, Boyle MJ BMC Emergency Medicine 2009, 9:4
(20 February 2009)
[Abstract] [Provisional PDF] [PubMed]

EMJ Jan 2008 Vol 25 No 1

"ED patients with severe sepsis are already critically ill and require immediate attention to prevent deterioration"

Editors choice: Surviving Sepsis

Prehospital care: Retention of basic ventilation skills

www.emj.bmj.com or held locally in HS Library

INTENSIVE CARE MEDICINE Vol 34

INTENSIVE CARE MEDICINE
VOL 34; NUMBER 12; 2008 , ISSN 0342-4642

p. 2306
Adaptive support ventilation is a patented technology.
Tehrani, F. T.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN240538764&field=zid

p. 2304
Microcirculation and multi-organ failure in patients with sepsis.
den Uil, C. A.; Lagrand, W. K.; Brugts, J. J.; Spronk, P. E.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN240538774&field=zid

pp. 2176-2184
Serum levels of osteopontin are increased in SIRS and sepsis.
Vaschetto, R.; Nicola, S.; Olivieri, C.; Boggio, E.; Piccolella, F.; Mesturini, R.; Damnotti, F.; Colombo, D.; Navalesi, P.; Della Corte, F.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN240538786&field=zid

Pressure support ventilation attenuates ventilator-induced protein modifications in the diaphragm.

p. R116

Futier, E.; Constantin, J.; Combaret, L.; Mosoni, L.; Roszyk, L.; Sapin, V.; Attaix, D.; Jung, B.; Jaber, S.; Bazin, J.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=PM018786263&field=zid

Excessive tidal volume from breath stacking during lung - protective ventilation for acute lung injury

Pohlman , M . C . ; McCallister , K . E . ; Schweickert , W . D . ; Pohlman , A . S . ; Nigos , C . P . ; Krishnan , J . A . ; Charbeneau , J . T . ; Gehlbach , B . K . ; Kress , J . P . ; Hall , J . B .
Ovid ( Journals @ Ovid ) via Athens Full Text (01/1995 - /)
Page: 3019-3023 Vol/Issue: 2008 ; VOL 36 ; PART 11
ISSN Print: 0090-3493 E-ISSN: 1530-0293 Print Holdings: Yes
Search Google: Article Author(s)

Effect of tidal volume , sampling duration , and cardiac contractility on pulse pressure and stroke volume variation during positive - pressure ventil

Bibliographic export Print Select

Kim , H . K . ; Pinsky , M . R .
Ovid ( Journals @ Ovid ) via Athens Full Text (01/1995 - /)
Page: 2858-2862 Vol/Issue: 2008 ; VOL 36 ; PART 10
ISSN Print: 0090-3493 E-ISSN: 1530-0293 Print Holdings: Yes
Search Google: Article Author(s)