scholarly journals Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure–Guided Strategy vs an Empirical High PEEP-Fio2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome

JAMA ◽  
2019 ◽  
Vol 321 (9) ◽  
pp. 846 ◽  
Author(s):  
Jeremy R. Beitler ◽  
Todd Sarge ◽  
Valerie M. Banner-Goodspeed ◽  
Michelle N. Gong ◽  
Deborah Cook ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Esophageal Pressure ◽  
High Peep ◽  
Positive End Expiratory Pressure

scholarly journals Positive End-Expiratory Pressure Setting in COVID-19-Related Acute Respiratory Distress Syndrome: Comparison Between Electrical Impedance Tomography, PEEP/FiO2 Tables, and Transpulmonary Pressure

2021 ◽  
Vol 8 ◽  
Author(s):  
Sébastien Gibot ◽  
Marie Conrad ◽  
Guilhem Courte ◽  
Aurélie Cravoisy
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Electrical Impedance Tomography ◽  
Electrical Impedance ◽  
Distress Syndrome ◽  
Invasive Technique ◽  
Positive End Expiratory Pressure ◽  
Impedance Tomography

Introduction: The best way to titrate the positive end-expiratory pressure (PEEP) in patients suffering from acute respiratory distress syndrome is still matter of debate. Electrical impedance tomography (EIT) is a non-invasive technique that could guide PEEP setting based on an optimized ventilation homogeneity.Methods: For this study, we enrolled the patients with 2019 coronavirus disease (COVID-19)-related acute respiratory distress syndrome (ARDS), who required mechanical ventilation and were admitted to the ICU in March 2021. Patients were monitored by an esophageal catheter and a 32-electrode EIT device. Within 48 h after the start of mechanical ventilation, different levels of PEEP were applied based upon PEEP/FiO2 tables, positive end-expiratory transpulmonary (PL)/ FiO2 table, and EIT. Respiratory mechanics variables were recorded.Results: Seventeen patients were enrolled. PEEP values derived from EIT (PEEPEIT) were different from those based upon other techniques and has poor in-between agreement. The PEEPEIT was associated with lower plateau pressure, mechanical power, transpulmonary pressures, and with a higher static compliance (Crs) and homogeneity of ventilation.Conclusion: Personalized PEEP setting derived from EIT may help to achieve a more homogenous distribution of ventilation. Whether this approach may translate in outcome improvement remains to be investigated.

Cardiorespiratory Effects of Positive End-expiratory Pressure during Progressive Tidal Volume Reduction (Permissive Hypercapnia) in Patients with Acute Respiratory Distress Syndrome

1995 ◽  
Vol 83 (4) ◽  
pp. 710-720. ◽  
Author(s):  
V. Marco Ranieri ◽  
Luciana Mascia ◽  
Tommaso Fiore ◽  
Francesco Bruno ◽  
Antonio Brienza ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Gas Exchange ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Tidal Volume ◽  
Distress Syndrome ◽  
Alveolar Recruitment ◽  
Permissive Hypercapnia ◽  
Positive End Expiratory Pressure

Background In patients with acute respiratory distress syndrome (ARDS), the ventilatory approach is based on tidal volume (VT) of 10-15 ml/kg and positive end-expiratory pressure (PEEP). To avoid further pulmonary injury, decreasing VT and allowing PaCO2 to increase (permissive hypercapnia) has been suggested. Effects of 10 cmH2O of PEEP on respiratory mechanics, hemodynamics, and gas exchange were compared during mechanical ventilation with conventional (10-15 ml/kg) and low (5-8 ml/kg) VT. Methods Nine sedated and paralyzed patients were studied. VT was decreased gradually (50 ml every 20-30 min). Static volume-pressure (V-P) curves, hemodynamics, and gas exchange were measured. Results During mechanical ventilation with conventional VT, V-P curves on PEEP 0 (ZEEP) exhibited an upward convexity in six patients reflecting a progressive reduction in compliance with inflating volume, whereas PEEP resulted in a volume displacement along the flat part of this curve. After VT reduction, V-P curves in the same patients showed an upward concavity, reflecting progressive alveolar recruitment with inflating volume, and application of PEEP resulted in alveolar recruitment. The other three patients showed a V-P curve with an upward concavity; VT reduction increased this concavity, and application of PEEP induced greater alveolar recruitment than during conventional VT. With PEEP, cardiac index decreased by, respectively, 31% during conventional VT and 11% during low VT (P < 0.01); PaO2 increased by 32% and 71% (P < 0.01), respectively, whereas right-to-left venous admixture (Qs/Qt) decreased by 11% and 40%, respectively (P < 0.01). The greatest values of PaO2, static compliance, and oxygen delivery and the lowest values of Qs/Qt (best PEEP) were obtained during application of PEEP with low VT (P < 0.01). Conclusions Although PEEP induced alveolar hyperinflation in most patients during mechanical ventilation with conventional VT, at low VT, there appeared to be a significant alveolar collapse, and PEEP was able to expand these units, improving gas exchange and hemodynamics.

scholarly journals Use of Transpulmonary Pressure Monitoring in the Management of Extrapulmonary Pediatric Acute Respiratory Distress Syndrome With multi organ dysfunction syndrome (MODS): Are We Peepophobic?

2019 ◽  
Vol 12 ◽  
pp. 117954761984218 ◽  
Author(s):  
Mukul Pandey ◽  
Dhiren Gupta ◽  
Neeraj Gupta ◽  
Anil Sachdev
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Transpulmonary Pressure ◽  
Esophageal Pressure ◽  
Positive End Expiratory Pressure ◽  
Pressure Monitoring ◽  
Ventilator Settings ◽  
The Ideal

Manipulation of positive end-expiratory pressure (PEEP) has been shown to improve the outcome in pediatric acute respiratory distress syndrome (PARDS), but the “ideal” PEEP, in which the compliance and oxygenation are maximized, while overdistension and undesirable hemodynamic effects are minimized, is yet to be determined. Also, for a given level of PEEP, transpulmonary pressure (TPP) may vary unpredictably from patient to patient. Patients with high pleural pressure who are on conventional ventilator settings under inflation may cause hypoxemia. In such patients, raising PEEP to maintain a positive TPP might improve aeration and oxygenation without causing overdistension. We report a case of PARDS, who was managed using real-time esophageal pressure monitoring using the AVEA ventilator and thereby adjusting PEEP to maintain the positive TPP.

scholarly journals Επίδραση του μηχανικού αερισμού με χαμηλούς όγκους, του αερισμού υψηλής συχνότητας και του συνδυασμού του τελευταίου με ενδοτραχειακή εμφύσηση αερίων, στις αναπνευστικές και καρδιαγγειακές φυσιολογικές μεταβλητές στο σύνδρομο αναπνευστικής δυσπραγίας

2013 ◽  
Author(s):  
Σωτήριος Μαλαχίας
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
High Frequency ◽  
Distress Syndrome ◽  
Conventional Mechanical Ventilation ◽  
High Frequency Oscillation ◽  
Positive End Expiratory Pressure ◽  
Frequency Oscillation

Στο σύνδρομο οξείας αναπνευστικής δυσπραγίας (Acute Respiratory Distress Syndrome-ARDS), οι συνεδρίες επιστράτευσης με μηχανικό αερισμό υψηλής συχνότητας (High Frequency Oscillation-HFO) και ενδοτραχειακής εμφύσησης αεριών (Tracheal Gas Insuflation-TGI) με σύντομους, «κλασσικούς» χειρισμούς επιστράτευσης (εφαρμογή συνεχούς θετικής πίεσης αεραγωγών 45cmH2O για 45 δευτερόλεπτα-Recruitment Maneuvers-RMs), μπορεί να βελτιώσει την οξυγόνωση και να επιτρέψει την ελάττωση των πιέσεων του συμβατικού μηχανικού αερισμού (Conventional Mechanical Ventilation-CMV). Καταγράφηκε η επίπτωση της προσθήκης συνεδριών HFO-TGI στο μοντέλο του προστατευτικού CMV πάνω στις φυσιολογικές μεταβλητές των ασθενών με πρώιμο/βαρύ ARDS. Πραγματοποιήσαμε μία προοπτική, τυχαιοποιημένη, μη τυφλή κλινική μελέτη, η οποία χωρίστηκε χρονικά σε μία πρώτη, μονοκεντρική, περίοδο και σε μία δεύτερη, δικεντρική, περίοδο. Συμπεριελήφθησαν 125 συνολικά ασθενείς (54 ασθενείς από την πρώτη περίοδο), με τιμή του λόγου της μερικής τάσης του οξυγόνου του αρτηριακού αίματος (PaO2) προς την κλασματική συγκέντρωση του οξυγόνου στον εισπνεόμενο αέρα (FiO2) μικρότερη των 150mmHg για περισσότερες από 12 συνεχείς ώρες και με τιμή θετικής τελοεκπνευστικής πίεσης (Positive End-Expiratory Pressure-PEEP) στον CMV μεγαλύτερη ή ίση των 8cmH2O. Οι ασθενείς τυχαιοποιήθηκαν είτε στην ομάδα του HFO-TGI (λαμβάνοντας συνεδρίες με συνδυασμό HFO-TGI με χειρισμούς επιστράτευσης (RMs) και εναλλαγή με προστατευτικό μοντέλο CMV, σύνολο=61 ασθενείς) είτε στην ομάδα του CMV (λαμβάνοντας συνδυασμό προστατευτικού μοντέλου CMV με χειρισμούς επιστράτευσης, σύνολο=64 ασθενείς). Η χρονική διάρκεια του CMV πριν την τυχαιοποίηση, ήταν μεταβλητή ανάμεσα στους ασθενείς. Κατά την διάρκεια των ημερών 1-10 μετά την τυχαιοποίηση, ο λόγος PaO2/FiO2, ο δείκτης οξυγόνωσης, η τελοεισπνευστική πίεση ισορροπίας και η ενδοτικότητα του αναπνευστικού συστήματος, ήταν βελτιωμένοι στους ασθενείς της ομάδας του HFO-TGI σε σχέση με την ομάδα του CMV (P<0,001 για την αλληλεπίδραση ομάδα × χρόνος). Η PaCO2 και οι αιμοδυναμικές μεταβλητές δεν παρουσίασαν στατιστικά σημαντική μεταβολή [P=0,19 για τον καρδιακό δείκτη (CI), P>0,09 για την μέση αρτηριακή πίεση (MAP) και P=0,08 για την κεντρική φλεβική πίεση (CVP)].

scholarly journals Mechanical power in pediatric acute respiratory distress syndrome: a PARDIE study

Critical Care ◽  
2022 ◽  
Vol 26 (1) ◽  
Author(s):  
Anoopindar K. Bhalla ◽  
Margaret J. Klein ◽  
Vicent Modesto I Alapont ◽  
Guillaume Emeriaud ◽  
Martin C. J. Kneyber ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Intensive Care ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Mechanical Power ◽  
Positive End Expiratory Pressure ◽  
Ventilator Management ◽  
Ventilation Management

Abstract Background Mechanical power is a composite variable for energy transmitted to the respiratory system over time that may better capture risk for ventilator-induced lung injury than individual ventilator management components. We sought to evaluate if mechanical ventilation management with a high mechanical power is associated with fewer ventilator-free days (VFD) in children with pediatric acute respiratory distress syndrome (PARDS). Methods Retrospective analysis of a prospective observational international cohort study. Results There were 306 children from 55 pediatric intensive care units included. High mechanical power was associated with younger age, higher oxygenation index, a comorbid condition of bronchopulmonary dysplasia, higher tidal volume, higher delta pressure (peak inspiratory pressure—positive end-expiratory pressure), and higher respiratory rate. Higher mechanical power was associated with fewer 28-day VFD after controlling for confounding variables (per 0.1 J·min−1·Kg−1 Subdistribution Hazard Ratio (SHR) 0.93 (0.87, 0.98), p = 0.013). Higher mechanical power was not associated with higher intensive care unit mortality in multivariable analysis in the entire cohort (per 0.1 J·min−1·Kg−1 OR 1.12 [0.94, 1.32], p = 0.20). But was associated with higher mortality when excluding children who died due to neurologic reasons (per 0.1 J·min−1·Kg−1 OR 1.22 [1.01, 1.46], p = 0.036). In subgroup analyses by age, the association between higher mechanical power and fewer 28-day VFD remained only in children < 2-years-old (per 0.1 J·min−1·Kg−1 SHR 0.89 (0.82, 0.96), p = 0.005). Younger children were managed with lower tidal volume, higher delta pressure, higher respiratory rate, lower positive end-expiratory pressure, and higher PCO2 than older children. No individual ventilator management component mediated the effect of mechanical power on 28-day VFD. Conclusions Higher mechanical power is associated with fewer 28-day VFDs in children with PARDS. This association is strongest in children < 2-years-old in whom there are notable differences in mechanical ventilation management. While further validation is needed, these data highlight that ventilator management is associated with outcome in children with PARDS, and there may be subgroups of children with higher potential benefit from strategies to improve lung-protective ventilation. Take Home Message: Higher mechanical power is associated with fewer 28-day ventilator-free days in children with pediatric acute respiratory distress syndrome. This association is strongest in children <2-years-old in whom there are notable differences in mechanical ventilation management.

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