BACKGROUND Acute respiratory distress syndrome(ARDS)is an acute,diffuse,inflammatory lung injury.Previous studies have shown prone position ventilation(PPV)to be associated with improvement in oxygenation.However,its ...BACKGROUND Acute respiratory distress syndrome(ARDS)is an acute,diffuse,inflammatory lung injury.Previous studies have shown prone position ventilation(PPV)to be associated with improvement in oxygenation.However,its role in patients with ARDS caused by sepsis remains unknown.AIM To analyze the clinical effects of PPV in patients with ARDS caused by sepsis.METHODS One hundred and two patients with ARDS were identified and divided into a control group(n=55)and a PPV treatment group(n=47).Outcomes included oxygenation index,lung compliance(Cst)and platform pressure(Pplat),which were compared between the two groups after ventilation.Other outcomes included heart rate(HR),mean arterial pressure(MAP),central venous pressure(CVP),left ventricular ejection fraction(LVEF),the length of mechanical ventilation time and intensive care unit(ICU)stay,and levels of C-reactive protein(CRP),procalcitonin(PCT),and interleukin-6(IL-6)after ventilation.Finally,mortality rate was also compared between the two groups.RESULTS On the first day after ventilation,the oxygenation index and Cst were higher and Pplat level was lower in the PPV group than in the conventional treatment group(P<0.05).There were no significant differences in oxygenation index,Cst,and Pplat levels between the two groups on the 2^(nd),4^(th),and 7^(th) day after ventilation(P>0.05).There were no significant differences in HR,MAP,CVP,LVEF,duration of mechanical ventilation and ICU stay,and the levels of CRP,PCT,and IL-6 between the two groups on the first day after ventilation(all P>0.05).The mortality rates on days 28 and 90 in the PPV and control groups were 12.77% and 29.09%,and 25.53% and 45.45%,respectively(P<0.05).CONCLUSION PPV may improve respiratory mechanics indices and may also have mortality benefit in patients with ARDS caused by sepsis.Finally,PPV was not shown to cause any adverse effects on hemodynamics and inflammation indices.展开更多
Acute respiratory distress syndrome(ARDS) represents a serious problem in critically ill patients and is associated with in-hospital mortality rates of 33%-52%. Recruitment maneuvers(RMs) are a simple, low-cost, feasi...Acute respiratory distress syndrome(ARDS) represents a serious problem in critically ill patients and is associated with in-hospital mortality rates of 33%-52%. Recruitment maneuvers(RMs) are a simple, low-cost, feasible intervention that can be performed at the bedside in patients with ARDS. RMs are characterized by the application of airway pressure to increase transpulmonary pressure transiently. Once non-aerated lung units are reopened, improvements are observed in respiratory system mechanics, alveolar reaeration on computed tomography, and improvements in gas exchange(functional recruitment). However, the reopening process could lead to vascular compression, which can be associated with overinflation, and gas exchange may not improve as expected(anatomical recruitment). The purpose of this review was to discuss the effects of different RM strategies- sustained inflation, intermittent sighs, and stepwise increases of positive end-expiratory pressure(PEEP) and/or airway inspiratory pressure- on the following parameters: hemodynamics, oxygenation, barotrauma episodes, and lung recruitability through physiological variables and imaging techniques. RMs and PEEP titration are interdependent events for the success of ventilatory management. PEEP should be adjusted on the basis of respiratory system mechanics and oxygenation. Recent systematic reviews and meta-analyses suggest that RMs are associated with lower mortality in patients with ARDS. However, the optimal RM method(i.e., that providing the best balance of benefit and harm) and the effects of RMs on clinical outcome are still under discussion, and further evidence is needed.展开更多
Objective:To evaluate the efficacy and safety of protective lung ventilation strategy combined with lung recruitment maneuver (RM) in the treatment patients with acute respiratory distress syndrome (ARDS).Methods:Tota...Objective:To evaluate the efficacy and safety of protective lung ventilation strategy combined with lung recruitment maneuver (RM) in the treatment patients with acute respiratory distress syndrome (ARDS).Methods:Totally 74 patients with ARDS admitted to the Department of Intensive Care Unit, Changshu Second People's Hospital in Jiangsu Province between September 2010 and June 2013 were selected and randomly divided into lung recruitment group and non-lung recruitment group, and the initial ventilation solution for both groups was synchronized intermittent mandatory ventilation (SIMV). For RM, SIMV mode (pressure control and pressure support) was adopted. Positive end expiratory pressure (PEEP) was increased by 5 cm H2O every time and maintained for 40-50 s before entering the next increasing period, and the peak airway pressure was kept below 45 cm H2O. After PEEP reached the maximum value, it was gradually reduced by 5 cm H2O every time and finally maintained at 15 cm H2O for 10 min.Results:A total of 74 patients with mean age of (49.0±18.6) years old were enrolled, 36 patients were enrolled in lung recruitment maneuver (RM) group and 38 patients were enrolled into non-lung recruitment maneuver (non-RM) group. 44 were male and accounted for 59.5% of all the patients. For the indicators such as PEEP, pressure support (PS), plateau airway pressure (Pplat), peak airway pressure (Ppeak), vital capacity (VC) and fraction of inspired oxygen (FiO2), no statistical differences in the indicators were found between the RM group and non-RM group on D1, D3 and D7 (P>0.05), except that only FiO2 of RM group on D7 was significantly lower than that of non-RM group (47.2±10.0) vs. (52.2±10.5),P<0.05]. For the indicators of blood gas analysis, including pH, arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2) and oxygenation index (PaO2/FiO2), PaO2 and PaO2/FiO2 of RM group were significantly higher than those of non-RM group on D7, and the values were [(90.2±16.1) mmHg vs. (76.4±11.3) mmHg,P<0.05] and [(196.5±40.7) mmHg vs. (151.7±37.3) mmHg,P<0.05] respectively. There was no statistical difference in heart rate (HR), cardiac index (CI), central venous pressure (CVP) or mean arterial pressure (MAP) between RM group and non-RM group on D1, D3 and D7 (P>0.05). 28-day mortality, ICU mortality and in-hospital mortality were 25% vs. 28.9%, 25% vs. 26.3% and 36.1% vs. 39.5% respectively between RM group and non-RM group (allP>0.05).Conclusion:Protective lung ventilation strategy combined with lung recruitment maneuver can improve the indicators such as PaO2, FiO2 and PaO2/FiO2 on D7, but failed to improve the final outcomes such as 28-day mortality, ICU mortality and in-hospital mortality.展开更多
The novel coronavirus,which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality.It has increased hospital occupancy,heralded economic turmoil,an...The novel coronavirus,which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality.It has increased hospital occupancy,heralded economic turmoil,and the rapid transmission and community spread have added to the burden of the virus.Most of the patients are admitted to the intensive care unit(ICU)for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome(ARDS).Based on the limited data available,there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019(COVID-19).Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS.Based on these differences,our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS.We critically analyze the role of positive end-expiratory pressure(PEEP)and proning in the ICU patients.Through the limited data and clinical experience are available,we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.展开更多
Background It is still controversial as to the implementation of higher positive end-expiratory pressure （PEEP） in patients with acute respiratory distress syndrome （ARDS）. This study was conducted to compare the ...Background It is still controversial as to the implementation of higher positive end-expiratory pressure （PEEP） in patients with acute respiratory distress syndrome （ARDS）. This study was conducted to compare the lower and higher PEEP in patients with ARDS ventilated with low tidal volume, to investigate the relationship between the recruited lung volume by higher PEEP and relevant independent variables and to provide a bedside estimate of the percentage of potentially recruitable lung by higher PEEP. Methods Twenty-four patients with ARDS were studied. A lung recruiting maneuver was performed, then each patient was ventilated with PEEP of 8 cmH20 for 4 hours and subsequently with PEEP of 16 cmH20 for 4 hours. At the end of each PEEP level period, gas exchange, hemodynamic data, lung mechanics, stress index ＂b＂ of the dynamic pressure-time curve, intrinsic PEEP and recruited volume by PEEP were measured. Results Fourteen patients were recruiters whose alveolar recruited volumes induced by PEEP 16 cmH20 were （425_＋65） ml and 10 patients were non-recruiters. Compared with the PEEP 8 cmH20 period, after the application of the PEEP 16 cmH20, the PaO2/FiO2 ratio and static lung compliance both remained unchanged in non-recruiters, whereas they increased significantly in recruiters. Changes in PaO2/FiO2 and static lung compliance after PEEP increase were independently associated with the alveolar recruitment. Analyzing the relationship between recruiting maneuver （RM）-induced change in end-expiratory lung volume and the alveolar recruitment induced by PEEP, we found a notable correlation. Conclusions The results of this study indicated that the potential for alveolar recruitment might vary among the ARDS population and the higher PEEP levels should be limited to recruiters. Improving in PaO2/FiO2, static lung compliance after PEEP increase and the shape of the pressure-time curve could be helpful for PEEP application.展开更多
Driving pressure(ΔP)is a core therapeutic component of mechanical ventilation(MV).Varying levels ofΔP have been employed during MV depending on the type of underlying pathology and severity of injury.However,ΔP lev...Driving pressure(ΔP)is a core therapeutic component of mechanical ventilation(MV).Varying levels ofΔP have been employed during MV depending on the type of underlying pathology and severity of injury.However,ΔP levels have also been shown to closely impact hard endpoints such as mortality.Considering this,conducting an in-depth review ofΔP as a unique,outcome-impacting therapeutic modality is extremely important.There is a need to understand the subtleties involved in making sureΔP levels are optimized to enhance outcomes and minimize harm.We performed this narrative review to further explore the various uses ofΔP,the different parameters that can affect its use,and how outcomes vary in different patient populations at different pressure levels.To better utilizeΔP in MV-requiring patients,additional large-scale clinical studies are needed.展开更多
Background： Electrical impedance tomography （EIT） is a real-time bedside monitoring tool, which can reflect dynamic regional lung ventilation. The aim of the present study was to monitor regional gas distribution i...Background： Electrical impedance tomography （EIT） is a real-time bedside monitoring tool, which can reflect dynamic regional lung ventilation. The aim of the present study was to monitor regional gas distribution in patients with acute respiratory distress syndrome （ARDS） during positive-end-expiratory pressure （PEEP） titration using EIT. Methods： Eighteen ARDS patients under mechanical ventilation in Department of Critical Care Medicine of Peking Union Medical College Hospital from January to April in 2014 were included in this prospective observational study. After recruitment maneuvers （RMs）, decremental PEEP titration was performed from 20 cmH20 to 5 cmH20 in steps of 3 cmH20 every 5-10 min. Regional over-distension and recruitment were monitored with EIT. Results： After RMs, patient with arterial blood oxygen partial pressure （PaO2） ＋ carbon dioxide partial pressure （PaCO2） 〉400 mmHg with 100% of fractional inspired oxygen concentration were defined as RM responders. Thirteen ARDS patients was diagnosed as responders whose PaO2 ＋ PaCO2, were higher than nonresponders （419 ± 44 mmHg vs. 170 ±73 mmHg, P 〈 0.0001）. In responders, PEEP mainly increased-recruited pixels in dependent regions and over-distended pixels in nondependent regions. PEEP alleviated global inhomogeneity of tidal volume and end-expiratory lung volume. PEEP levels without significant alveolar derecruitment and over-distension were identified individually. Conclusions： After RMs, PEEP titration significantly affected regional gas distribution in lung, which could be monitored with EIT. EIT has the potential to optimize PEEP titration.展开更多
基金Supported by Science and Technology Plan of Jiangxi Provincial Health Commission,No.202130095.
文摘BACKGROUND Acute respiratory distress syndrome(ARDS)is an acute,diffuse,inflammatory lung injury.Previous studies have shown prone position ventilation(PPV)to be associated with improvement in oxygenation.However,its role in patients with ARDS caused by sepsis remains unknown.AIM To analyze the clinical effects of PPV in patients with ARDS caused by sepsis.METHODS One hundred and two patients with ARDS were identified and divided into a control group(n=55)and a PPV treatment group(n=47).Outcomes included oxygenation index,lung compliance(Cst)and platform pressure(Pplat),which were compared between the two groups after ventilation.Other outcomes included heart rate(HR),mean arterial pressure(MAP),central venous pressure(CVP),left ventricular ejection fraction(LVEF),the length of mechanical ventilation time and intensive care unit(ICU)stay,and levels of C-reactive protein(CRP),procalcitonin(PCT),and interleukin-6(IL-6)after ventilation.Finally,mortality rate was also compared between the two groups.RESULTS On the first day after ventilation,the oxygenation index and Cst were higher and Pplat level was lower in the PPV group than in the conventional treatment group(P<0.05).There were no significant differences in oxygenation index,Cst,and Pplat levels between the two groups on the 2^(nd),4^(th),and 7^(th) day after ventilation(P>0.05).There were no significant differences in HR,MAP,CVP,LVEF,duration of mechanical ventilation and ICU stay,and the levels of CRP,PCT,and IL-6 between the two groups on the first day after ventilation(all P>0.05).The mortality rates on days 28 and 90 in the PPV and control groups were 12.77% and 29.09%,and 25.53% and 45.45%,respectively(P<0.05).CONCLUSION PPV may improve respiratory mechanics indices and may also have mortality benefit in patients with ARDS caused by sepsis.Finally,PPV was not shown to cause any adverse effects on hemodynamics and inflammation indices.
基金Supported by Brazilian Council for Scientific and Technological Development(CNPq),Carlos Chagas Filho Rio de Janeiro State Research Foundation(FAPERJ),Department of Science and Technology(DECIT)/Brazilian Ministry of HealthCoordination for the Improvement of Higher Level Personnel(CAPES)
文摘Acute respiratory distress syndrome(ARDS) represents a serious problem in critically ill patients and is associated with in-hospital mortality rates of 33%-52%. Recruitment maneuvers(RMs) are a simple, low-cost, feasible intervention that can be performed at the bedside in patients with ARDS. RMs are characterized by the application of airway pressure to increase transpulmonary pressure transiently. Once non-aerated lung units are reopened, improvements are observed in respiratory system mechanics, alveolar reaeration on computed tomography, and improvements in gas exchange(functional recruitment). However, the reopening process could lead to vascular compression, which can be associated with overinflation, and gas exchange may not improve as expected(anatomical recruitment). The purpose of this review was to discuss the effects of different RM strategies- sustained inflation, intermittent sighs, and stepwise increases of positive end-expiratory pressure(PEEP) and/or airway inspiratory pressure- on the following parameters: hemodynamics, oxygenation, barotrauma episodes, and lung recruitability through physiological variables and imaging techniques. RMs and PEEP titration are interdependent events for the success of ventilatory management. PEEP should be adjusted on the basis of respiratory system mechanics and oxygenation. Recent systematic reviews and meta-analyses suggest that RMs are associated with lower mortality in patients with ARDS. However, the optimal RM method(i.e., that providing the best balance of benefit and harm) and the effects of RMs on clinical outcome are still under discussion, and further evidence is needed.
文摘Objective:To evaluate the efficacy and safety of protective lung ventilation strategy combined with lung recruitment maneuver (RM) in the treatment patients with acute respiratory distress syndrome (ARDS).Methods:Totally 74 patients with ARDS admitted to the Department of Intensive Care Unit, Changshu Second People's Hospital in Jiangsu Province between September 2010 and June 2013 were selected and randomly divided into lung recruitment group and non-lung recruitment group, and the initial ventilation solution for both groups was synchronized intermittent mandatory ventilation (SIMV). For RM, SIMV mode (pressure control and pressure support) was adopted. Positive end expiratory pressure (PEEP) was increased by 5 cm H2O every time and maintained for 40-50 s before entering the next increasing period, and the peak airway pressure was kept below 45 cm H2O. After PEEP reached the maximum value, it was gradually reduced by 5 cm H2O every time and finally maintained at 15 cm H2O for 10 min.Results:A total of 74 patients with mean age of (49.0±18.6) years old were enrolled, 36 patients were enrolled in lung recruitment maneuver (RM) group and 38 patients were enrolled into non-lung recruitment maneuver (non-RM) group. 44 were male and accounted for 59.5% of all the patients. For the indicators such as PEEP, pressure support (PS), plateau airway pressure (Pplat), peak airway pressure (Ppeak), vital capacity (VC) and fraction of inspired oxygen (FiO2), no statistical differences in the indicators were found between the RM group and non-RM group on D1, D3 and D7 (P>0.05), except that only FiO2 of RM group on D7 was significantly lower than that of non-RM group (47.2±10.0) vs. (52.2±10.5),P<0.05]. For the indicators of blood gas analysis, including pH, arterial oxygen pressure (PaO2), arterial carbon dioxide pressure (PaCO2) and oxygenation index (PaO2/FiO2), PaO2 and PaO2/FiO2 of RM group were significantly higher than those of non-RM group on D7, and the values were [(90.2±16.1) mmHg vs. (76.4±11.3) mmHg,P<0.05] and [(196.5±40.7) mmHg vs. (151.7±37.3) mmHg,P<0.05] respectively. There was no statistical difference in heart rate (HR), cardiac index (CI), central venous pressure (CVP) or mean arterial pressure (MAP) between RM group and non-RM group on D1, D3 and D7 (P>0.05). 28-day mortality, ICU mortality and in-hospital mortality were 25% vs. 28.9%, 25% vs. 26.3% and 36.1% vs. 39.5% respectively between RM group and non-RM group (allP>0.05).Conclusion:Protective lung ventilation strategy combined with lung recruitment maneuver can improve the indicators such as PaO2, FiO2 and PaO2/FiO2 on D7, but failed to improve the final outcomes such as 28-day mortality, ICU mortality and in-hospital mortality.
文摘The novel coronavirus,which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality.It has increased hospital occupancy,heralded economic turmoil,and the rapid transmission and community spread have added to the burden of the virus.Most of the patients are admitted to the intensive care unit(ICU)for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome(ARDS).Based on the limited data available,there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019(COVID-19).Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS.Based on these differences,our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS.We critically analyze the role of positive end-expiratory pressure(PEEP)and proning in the ICU patients.Through the limited data and clinical experience are available,we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.
文摘Background It is still controversial as to the implementation of higher positive end-expiratory pressure （PEEP） in patients with acute respiratory distress syndrome （ARDS）. This study was conducted to compare the lower and higher PEEP in patients with ARDS ventilated with low tidal volume, to investigate the relationship between the recruited lung volume by higher PEEP and relevant independent variables and to provide a bedside estimate of the percentage of potentially recruitable lung by higher PEEP. Methods Twenty-four patients with ARDS were studied. A lung recruiting maneuver was performed, then each patient was ventilated with PEEP of 8 cmH20 for 4 hours and subsequently with PEEP of 16 cmH20 for 4 hours. At the end of each PEEP level period, gas exchange, hemodynamic data, lung mechanics, stress index ＂b＂ of the dynamic pressure-time curve, intrinsic PEEP and recruited volume by PEEP were measured. Results Fourteen patients were recruiters whose alveolar recruited volumes induced by PEEP 16 cmH20 were （425_＋65） ml and 10 patients were non-recruiters. Compared with the PEEP 8 cmH20 period, after the application of the PEEP 16 cmH20, the PaO2/FiO2 ratio and static lung compliance both remained unchanged in non-recruiters, whereas they increased significantly in recruiters. Changes in PaO2/FiO2 and static lung compliance after PEEP increase were independently associated with the alveolar recruitment. Analyzing the relationship between recruiting maneuver （RM）-induced change in end-expiratory lung volume and the alveolar recruitment induced by PEEP, we found a notable correlation. Conclusions The results of this study indicated that the potential for alveolar recruitment might vary among the ARDS population and the higher PEEP levels should be limited to recruiters. Improving in PaO2/FiO2, static lung compliance after PEEP increase and the shape of the pressure-time curve could be helpful for PEEP application.
文摘Driving pressure(ΔP)is a core therapeutic component of mechanical ventilation(MV).Varying levels ofΔP have been employed during MV depending on the type of underlying pathology and severity of injury.However,ΔP levels have also been shown to closely impact hard endpoints such as mortality.Considering this,conducting an in-depth review ofΔP as a unique,outcome-impacting therapeutic modality is extremely important.There is a need to understand the subtleties involved in making sureΔP levels are optimized to enhance outcomes and minimize harm.We performed this narrative review to further explore the various uses ofΔP,the different parameters that can affect its use,and how outcomes vary in different patient populations at different pressure levels.To better utilizeΔP in MV-requiring patients,additional large-scale clinical studies are needed.
文摘Background： Electrical impedance tomography （EIT） is a real-time bedside monitoring tool, which can reflect dynamic regional lung ventilation. The aim of the present study was to monitor regional gas distribution in patients with acute respiratory distress syndrome （ARDS） during positive-end-expiratory pressure （PEEP） titration using EIT. Methods： Eighteen ARDS patients under mechanical ventilation in Department of Critical Care Medicine of Peking Union Medical College Hospital from January to April in 2014 were included in this prospective observational study. After recruitment maneuvers （RMs）, decremental PEEP titration was performed from 20 cmH20 to 5 cmH20 in steps of 3 cmH20 every 5-10 min. Regional over-distension and recruitment were monitored with EIT. Results： After RMs, patient with arterial blood oxygen partial pressure （PaO2） ＋ carbon dioxide partial pressure （PaCO2） 〉400 mmHg with 100% of fractional inspired oxygen concentration were defined as RM responders. Thirteen ARDS patients was diagnosed as responders whose PaO2 ＋ PaCO2, were higher than nonresponders （419 ± 44 mmHg vs. 170 ±73 mmHg, P 〈 0.0001）. In responders, PEEP mainly increased-recruited pixels in dependent regions and over-distended pixels in nondependent regions. PEEP alleviated global inhomogeneity of tidal volume and end-expiratory lung volume. PEEP levels without significant alveolar derecruitment and over-distension were identified individually. Conclusions： After RMs, PEEP titration significantly affected regional gas distribution in lung, which could be monitored with EIT. EIT has the potential to optimize PEEP titration.
