Lung ultrasound score evaluation of the effect of pressure-controlled ventilation volume-guaranteed on patients undergoing laparoscopicassisted radical gastrectomy

BACKGROUND Laparoscopic-assisted radical gastrectomy(LARG)is the standard treatment for early-stage gastric carcinoma(GC).However,the negative impact of this proce-dure on respiratory function requires the optimized intraoperative management of patients in terms of ventilation.AIM To investigate the influence of pressure-controlled ventilation volume-guaranteed(PCV-VG)and volume-controlled ventilation(VCV)on blood gas analysis and pulmonary ventilation in patients undergoing LARG for GC based on the lung ultrasound score(LUS).METHODS The study included 103 patients with GC undergoing LARG from May 2020 to May 2023,with 52 cases undergoing PCV-VG(research group)and 51 cases undergoing VCV(control group).LUS were recorded at the time of entering the operating room(T0),20 minutes after anesthesia with endotracheal intubation(T1),30 minutes after artificial pneumoperitoneum(PP)establishment(T2),and 15 minutes after endotracheal tube removal(T5).For blood gas analysis,arterial partial pressure of oxygen(PaO_(2))and partial pressure of carbon dioxide(PaCO_(2))were observed.Peak airway pressure(P_(peak)),plateau pressure(Pplat),mean airway pressure(P_(mean)),and dynamic pulmonary compliance(C_(dyn))were recorded at T1 and T2,1 hour after PP establishment(T3),and at the end of the operation(T4).Postoperative pulmonary complications(PPCs)were recorded.Pre-and postoperative serum interleukin(IL)-1β,IL-6,and tumor necrosis factor-α(TNF-α)were measured by enzyme-linked immunosorbent assay.RESULTS Compared with those at T0,the whole,anterior,lateral,posterior,upper,lower,left,and right lung LUS of the research group were significantly reduced at T1,T2,and T5;in the control group,the LUS of the whole and partial lung regions(posterior,lower,and right lung)decreased significantly at T2,while at T5,the LUS of the whole and some regions(lateral,lower,and left lung)increased significantly.In comparison with the control group,the whole and regional LUS of the research group were reduced at T1,T2,and T5,with an increase in PaO_(2),decrease in PaCO_(2),reduction in P_(peak) at T1 to T4,increase in P_(mean) and C_(dyn),and decrease in Pplat at T4,all significant.The research group showed a significantly lower incidence of PPCs than the control group within 3 days postoperatively.Postoperative IL-1β,IL-6,and TNF-αsignificantly increased in both groups,with even higher levels in the control group.CONCLUSION LUS can indicate intraoperative non-uniformity and postural changes in pulmonary ventilation under PCV-VG and VCV.Under the lung protective ventilation strategy,the PCV-VG mode more significantly improved intraop-erative lung ventilation in patients undergoing LARG for GC and reduced lung injury-related cytokine production,thereby alleviating lung injury.

A Comparison of Arterial Oxygenation between 60% O2 CPAP and 100% O2 CPAP during One-Lung Ventilation: A Prospective Randomized Controlled Study

Background: One-lung ventilation (OLV) is generally adopted for thoracic surgery. The systemic application of a high fraction of inspiratory oxygen (F1O2) and continuous positive airway pressure (CPAP) to the non-ventilated lung is useful for preventing arterial oxygen desaturation. The adverse effects of elevated F1O2 include oxidative lung injury, resorption atelectasis and coronary and peripheral vasoconstriction. It is preferable to avoid hyperoxemia in patients with complications such as chronic obstructive pulmonary disease, idiopathic pneumonia, and bleomycin-treated lungs. We aimed to determine whether the application of 60% O2 CPAP to the non-ventilated lung is sufficient to provide adequate oxygenation with 60% O2 to the ventilated lung. Methods: A total of 70 patients scheduled to receive elective thoracic surgery requiring OLV were recruited. Left double-lumen tubes were applicable in all surgeries. Patients were randomly allocated to one of two groups, to receive either 60% O2 CPAP (60% CPAP group, n = 35), or 100% O2 CPAP (100% CPAP group, n = 35) at a setting of 2 - 3 cmH2O, applied to the non-ventilated lung. Arterial blood gas analyses were obtained at the following stages: RA, spontaneous breathing under room air (RA);TLV, during total lung ventilation (TLV) prior to the initiation of OLV;T5, 5 min after the initiation of OLV;T15, 15 min after the initiation of OLV;T30, 30 min after the initiation of OLV. Results: The PaO2 value in 60% CPAP group vs. 100% CPAP group at each measurement were as follows: RA (mean [standard deviation: SD], 89.7 [8.2] mmHg vs. 85.8 [11.9] mmHg);TLV (277.9 [52.9] mmHg vs. 269.2 [44.0] mmHg);T5 (191.4 [67.9] mmHg vs. 192.3 [66.0] mmHg);T15 (143.2 [67.3] mmHg vs. 154.7 [60.8] mmHg) and T30 (95.6 [32.0] mmHg vs. 112.5 [36.5] mmHg), respectively. Among the five measurement points, T30 was the only time point at which the 100% CPAP group showed a significantly greater PaO2 value than the 60% CPAP group (p = 0.0495). The SaO2 at T30 in the 100% CPAP group (97.4 [2.0]%) was also significantly greater than that in the 60% CPAP group (96.3 [2.2]%, p = 0.039). No differences were found between the groups regarding changes to the overall PaO2 values (p = 0.44) and SaO2 values (p = 0.23) during the study period. Conclusions: Oxygenation could be safely maintained in relatively healthy patients with 60% O2 OLV and 60% O2 CPAP. The application of 60% O2 CPAP during OLV for patients who are not suited to exposure to high F1O2 may be an alternative form of respiratory management.

Oxygenation,inflammatory response and lung injury during one lung ventilation in rabbits using inspired oxygen fraction of 0.6 vs.1.0

Maintaining adequate oxygenation during one-lung ventilation（OLV） requires high inspired oxygen fraction（FiO_2）.However,high FiO_2 also causes inflammatory response and lung injury.Therefore,it remains a great interest to clinicians and scientists to optimize the care of patients undergoing OLV.The aim of this study was to determine and compare oxygenation,inflammatory response and lung injury during OLV in rabbits using FiO_2 of 0.6 vs.1.0.After 30 minutes of two-lung ventilation（TLV） as baseline,30 rabbits were randomly assigned to three groups receiving mechanical ventilation for 3 hours：the sham group,receiving TLV with 0.6 FiO_2;the 1.0 FiO_2 group,receiving OLV with 1.0 FiO_2;the 0.6 FiO_2 group,receiving OLV with 0.6 FiO_2.Pulse oximetry was continuously monitored and arterial blood gas analysis was intermittently conducted.Histopathologic study of lung tissues was performed and inflammatory cytokines and the mRNA and protein of nuclear factor kappa B（NF-κB） p65 were determined.Three of the 10 rabbits in the 0.6 FiO_2 group suffered hypoxemia,defined by pulse oximetric saturation（SpO_2） less than 90%.Partial pressure of oxygen（PaO_2）,acute lung injury（ALI） score,myeloperoxidase（MPO）,tumor necrosis factor-a（TNF-α）,interleukin-6（IL-6）,mRNA and protein of NF-kB p65 were lower in the 0.6 FiO_2group than in the 1.0 FiO_2 group.In conclusion,during OLV,if FiO_2 of 0.6 can be tolerated,lung injury associated with high FiO_2 can be minimized.Further study is needed to validate this finding in human subjects.

Effect of Nalmefene on Delayed Neurocognitive Recovery in Elderly Patients Undergoing Video-assisted Thoracic Surgery with One Lung Ventilation

The intravenous use of nalmefene has been found to exert neuroprotective effect in patients with severe traumatic brain injury and acute cerebral infarction;nonetheless,it is unknown whether nalmefene alleviates delayed neurocognitive recovery.Our purpose of the current research was to clarify the impact of nalmefene on delayed neurocognitive recovery in aged patients experiencing video-assisted thoracic surgery(VATS)with intraoperative use of one lung ventilation(OLV).The present study involved 120 paticents undergoing selective VATS,randomized to accept low-dose nalmefene(N1 group,n=40),high-dose nalmefene(N2 group,1n=40)or equal volume of physiologic saline(control group,1=40).A battery of neuropsychological tests were used to estimate cognitive function I day before surgery(o)and 10 days after surgery or before discharge(t).Regional cerebral oxygen saturation(rSO2)was detected 5 min before induction(t),5 min after induction(1),15 and 60 min after onset of OLV(62 and 13),and 15 min after termination of OLV(4).The plasma values of interleukin(IL)-1β,IL-6,tumor necrosis factor(TNF)-a1 and adiponectin(ADP)were also detected prior to induction of anesthesia(T0),1 h,2 h and 6 h after surgery(TI,T2,T3).On 1,delayed neurocognitive recovery occurred in 5/40(12.5%)patients of NI group,in 5/40(12.5%)patients of N2 group and in 13/40(32.5%)patients of control group(P<0.05).There were no statistical differences in rSO2 among three groups at different time points.At Tl,T2 and T3,IL-1β,IL-6 and TNF-a values significantly increased and ADP value significantly decreased(P<0.05)in control group.In contrast,at TI,T2 and T3,IL-1β,IL-6 and TNF-a values decreased and ADP value decreased less in N1 and N2 groups(P<0.05).At TI,T2 and T3,IL-1β,IL-6 and TNF-a concentrations presented a trend of N2 group<N1 group<control group and ADP presented a trend of N2 group>Nl group>control group(P<0.05).The result of our present research supports the hypothesis that the perioperative intravenous treatment with nalmefene to VATS with OLV ameliorates postoperative cognitive function and decreases the incidence of delayed neurocognitive recovery,most likely by suppression of inflammatory responses.

Driving pressure in mechanical ventilation:A review

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.

The Effect of Dexmedetomidine on Oxygenation and Intrapulmonary Shunt during One Lung Ventilation

Background: The effect of intravenously administered dexmedetomidine on oxygenation during one-lung ventilation has not been studied. The hypothesis of this prospective, randomized study was that dexmedetomidine would be associated with an improvement in oxygenation during one-lung ventilation. The secondary outcome was the change in the intrapulmonary shunt. Materials and Methods: Thirty patients undergoing one-lung ventilation were included. Patients in Group D (n = 15) received a bolus dose of 1 μg·kg-1 dexmedetomidine at 10 min after induction of anaesthesia followed by an infusion of 0.4 μg·kg-1·hr-1 that was stopped at the end of the surgery, and those in the control group(Group C, n = 15) were given saline at the same dosage. Vital signs, PaO2, and pulmonary shunting (Qs/Qt) were compared. Results: During one-lung ventilation, the PaO2 in Group D increased significantly and Qs/Qt significantly decreased compared to Group C (PaO2, 203.7 ± 42.3 mmHg vs. 173 ± 37.6 mmHg [P = 0.04] and Qs/Qt 19.8% ± 4.5% vs. 31% ± 2.4% [P < 0.0001], Group D and Group C, respectively). Conclusion: Intravenous administration of dexmedetomidine achieved an improvement in oxygenation during one-lung ventilation. This was associated with a decrease in pulmonary shunt. Use of intraoperative dexmedetomidine during thoracic surgery can be suggested.

Effects of acetylcysteine on micro-inflammation and pulmonary ventilation in chronic obstructive pulmonary disease exacerbation

BACKGROUND Acute exacerbation of chronic obstructive pulmonary disease(AECOPD)is a serious complication of chronic obstructive pulmonary disease,often characterized by increased morbidity and mortality.In traditional Chinese medicine,AECOPD is linked to phlegm-heat and blood-stasis,presenting symptoms like thick sputum,fever,and chest pain.It has been shown that acetylcysteine inhalation in conjunction with conventional therapy significantly reduced inflammatory markers and improved lung function parameters in patients with AECOPD,suggesting that acetylcysteine may be an important adjunctive therapy for patients with phlegm-heat-blood stasis type AECOPD.AIM To investigate the effect of acetylcysteine on microinflammation and lung ventilation in patients with phlegm-heat and blood-stasis-type AECOPD.METHODS One hundred patients with phlegm-heat and blood-stasis-type AECOPD were randomly assigned to two groups.The treatment group received acetylcysteine inhalation(10%solution,5 mL,twice daily)along with conventional therapy,whereas the control group received only conventional therapy.The treatment duration was 14 d.Inflammatory markers(C-reactive protein,interleukin-6,and tumor necrosis factor-alpha)in the serum and sputum as well as lung function parameters(forced expiratory volume in one second,forced vital capacity,and peak expiratory flow)were assessed pre-and post-treatment.Acetylcysteine inhalation led to significant reductions in inflammatory markers and improvements in lung function parameters compared to those in the control group(P<0.05).This suggests that acetylcysteine could serve as an effective adjunct therapy for patients with phlegm-heat and blood-stasis-type AECOPD.RESULTS Acetylcysteine inhalation significantly reduced inflammatory markers in the serum and sputum and improved lung ventilation function parameters in patients with phlegm-heat and blood-stasis type AECOPD compared with the control group.These differences were statistically significant(P<0.05).The study concluded that acetylcysteine inhalation had a positive effect on microinflammation and lung ventilation function in patients with this type of AECOPD,suggesting its potential as an adjuvant therapy for such cases.CONCLUSION Acetylcysteine inhalation demonstrated significant improvements in reducing inflammatory markers in the serum and sputum,as well as enhancing lung ventilation function parameters in patients with phlegm-heat and bloodstasis type AECOPD.These findings suggest that acetylcysteine could serve as a valuable adjuvant therapy for individuals with this specific type of AECOPD,offering benefits for managing microinflammation and optimizing lung function.

Influence of the dexmedetomidine combined with parecoxib sodium on inflammatory factor, blood gas analysis and stress hormone levels in patients undergoing radical resection of esophageal carcinoma during one lung ventilation

Objective: To investigate the effect of dexmedetomidine combined with parecoxib sodium on the levels of inflammatory factors, blood gas analysis and stress hormone in patients undergoing radical resection of esophageal carcinoma during one lung ventilation. Methods:According to the random data table, 81 cases of esophageal cancer patients were divided into the control group (n=41) and observation group (n=40), the patients in the two groups underwent left thoracotomy esophageal cancer radical resection, the control group patients were treated with parecoxib sodium, and patients in the observation group were treated with parecoxib sodium combined with dexmedetomidine medetomidine treatment, before induction of anesthesia (T0), 30 min of one lung ventilation (T1) and 120 min after operation (T2) at three time points, the levels of inflammatory factors [tumor necrosis factor-α (TNF-α), C reactive protein (CRP)], blood gas analysis[oxygen partial pressure (PaO2), carbon dioxide partial pressure (PaCO2)] and stress hormone[epinephrine (E), norepinephrine (NE)] of the two groups were compared. Results: Intra group level comparison, compared with the levels of two groups at the T0 moment, the levels of TNF-α, CRPand NE of theT1 and T2 moment were significantly increased, the level of PaO2 were significantly decreased, and T2 moment levels were significantly higher than that of T1 moment, the difference was statistical significance;There were no significant differences between the two groups of the levels of TNF-α, CRP, PaO2, E and NE of the T0 moment, the levels of TNF-α, CRP, E and NE of the observation group at the T1 and T2 moment were significantly lower than the control group, at the same time the PaO2 level was significantly higher than the control group, the difference was statistically significant;There were no statistically significant differences in PaCO2 levels between groups and at any time. Conclusion: Dexmedetomidine combined with parecoxib sodium can effectively relieve the inflammatory stress, improve the levels of the blood gas analysis index and stress hormone during one lung ventilation, has an important clinical value.

Intensive care unit-acquired weakness–preventive,and therapeutic aspects;future directions and special focus on lung transplantation

In this editorial,comments are made on an interesting article in the recent issue of the World Journal of Clinical Cases by Wang and Long.The authors describe the use of neural network model to identify risk factors for the development of intensive care unit(ICU)-acquired weakness.This condition has now become common with an increasing number of patients treated in ICUs and continues to be a source of morbidity and mortality.Despite identification of certain risk factors and corrective measures thereof,lacunae still exist in our understanding of this clinical entity.Numerous possible pathogenetic mechanisms at a molecular level have been described and these continue to be increasing.The amount of retrievable data for analysis from the ICU patients for study can be huge and enormous.Machine learning techniques to identify patterns in vast amounts of data are well known and may well provide pointers to bridge the knowledge gap in this condition.This editorial discusses the current knowledge of the condition including pathogenesis,diagnosis,risk factors,preventive measures,and therapy.Furthermore,it looks specifically at ICU acquired weakness in recipients of lung transplantation,because–unlike other solid organ transplants-muscular strength plays a vital role in the preservation and survival of the transplanted lung.Lungs differ from other solid organ transplants in that the proper function of the allograft is dependent on muscle function.Muscular weakness especially diaphragmatic weakness may lead to prolonged ventilation which has deleterious effects on the transplanted lung–ranging from ventilator associated pneumonia to bronchial anastomotic complications due to prolonged positive pressure on the anastomosis.

Effect of the adaptive intermittent ventilation before radical operation for lung cancer under one-lung ventilation on the non-ventilated lung tissue injury and apoptosis molecule protein expression

Objective: To study the effect of the adaptive intermittent ventilation before radical operation for lung cancer under one-lung ventilation on non-ventilated lung tissue injury and apoptosis molecule protein expression. Methods: A total of 288 patients who received radical operation for lung cancer in the hospital between February 2015 and January 2017 were divided into control group and observation group by random number table method, each with 144 cases. Control group received routine one-lung ventilation, and observation group received preoperative adaptive intermittent ventilation of non-ventilated lung tissue. The differences in the levels of inflammatory factors and oxidative stress indexes in serum as well as the apoptosis molecule protein expression in affected-side normal lung tissue were compared between the two groups of patients immediately after intubation and at two-lung ventilation (T0) as well as 10 min before operation ended and at one-lung ventilation (T1). Results: At T0, the differences in the levels of inflammatory factors and oxidative stress indexes in serum as well as the apoptosis molecule protein expression in affected-side normal lung tissue were not significantly significant between the two groups of patients;at T1, IL-1β, IL-8, TNF-α, MPO and MDA levels in serum as well as Bax, caspase-2 and caspase-3 protein expression in normal lung tissue of observation group were lower than those of control group while SOD level in serum and Bcl-2 protein expression in normal lung tissue were higher than those of control group. Conclusion: Adaptive intermittent ventilation before radical operation for lung cancer under one-lung ventilation can effectively reduce the non-ventilated lung tissue injury and inhibit the apoptosis of normal lung cells.

Clinical Study of P_(ET)CO_2 in One-lung Ventilation

Fourty-eight patients (ASA physical status Ⅰ - Ⅱ) undergoing selected thoracotomy and pulmonectomy were studied. They were divided into two groups according to different respiratory modes, two-lung ventilation (TLV) and onelung ventilation (OLV) or TLV and OLV with a Bain cyclic system for CPAP on the side of operated lung. PETCO2 and PaCO2 were measured after 30 min TLV,30 min and 60 min OLV, and repeated TLV (R-TLV) 30 min after pulmonectomy, to evaluate the difference between PETCO2 and PaCO2 in OLV and to observethe effect of abating hypoxemia and discharge of CO2 in OLV with Bain system.Our results showed that the PaCO2 and PETCO2 in different test groups were normal though the measured values in OLV were slightly higher than that in TLV (P<0. 05) , and then they were recovered after R-TLV (P>0. 05). There was nosignificant difference between group 1. and 2. in OLV (P>0. 05). There was aclose correlation between PETCO2 and PaCO2 (P<0. 05). The differences of the calculated P(a-ET)CO2 and radio of PETCO2/PaCO2 in different ventilation modes were not significant. Hypoxemia in OLV was corrected by Bain system, but the discharge of CO2 was not affected. The results showed that measurement of PET CO2 as a non-invasive procedure can be commonly used to monitor OLV.

Analysis and Comparison of the Effect of Preserving Spontaneous Breathing Without Intubation and Endotracheal Intubation with One Lung Ventilation in Single-hole Thoracoscopic Bulla Suture

Objective:To explore the situation of patients and the compare the effect between two methods,which are preserving spontaneous breathing without intubation and endotracheal intubation with one lung ventilation in the single-hole thoracoscopic bulla suture.Method:42 patients who received single-hole thoracoscopic pulmonary bullae suture in our hospital from January 2020 to December 2021 were selected as the study subjects,including 19 patients who underwent endotracheal intubation and one lung ventilation as the control group and 23 patients who underwent single-hole thoracoscopic pulmonary bullae suture without intubation as the study group.The relevant indexes,postoperative general conditions,complications and pneumothorax recurrence of the two groups were analyzed and observed.Results:In the control group,the scores of anesthesia time(points),resuscitation time(points),surgical visual field score(points),surgical time(points),and surgical bleeding volume(points)were 20.8±4.6,19.9±7.9,1.7±0.5,44.9±7.9,and 11.4±2.4 respectively.In the study group,the scores of anesthesia time(points),resuscitation time(points),surgical visual field score(points),surgical time(points),and scores of surgical bleeding(points)were 17.9±4.3,15.4±3.4,1.9±0.4,48.4±7.1,10.9±2.2,respectively.There was no statistical difference in surgical visual field score,surgical time and surgical bleeding whereas there was a statistical difference between anesthesia time and resuscitation time.In the control group after operation,VAS score at 6 hours after operation,SaO_(2)(%)after operation,PaCO_(2)(mmHg)after operation,drainage volume(ML)after operation,feeding time(H)after operation,retention time of thoracic tube after operation(H),WBC(109)on the first day after operation,hospitalization time(d),and total hospitalization cost(RMB 1000)were 2.1±0.7,98.2±1.4,42.4±4.9,139.1±23.1,6.9±1.6,37.1±5.4,7.9±2.1,6.6±1.3,and 2.6±0.3 respectively.As for the study group,the VAS score at 6 hours after operation,SaO_(2)(%)after operation,PaCO_(2)(mmHg)after operation,drainage volume(ML)after operation,feeding time(H)after operation,retention time of thoracic tube after operation(H),WBC(109)on the first day after operation,hospitalization time(d),and total hospitalization cost(RMB 1000)were 1.9±0.4,97.9±1.2,42.8±5.1,151.8±21.9,4.3±1.4,15.3±2.6,5.2±2.3,4.2±1.2,and 1.8±0.4 respectively.Among them,there were no significant differences in visual analog scale(VAS)score at 6 hours after operation,SaO_(2) after operation and PaCO_(2) after operation between the two groups,but there were significant differences in other factors.The complication rate of the control group was 36.84%,which was significantly higher than that of the study group(4.35%),with statistical difference.The recurrence rate of the control group was 21.05%,which was not significantly different from that of the study group(4.35%).Conclusion:The single-hole thoracoscopic bullae suture without intubation can reduce the anesthesia time and resuscitation time of patients,reduce the hospitalization cost of patients,reduce the treatment burden,shorten the first feeding time,and reduce the complication rate of patients.Therefore,it is worthy of clinical promotion.

Effect of High Frequency Oscillatory Ventilation on EVLW and Lung Capillary Permeability of Piglets with Acute Respiratory Distress Syndrome Caused by Pulmonary and Extrapulmonary Insults

The effect of high frequency oscillatory ventilation（HFOV） at early stage on hemodynamic parameters, extravascular lung water（EVLW）, lung capillary permeability, CC16 and s ICAM-1 in piglets with pulmonary or extrapulmonary acute respiratory distress syndrome（ARDS） was explored. Central vein pressure（CVP） and pulse indicator continuous cardiac output（Pi CCO） were monitored in 12 anesthetized and intubated healthy piglets. Pulmonary ARDS（ARDSp） and extrapulmonary ARDS（ARDSexp） models were respectively established by lung lavage of saline solution and intravenous injection of oleic acid. Then the piglets received HFOV for 4 h. EVLW index（EVLWI）, EVLW/intratroracic blood volume（ITBV） and pulmonary vascular permeability index（PVPI） were measured before and after modeling（T0 and T1）, and T2（1 h）, T3（2 h）, T4（3 h） and T5（4 h） after HFOV. CC16 and s ICAM-1 were also detected at T1 and T5. Results showed at T1, T3, T4 and T5, EVLWI was increased more significantly in ARDSp group than in ARDSexp group（P〈0.05）. The EVLWI in ARDSp group was increased at T1（P=0.008）, and sustained continuously within 2 h（P=0.679, P=0.216）, but decreased at T4（P=0.007） and T5（P=0.037）. The EVLWI in ARDSexp group was also increased at T1（P=0.003）, but significantly decreased at T3（P=0.002） and T4（P=0.019）. PVPI was increased after modeling in both two groups（P=0.004, P=0.012）, but there was no significant change within 4 h（T5） under HFOV in ARDSp group, while PVPI showed the increasing trends at first, then decreased in ARDSexp group after HFOV. The changes of EVLW/ITBV were similar to those of PVPI. No significant differences were found in ΔEVLWI（P=0.13）, ΔPVPI（P=0.28） and ΔEVLW/ITBV between the two groups（P=0.63）. The significant decreases in both CC16 and s ICAM-1 were found in both two groups 4 h after HFOV, but there was no significant difference between the two groups. It was concluded that EVLWI and lung capillary permeability were markedly increased in ARDSp and ARDSexp groups. EVLW could be decreased 4 h after the HFOV treatment. HFOV, EVLW/ITBV and PVPI were increased slightly at first, and then decreased in ARDSexp group, while in ARDSp group no significant difference was found after modeling. No significant differences were found in the decreases in EVLW and lung capillary permeability 4 h after HFOV.

Preemptive mechanical ventilation can block progressive acute lung injury

Mortality from acute respiratory distress syndrome(ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation(APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury(ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.

High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study

BACKGROUND: We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen(HFNCO_(2)) therapy and noninvasive ventilation(NIV) using lung ultrasound score(LUS) in comparison with standard care among patients in the intensive care unit(ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days.METHODS: During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points(at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO_(2). Patients with an LUS score ≥14 points(at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress;patients received HFNCO2 therapy combined with sessions of preventive NIV(4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation.RESULTS: In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference(P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure(P=0.61). The length of ICU stay(9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate(at 48 hours: 18.4% vs. 10.2%;seven days: 22.4% vs. 12.2%) significantly varied between the two groups(P<0.05). There was no significant difference in the 28-day mortality rate(6.1% vs. 8.2%) between the control and treatment groups.CONCLUSIONS: Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO_(2) protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.

Lung Ventilation Functional Monitoring Based on Electrical Impedance Tomography

Medically, electrical impedance tomography （EIT） is a relatively inexpensive, safe, non-invasive and portable technique compared with computerized tomography （CT） and magnetic resonance imaging （MRI）. In this paper, EIT_TJU_ II system is developed including both the data collection system and image reconstruction algo- rithm. The testing approach of the system performance, including spatial resolution and sensitivity, is described through brine tank experiments. The images of the thorax physical model verify that the system can reconstruct the interior resistivity distribution. Finally, the lung ventilation functional monitoring in vivo is realized by EIT, and the visualized images indicate that the configuration and performance of EIT_TJU_ II system are feasible and EIT is a promising technique in clinical monitoring application.

Expression Changes of Early Response Genes in Lung Due to High Volume Ventilation

The expression changes of early response genes due to ventilation with high volume in adult rats in vivo were observed. Forty SD male rats were randomly divided into control and 30, 60, 90 and 120 min ventilation groups, respectively (n=8 in each group). The animals were ventilated with tidal volume of 42 ml/kg and a PEEP level of 0 cmH_2O at a rate of 40 breaths per minute in room air with a ventilator was given to the small animals. The expression of Egr-1, C-jun and IL-1β mRNA and proteins was detected by RT-PCR and immunohistochemical technique, respectively. The pathological changes in lung tissues were examined by HE staining. The results indicated that the expression of Egr-1, C-jun and IL-1β mRNA was detectable at 30th min after overventilation, but there was no significant difference in comparison with that in control group until overventilation for 60 min. However, at 90 and 120 min there was a significent increase as compared with 30 min or control group (P<0.05). The expression of Egr-1, C-jun and IL-1β deteced by immunohistochemical assay also showed a similar tendency of the gradual increase. In the 120 min ventilation group, the expression intensity of Egr-1, C-jun and IL-1β proteins in lung cells was the strongest and the nuclear translocation was increased markedly in comparison with any other groups (P<0.05). HE staining suggested that the degree of lung injury was aggravated gradually with the ventialtion going on and had a similar tendency to the expression of these early response genes and proteins. The current data suggested that overventilation activated and upregulated the expression of early response genes and the expression of these genes may be taken as the early signal to predict the onset and degree of lung injury. These results may demonstrated partially that the expression of early response genes induced by the mechanical stretch is associated with biochamic lung injury.

Effect of protective lung ventilation strategy combined with lung recruitment maneuver in patients with acute respiratory distress syndrome (ARDS)

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.

Zinc-deficient diet aggravates ventilation-induced lung injury in rats

We investigated the effects of zinc deficiency on acute lung injury （ALI） induced by mechanical ventilation. Male Sprague-Dawley rats were fed with a zinc-deficient or zinc-proficient diet for 4 weeks, and then received mechanical ventilation at normal frequency and pressure for 30 min. Total protein, cell count, the number of poly- morphonuclear neutrophil （PMN） in the bronchoalveolar lavage （BAL）, and vascular endothelial growth factor （VEGF） expression in the lung were determined. Activation of nuclear factor-t^B （NF-~cB） was detected by exam- ining the phosphorylation of NF-kB （pNF-kB p65） and the expression of inhibitor of NF-kB （pI-kBa）. Compared to the controls, total cell count and the number of PMNs were significantly increased to 160% and 140%, respec- tively, in zinc-deficient rats treated with ventilation. Activation of NF-kB was significantly increased and VEGF was also increased to three-folds. Zinc deficiency aggravated the inflammatory response in rats and was associated with the overexpression of VEGF in response to mechanical ventilation. Zinc supplementation may be beneficial to zinc-deficient patients during mechanical ventilation.

Effect of glucocorticoid on MIP-1α and NF-кb expressing in the lung of rats undergoing mechanical ventilation with a high tidal volume

BACKGROUND： Ventilator induced lung injury （VILI） is a serious complication in the treatment of mechanical ventilating patients, and it is also the main cause that results in exacerbation or death of patients. In this study, we produced VILI models by using glucocorticoid in rats with high tidal volume mechanical ventilation, and observed the content of macrophage inflammatory protein-1α （MIP-1α） in plasma and bronchoalveolar lavage fluid （BALF） and the expression of MIP-1α mRNA and nuclear factor-kappa B （NF-кB） p65 mRNA in the lung so as to explore the role of glucocorticoid in mechanical ventilation.METHODS： Thirty-two healthy Wistar rats were randomly divided into a control group, a ventilator induced lung injury （VILI） group, a dexamethasone （DEX） group and a budesonide （BUD） group. The content of MIP-1a in plasma and BALF was measured with ELISA and the level of MIP-1α mRNA and NF-кBp65 mRNA expressing in the lung of rats were detected by RT-PCR. The data were expressed as mean±SD and were compared between the groups.RESULTS： The content of MIP-1α in plasma and BALF and the level of MIP-1α mRNA and NF-кBp65 mRNA in the lung in the DEX and BUD groups were signifi cantly lower than those in the VILI group （P〈0.001）. Although the content of MIP-1α in plasma and BALF and the level of MIP-1α mRNA and NF-кBp65 mRNA in the lung in the BUD group were higher than those in the DEX group, there were no signifi cant differences between them （P〉0.05）.CONCLUSIONS： Glucocorticoid could down-regulate the expression of MIP-1α by inhibiting the activity of NF-кB in the lung and may exert preventive and therapeutic effects on VILI to some extent. The effect of local use of glucocorticoid against VILI is similar to that of systemic use, but there is lesser adverse reaction.