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Plens GM, Costa ELV. Mechanical power and VILI: navigating heterogeneity in critical illness. Intensive Care Med Exp 2025; 13:51. [PMID: 40372519 DOI: 10.1186/s40635-025-00760-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2025] [Accepted: 05/07/2025] [Indexed: 05/16/2025] Open
Affiliation(s)
- Glauco M Plens
- Laboratório de Pneumologia LIM-09, Divisao de Pneumologia, Faculdade de Medicina, Instituto Do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455, Sala 2144 (2nd Floor), 01246-903, Sao Paulo, Brasil.
- Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.
| | - Eduardo Leite Vieira Costa
- Laboratório de Pneumologia LIM-09, Divisao de Pneumologia, Faculdade de Medicina, Instituto Do Coracao, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455, Sala 2144 (2nd Floor), 01246-903, Sao Paulo, Brasil
- Research and Education Institute, Hospital Sírio-Libanês, Sao Paulo, Brazil
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2
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Fajardo-Campoverdi A, González-Castro A, Modesto I Alapont V, Ibarra-Estrada M, Chica-Meza C, Medina A, Escudero-Acha P, Battaglini D, Rocco PRM, Robba C, Pelosi P. Elastic static power, its correlation with acute respiratory distress syndrome severity: A Bayesian post-hoc analysis of the Mechanical Power Day cross-sectional trial. Med Intensiva 2025; 49:502128. [PMID: 39741096 DOI: 10.1016/j.medine.2024.502128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 10/12/2024] [Accepted: 10/15/2024] [Indexed: 01/02/2025]
Abstract
OBJECTIVE The relationship between different power equations and the severity of acute respiratory distress syndrome (ARDS) remains unclear. This study aimed to evaluate various power equations: total mechanical power, total elastic power (comprising elastic static and elastic dynamic power), and resistive power, in a cohort of mechanically ventilated patients with and without ARDS. Bayesian analysis was employed to refine estimates and quantify uncertainty by incorporating a priori distributions. DESIGN A Bayesian post-hoc analysis was conducted on data from the Mechanical Power Day study. SETTING 113 intensive care units across 15 countries and 4 continents. PATIENTS Adults who received invasive mechanical ventilation in volume-controlled mode, with (mild and moderate/severe ARDS) and without ARDS. INTERVENTIONS None. MAIN VARIABLES OF INTEREST ARDS, Elastic static power. RESULTS Elastic static power was 5.8 J/min (BF: 0.3) in patients with mild ARDS and 7.4 J/min (BF: 0.9) in moderate/severe ARDS patients. Bayesian regression and modeling analysis revealed that elastic static power was independently correlated with mild (a posteriori Mean: 1.3; 95% Credible Interval [Cred. Interval]: 0.2-2.2) and moderate/severe ARDS (a posteriori Mean: 2.8; 95% Cred. Interval: 1.7-3.8) more strongly than other power equations. CONCLUSIONS Elastic static power was found to have the strongest correlation with ARDS severity among the power equations studied. Prospective studies are needed to further validate these findings.
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Affiliation(s)
- Aurio Fajardo-Campoverdi
- Universidad de la Frontera, Critical Care Unit, Hospital Biprovincial Quillota-Petorca, Quillota, Chile.
| | | | | | - Miguel Ibarra-Estrada
- Medicine of the Critically Ill, Civil Hospital Fray Antonio Alcalde and Instituto Jalisciense de Cancerología, Guadalajara, Mexico
| | - Carmen Chica-Meza
- University of Rosario, Asociación Colombiana de Medicina Crítica y Cuidado Intensivo, Bogotá, Colombia
| | | | | | | | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Chiara Robba
- IRCCS Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- IRCCS Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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3
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Leng N, Mittel AM, Levine D, Nitta S, Berman MF, Hua M, Patel VI, Kurlansky PA, Takayama H, Melo MFV. Intraoperative Factors Associated With Mechanical Ventilation Duration Following Aortic Surgery. J Cardiothorac Vasc Anesth 2025; 39:1205-1213. [PMID: 40037958 PMCID: PMC11993328 DOI: 10.1053/j.jvca.2025.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Revised: 01/27/2025] [Accepted: 02/12/2025] [Indexed: 03/06/2025]
Abstract
OBJECTIVES Prolonged postoperative mechanical ventilation is a common complication after major aortic surgery. The relationship between prolonged ventilation and intraoperative variables influenced by anesthesiologists, such as ventilation practices, fluid administration, and blood pressure control during major aortic surgery is unknown. We sought to identify perioperative factors, including intraoperative physiologic and anesthesia-related variables, which are associated with ventilation duration following aortic surgery. DESIGN Single-center retrospective observational study. SETTING A tertiary, high-volume cardiac surgery referral center. PARTICIPANTS Adult patients undergoing major aortic surgery requiring cardiopulmonary bypass (CPB). INTERVENTIONS None (retrospective observational study). MEASUREMENTS AND MAIN RESULTS The primary outcome was the duration of postoperative ventilation (hours). Mixed-effects regression was performed to identify factors associated with the primary outcome. Among the 647 patients included in this study, the median of postoperative mechanical ventilation duration was 9.0 (IQR 6.0, 14.4) hours, with 73 (11.3%) of patients receiving mechanical ventilation for more than 24 hours. Variables significantly associated with the outcome were increases in pre- to post-CPB driving pressure (β = 4.23; 95% CI [0.08, 8.39]; p = 0.04), reduction in pre- to post-CPB end-tidal carbon dioxide partial pressure (β = -5.12; 95% CI [-8.85, -1.39]; p < 0.001), and normalized transfusion volumes (β = 11.14; 95% CI [4.36, 17.91]; p < 0.001). Mechanical power was not associated with postoperative ventilation duration (β = -2.29; 95% CI [-6.48, 1.90]; p = 0.52). CONCLUSIONS Patients undergoing major aortic surgery are at risk for prolonged mechanical ventilation. Transfusion volume and pre- to post-CPB changes in driving pressures and end-tidal carbon dioxide are significantly associated with postoperative ventilation duration. Intraoperative mechanical ventilator power is not a significant predictor of mechanical ventilation duration after major aortic surgery. These variables are potentially modifiable by anesthesiologists and may be future therapeutic targets.
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Affiliation(s)
- Nan Leng
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Aaron M Mittel
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY.
| | - Dov Levine
- Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Suzuka Nitta
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Mitchell F Berman
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - May Hua
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Paul A Kurlansky
- Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York, NY; Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiac, Vascular & Thoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
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4
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Manrique S, Gordo F. The role of static elastic power in the severity and prognosis of acute respiratory distress syndrome. Med Intensiva 2025; 49:502160. [PMID: 40090797 DOI: 10.1016/j.medine.2025.502160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2024] [Accepted: 01/07/2025] [Indexed: 03/18/2025]
Affiliation(s)
- Sara Manrique
- Unidad de Cuidados Intensivos, Hospital Universitari Joan XXIII, Tarragona, Spain.
| | - Federico Gordo
- Unidad de Cuidados Intensivos, Hospital Universitario de Henares, Coslada, Madrid, Spain
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5
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Serafini SC, Cinotti R, Asehnoune K, Battaglini D, Robba C, Neto AS, Pisani L, Mazzinari G, Tschernko EM, Schultz MJ. Potentially modifiable ventilation factors associated with outcome in neurocritical care vs. non-neurocritical care patients: Rational and protocol for a patient-level analysis of PRoVENT, PRoVENT-iMiC and ENIO (PRIME). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2025; 72:501690. [PMID: 39961531 DOI: 10.1016/j.redare.2025.501690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Accepted: 09/21/2024] [Indexed: 02/25/2025]
Abstract
INTRODUCTION Ventilator settings and ventilation variables and parameters vary between neurocritical care and non-neurocritical care patients. We aim to compare ventilation management in neurocritical care patients versus non-neurocritical care patients under invasive mechanical ventilation support, and to determine which factors related to ventilatory management have an independent association with outcome in neurocritical patients. METHODS AND ANALYSIS We meta-analyze harmonized individual patient data from three observational studies ('PRactice of VENTilation in critically ill patients without ARDS' [PRoVENT], 'PRactice of VENTilation in critically ill patients in Middle-income Countries' [PRoVENT-iMiC] and 'Extubation strategies and in neuro-intensive care unit patients and associations with outcomes' [ENIO]), pooled into a database named 'PRIME'. The primary endpoint is all cause ICU mortality. Secondary endpoints are key ventilator settings and ventilation variables and parameters. To identify potentially modifiable and non-modifiable factors contributing to ICU mortality, a multivariable model will be built using demographic factors, comorbidities, illness severities, and respiratory and laboratorial variables. In analyses examining the impact of ventilatory variables on outcome, we will estimate the relative risk of ICU mortality for neurocritical and non-neurocritical care patients by dividing the study population based on key ventilator variables and parameters. ETHICS AND DISSEMINATION This meta-analysis will address a clinically significant research question by comparing neurocritical care with non-neurocritical care patients. As this is a meta-analysis, additional ethical committee approval is not required. Findings will be disseminated to the scientific community through abstracts and original articles in peer-reviewed journals. Furthermore, the PRIME database will be made accessible for further post-hoc analyses. REGISTRATION PROVENT, PROVENT-iMiC and ENIO, and the pooled database PRIME are registered at clinicaltrials.gov (NCT01868321 for PRoVENT, NCT03188770 for PRoVENT-iMiC, and NCT03400904 for ENIO, and for PRIME is pending).
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Affiliation(s)
- S C Serafini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria; Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
| | - R Cinotti
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes Université, Nantes, France
| | - K Asehnoune
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes Université, Nantes, France
| | - D Battaglini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Anesthesia and Critical Care, San Martino Policlinic Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - C Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Anesthesia and Critical Care, San Martino Policlinic Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - A S Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Critical Care, Austin Hospital, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia; Department of Critical Care, Data Analytics Research and Evaluation Centre, University of Melbourne, Melbourne, Victoria, Australia; Department of Critical Care, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - L Pisani
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands; Anesthesia and Critical Care, Giovanni XXIII Policlinic Hospital, Bari, Italy; Mahidol Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - G Mazzinari
- Department of Anesthesiology, Hospital Universitario La Fe, Valencia, Spain; Perioperative Medicine Research Group, Instituto de Investigación Sanitaria, Valencia, Spain; Department of Statistics and Operational Research, Universidad de Valencia, Valencia, Spain
| | - E M Tschernko
- Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - M J Schultz
- Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria; Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands; Mahidol Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Buiteman-Kruizinga LA. Stress, strain and mechanical power: a reply. Anaesthesia 2025. [PMID: 40254749 DOI: 10.1111/anae.16617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2025] [Indexed: 04/22/2025]
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Chiumello D, Panina F. Mechanical Power and Ventilator-Induced Lung Injury: A Step Forward. Crit Care Med 2025:00003246-990000000-00514. [PMID: 40249226 DOI: 10.1097/ccm.0000000000006681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
Affiliation(s)
- Davide Chiumello
- Department of Health Sciences, University of Milan, Milan, Italy
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Milan, Italy
- Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy
| | - Francesca Panina
- Department of Health Sciences, University of Milan, Milan, Italy
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Harder J, Iwuji K, Nugent K. Beyond pressure and volume: mechanical power levels in a cohort of intensive care unit patients. Am J Med Sci 2025:S0002-9629(25)00987-5. [PMID: 40252725 DOI: 10.1016/j.amjms.2025.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Revised: 03/27/2025] [Accepted: 04/16/2025] [Indexed: 04/21/2025]
Abstract
BACKGROUND Several ventilator parameters can be used to evaluate gas exchange and mechanical properties of the respiratory system in acute respiratory failure patients. The calculation of mechanical power (MP), a critical parameter that summarizes the energy transferred from the ventilator to the patient's lungs, is not routinely made in these patients. METHODS This study analyzed the distribution of MP in a cohort of 70 patients requiring mechanical ventilation and investigated its association with clinical outcomes. RESULTS This study included 39 men and 31 women with a mean age of 57.7 ± 15.1 years. The mean MP index decreased significantly from 10.4 J/min ± 5.65 on day 2 of mechanical ventilation to 8.3 J/min ± 4.1 on day 4 (p = 0.045). The mean length of mechanical ventilation was 5.2 ±6.5days. Mechanical power measured on day 2 (r = 0.317, p = 0.052) and day 4 (r = 0.352, p = 0.030) positively correlated with the duration of mechanical ventilation. There were no differences in MP between survivors and non-survivors on both day 2 (p = 0.458) and day 4 (p = 0.373). CONCLUSIONS This study analyzed the distribution of MP levels in mechanically ventilated patients in an ICU. Mechanical power measured on days 2 and 4 of mechanical ventilation had a positive correlation with the duration of ventilation, but it was not a significant predictor of ICU mortality.
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Affiliation(s)
- Jacob Harder
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth Iwuji
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Karaarslan E, Tire Y, Tutar MS, Akıncı N, Mermer HA, Uyar S, Ateş D, Şimşek G, Kozanhan B. The effect of bilateral rectus sheath and oblique subcostal transversus abdominis plane blocks on mechanical power in patients undergoing laparoscopic cholecystectomy surgery: a randomized controlled trial. BMC Anesthesiol 2025; 25:186. [PMID: 40241019 PMCID: PMC12004598 DOI: 10.1186/s12871-025-03062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Accepted: 04/08/2025] [Indexed: 04/18/2025] Open
Abstract
BACKGROUND In this study, we aimed to investigate the effects of bilateral rectus sheath blocks (RSBs) and oblique subcostal transversus abdominis plane (OSTAP) blocks on mechanical power (MP) in patients receiving laparoscopic cholecystectomy under general anesthesia. Additionally, we sought to evaluate the impact of these blocks on postoperative pain and quality of patient recovery. METHODS In this prospective, double-blind study, 66 patients who underwent laparoscopic cholecystectomy were randomized into two groups: Group C (control), which received a standard analgesic intravenous regimen; and Group B (block), which received bilateral RSB and OSTAP blocks. Intraoperative mechanical power was measured for all patients. Postoperative pain was assessed using visual analog scale (VAS) scores, and recovery quality was measured using the 15-item quality of recovery (QoR-15) questionnaire. RESULTS The mechanical power values for patients in Group C were consistently greater at all measured times: baseline, before bridion, and after bridion. Although the difference at baseline was not statistically significant, significant differences were observed before and after bridion (p values = 0.112, 0.021, and 0.003, respectively). Patients in Group B exhibited significantly lower VAS scores at all time points (30 min, 2 h, 8 h, and 24 h) (p < 0.05). Additionally, essential variations were noted in the administration of rescue analgesia between the groups (p < 0.001). Regarding tramadol consumption, Group C patients had significantly greater values [84 (74-156) vs. 0 (0-75), median (25-75th percentiles)] (p < 0.001). For the QoR-15 scores, Group C also had significantly greater values [129 (124-133) vs. 122 (115-125), median (25-75th percentiles)] (p < 0.001). CONCLUSIONS Bilateral RSB and OSTAP blocks significantly reduce mechanical power during surgery. Moreover, they significantly decrease postoperative pain and analgesic consumption and increase patient recovery scores. TRIAL REGISTRATION The study protocol was registered in the international database ClinicalTrials.gov (registration no. NCT06202040). This study was conducted between December 2023 and January 2024 at the Department of Anesthesiology and Reanimation of Konya City Hospital.
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Affiliation(s)
- Esma Karaarslan
- Department of Anesthesiology and Reanimation, Konya City Hospital, Konya, Turkey.
| | - Yasin Tire
- Department of Anesthesiology and Reanimation, Konya City Hospital, Konya, Turkey
| | - Mahmut Sami Tutar
- Department of Anesthesiology and Reanimation, Konya City Hospital, Konya, Turkey
| | - Nuran Akıncı
- Department of Anesthesiology and Reanimation, Konya City Hospital, Konya, Turkey
| | - Hasan Alp Mermer
- Department of Anesthesiology and Reanimation, Konya City Hospital, Konya, Turkey
| | - Sami Uyar
- Department of Anesthesiology and Reanimation, Konya Beyhekim Training and Research Hospital, Konya, Turkey
| | - Dilek Ateş
- Department of Anesthesiology and Reanimation, Konya City Hospital, Konya, Turkey
| | - Gürcan Şimşek
- General Surgery Department, Konya City Hospital, Konya, Turkey
| | - Betül Kozanhan
- Department of Anesthesiology and Reanimation, Konya City Hospital, Konya, Turkey
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Mihatsch LL, Huber A, Weiland S, Friederich P. Prospective in-depth analysis of anaesthetic management of spontaneous ventilation VATS for lung cancer resection: a matched pairs comparison to intubated VATS. BMC Anesthesiol 2025; 25:185. [PMID: 40241009 PMCID: PMC12004653 DOI: 10.1186/s12871-025-03027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Accepted: 03/26/2025] [Indexed: 04/18/2025] Open
Abstract
BACKGROUND Spontaneous ventilation video-assisted thoracoscopic surgery (SV-VATS) has been propagated for nearly two decades without a prospective in-depth analysis of anaesthetic management and anaesthetic processing times. This would be important as anaesthetic management of SV-VATS imposes fundamental changes to standards in thoracic anaesthesia and may increase anaesthetic risks. Therefore, this study aimed to provide such in-depth analysis and compare the results to data from matched intubated VATS (I-VATS) patients. 3D-reconstruction of bronchial airways helped to estimate the risk reduction by avoiding double-lumen tube (DLT) intubation according to common selection methods in SV-VATS patients. METHODS SV-VATS patients receiving anatomical (N = 22) and non-anatomical (N = 16) lung cancer resections were prospectively enrolled. A retrospective I-VATS control cohort (N = 76) allowed for a 2:1 propensity score matching. DLT sizes necessary for SV-VATS patients according to common selection methods were evaluated by 3D-reconstruction of the left main bronchus and the ≥ 1 mm criterion. RESULTS SV-VATS patients required substantially less propofol dosage (P < 0.001) with an increase in variability of drug dosing (P < 0.001) and higher BIS values (P < 0.001) as compared to I-VATS patients. SV-VATS lead to higher variability in respiratory parameters (P < 0.001) with less driving pressure (P < 0.001) and similar mean tidal volumes, oxygenation, and hemodynamic parameters compared to I-VATS. Spontaneous ventilation was achieved by allowing for permissive hypercapnia and respiratory acidosis. Anaesthetic processing time was reduced by 7 min (P < 0.001). 5-10% of female and 5% of male patients would have received a DLT larger than their bronchial airway. CONCLUSIONS Our study provides the first prospective quantitative in-depth analysis of a standardised anaesthetic management regime for SV-VATS, including anaesthetic processing times. Respiratory parameters during SV-VATS are compatible with reduced mechanical power as compared to patients undergoing I-VATS. The anaesthetic management regime reduced the risk of airway damage imposed by choosing too-large DLTs in up to 10% of patients without compromising oxygenation and hemodynamic stability. Changes in anaesthetic processing time by 7 min would not allow for a higher caseload of SV-VATS for lung cancer surgery. CLINICAL TRIAL NUMBER Not applicable.
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Affiliation(s)
- Lorenz L Mihatsch
- TUM School of Medicine and Health, Technical University of Munich, TUM University Hospital, Munich, Germany.
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, München Klinik Bogenhausen, Technical University of Munich, Munich, Germany.
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig- Maximilians-Universität, Munich, Germany.
| | - Anastasia Huber
- TUM School of Medicine and Health, Technical University of Munich, TUM University Hospital, Munich, Germany
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, München Klinik Bogenhausen, Technical University of Munich, Munich, Germany
| | - Sandra Weiland
- TUM School of Medicine and Health, Technical University of Munich, TUM University Hospital, Munich, Germany
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, München Klinik Bogenhausen, Technical University of Munich, Munich, Germany
| | - Patrick Friederich
- TUM School of Medicine and Health, Technical University of Munich, TUM University Hospital, Munich, Germany
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, München Klinik Bogenhausen, Technical University of Munich, Munich, Germany
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11
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Bencze R, Kawati R, Hånell A, Lewen A, Enblad P, Engquist H, Bjarnadottir KJ, Joensen O, Barrueta Tenhunen A, Freden F, Brochard L, Perchiazzi G, Pellegrini M. Intracranial response to positive end-expiratory pressure is influenced by lung recruitability and gas distribution during mechanical ventilation in acute brain injury patients: a proof-of-concept physiological study. Intensive Care Med Exp 2025; 13:43. [PMID: 40229445 PMCID: PMC11996739 DOI: 10.1186/s40635-025-00750-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2024] [Accepted: 03/27/2025] [Indexed: 04/16/2025] Open
Abstract
BACKGROUND The effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) dynamics in patients with acute brain injury (ABI) remains controversial. PEEP can benefit oxygenation by promoting alveolar recruitment, but its influence on ICP is complex. The primary aims of this study were to investigate 1) how lung recruitability influences oxygenation and 2) how lung recruitability and regional gas distribution, measured via recruitment-to-inflation (RI) ratio and electrical impedance tomography (EIT), affect ICP in response to PEEP changes in critically ill patients in their early phase of ABI. METHODS Ten mechanically ventilated ABI patients were included. Pressure reactivity index (PRx) was estimated. Using RI manoeuvre and EIT, lung recruitability and gas distribution were assessed in response to a standardised PEEP change (from high to low levels, with a delta of 10 cmH2O). Changes in ICP (ΔICP) were calculated between high and low PEEP. Lung inhomogeneity indices (global inhomogeneity index [GI] and local inhomogeneity index [LI]) were derived from EIT. Correlations between ventilatory variables and ICP were analysed. RESULTS Blood oxygenation significantly decreased, going from high (14 [IQR: 12-15] cmH₂O) to low (4 [IQR: 2-5] cmH₂O) PEEP. Reducing PEEP significantly increased ICP (from 9 [IQR: 5-13] to 12 [IQR: 8-16] mmHg, p < 0.01), while cerebral perfusion pressure (CPP) improved (from 71 [IQR:67-83] to 75 [IQR: 70-84] mmHg, p = 0.03) and mean arterial pressure (MAP) increased (from 79 [IQR: 69-95] to 84 [IQR: 76-99] mmHg, p < 0.01). The RI ratio correlated significantly with ΔICP (rho = 0.87, p < 0.01), as did Vrec% (proportion of recruited volume, rho = 0.65) and GI (rho = 0.5). LI did not correlate with ΔICP. PRx was 0.30 [IQR: 0.12-0.42], indicating a deranged cerebral autoregulation. CONCLUSIONS Patients with a higher potential for lung recruitability had a more beneficial effect of PEEP on oxygenation. These effects should be interpreted cautiously, given that lung recruitability and global inhomogeneity of gas distribution significantly influenced the intracranial response to PEEP in ABI patients. As indicated by MAP and CPP, PEEP may impact systemic haemodynamics and cerebral perfusion when cerebral autoregulation is deranged. These findings underscore the importance of multimodal (i.e. respiratory, cerebral and haemodynamics) monitoring for optimising ventilation strategies in ABI patients and provide a framework for future research. Trial registration Registration number: NCT05363085, Date of registration: May 2022.
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Affiliation(s)
- Reka Bencze
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Rafael Kawati
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewen
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Henrik Engquist
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kristin Jona Bjarnadottir
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Odin Joensen
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Annelie Barrueta Tenhunen
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Filip Freden
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Laurent Brochard
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Gaetano Perchiazzi
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Mariangela Pellegrini
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden.
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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12
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Marabotti A, Cianchi G, Pelagatti F, Ciapetti M, Franci A, Socci F, Fulceri GE, Lazzeri C, Bonizzoli M, Peris A. Effect of Respiratory Support Type and Total Duration on Weaning From Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Patients. Respir Care 2025. [PMID: 40206021 DOI: 10.1089/respcare.12246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2025]
Abstract
Background: We evaluated the impact of noninvasive respiratory support (NRS) and invasive mechanical ventilation duration before venovenous extracorporeal membrane oxygenation (VV-ECMO) on weaning from venovenous ECMO and survival. Methods: In a retrospective single-center study, we studied subjects with COVID-19 ARDS treated with VV-ECMO. The subjects were divided and analyzed according to the cut-off of NRS, invasive ventilation, and total duration of respiratory support. Results: We identified a cut-off of NRS duration of 4 days, invasive ventilation duration of 5 days, and total respiratory support duration of 8 days. Weaning from VV-ECMO was observed in 63% (15/24) of subjects with NRS duration ≤ 4 days and in 16% (4/25) of subjects with NRS > 4 days (P = .001), in 50% (17/34) of subjects with invasive ventilation duration ≤ 5 days, in 13% (2/15) of subjects with invasive ventilation duration > 5 days (P = .02), in 68% (13/19) of subjects with total support duration < 8 days, and in 20% (6/30) of subjects with total support duration > 8 days (P = .001). The survival probability at 200 days demonstrated a statistically significant difference in NRS and total support duration comparison (P = .001 and P = .004, respectively). We did not find a statistically significant survival difference according to invasive ventilation duration (P = .13). Conclusions: In our population, the increase in NRS and total support days before ECMO could hamper weaning from VV-ECMO support. However, due to the pandemic, the small sample size, and the lack of precise data on ventilation settings, caution should be exercised in universalizing these results.
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Affiliation(s)
- Alberto Marabotti
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Cianchi
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Filippo Pelagatti
- Dr. Pelagatti is affiliated with Department of Anesthesia and Intensive Care, Careggi Hospital, University of Florence, Florence, Italy
| | - Marco Ciapetti
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Franci
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Filippo Socci
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giorgio Enzo Fulceri
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Chiara Lazzeri
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Drs. Marabotti, Cianchi, Ciapetti, Franci, Socci, Fulceri, Lazzeri, Bonizzoli, and Peris are affiliated with Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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13
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Nakama T, Umemura T, Hoshino S, Tamashiro M, Satoh K, Sekiguchi H. Mechanical Power to Predict Ventilator Liberation in Patients With a Tracheostomy. Respir Care 2025. [PMID: 40202484 DOI: 10.1089/respcare.12237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2025]
Abstract
Background: Mechanical power (MP) is useful for predicting the outcomes of attempts to liberate patients from mechanical ventilation. MP is computed based on measured variables derived to determine the power in joules required to breathe while receiving mechanical ventilation. The main objectives of this study were to calculate a cutoff value of MP that would predict successful liberation and to determine the prediction rate of liberation success based on this cutoff value. Methods: This was a single-center retrospective study. Data from 110 tracheostomized subjects receiving mechanical ventilation were analyzed. We divided subjects into two groups based on ventilator liberation outcome. Confounding factors in subject background were adjusted using propensity score matching (PSM). Statistically significant differences in MP at tracheostomy and liberation success between liberation success and failure groups were examined. We calculated the MP cutoff value for successful liberation using the area under the curve of the receiver operating characteristic (ROC) and its corresponding prediction rate of liberation success. Results: The number of subjects in the successful liberation group was 79 and that of the failed liberation group was 31. The MP cutoff value and corresponding prediction rate for liberation success were 256.5 J/min (area under the curve-ROC = 0.839) and 92.2%, respectively. After PSM, the low MP group (n = 36), divided based on the MP cutoff value, had a significantly higher liberation success rate than the high MP group (n = 36), with an odds ratio of 19.95 (CI 3.95, 91.23, P < .001). Conclusion: MP at tracheostomy was a strong predictor of successful ventilator liberation, and the prediction rate of liberation success based on the MP cutoff value was shown to be very high. We recommend that patients with low MP be actively considered for liberation. In contrast, those with high MP should continue weaning while simultaneously making early transfer arrangements if liberation is unsuccessful.
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Affiliation(s)
- Toshiharu Nakama
- Ms. Nakama, Mr. Hoshino and Sekiguchi are affiliated with Graduate School of Health Sciences, University of the Ryukyus, Nishihara, Okinawa, Japan
- Ms. Nakama and Dr. Tamashiro are affiliated with Yuuai Medical Center, Intensive Care Unit, Tomigusuku, Okinawa, Japan
| | - Takehiro Umemura
- Dr. Umemura is affiliated with Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Soukun Hoshino
- Ms. Nakama, Mr. Hoshino and Sekiguchi are affiliated with Graduate School of Health Sciences, University of the Ryukyus, Nishihara, Okinawa, Japan
| | - Masahiro Tamashiro
- Ms. Nakama and Dr. Tamashiro are affiliated with Yuuai Medical Center, Intensive Care Unit, Tomigusuku, Okinawa, Japan
| | - Kenichi Satoh
- Prof. Satoh is affiliated with The Center for Data Science Education and Research, Shiga University, Shiga, Japan
| | - Hiroshi Sekiguchi
- Ms. Nakama, Mr. Hoshino and Sekiguchi are affiliated with Graduate School of Health Sciences, University of the Ryukyus, Nishihara, Okinawa, Japan
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14
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Kim TW, Chung CR, Nam M, Ko RE, Suh GY. Associations of mechanical power, ventilatory ratio, and other respiratory indices with mortality in patients with acute respiratory distress syndrome undergoing pressure-controlled mechanical ventilation. Front Med (Lausanne) 2025; 12:1553672. [PMID: 40255591 PMCID: PMC12006839 DOI: 10.3389/fmed.2025.1553672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Accepted: 03/24/2025] [Indexed: 04/22/2025] Open
Abstract
Background Mechanical power (MP) and ventilatory ratio (VR) are crucial metrics in the management of acute respiratory distress syndrome (ARDS). This study aimed to evaluate the impact of these factors on ICU mortality in patients with ARDS undergoing pressure-controlled ventilation. Methods In this retrospective study, we included 600 adult patients with ARDS who required mechanical ventilation for > 48 h between March 2018 and February 2021 in a tertiary referral hospital in Korea. The MP was calculated using Becher's simplified equation, and the VR was determined using standard formulas. The ventilatory parameters were measured hourly during the first 12 h of ventilation. Clinical characteristics, ventilator settings, and outcomes were compared between the survivors and non-survivors. Multiple logistic regression models were used to assess the predictive performance of the respiratory and mechanical ventilation parameters for ICU mortality. Results Of the 600 patients, 61.5% (n = 369) survived to hospital discharge. Non-survivors had higher rates of chronic liver disease, hematologic malignancies, and solid tumors. The survivors demonstrated lower respiratory rates (21 vs. 22 breaths/min, p < 0.001), tidal volumes (491 vs. 445 mL, p = 0.048), and peak pressures (22.0 vs. 24.3 cm H2O, p < 0.001). Significant differences were observed in driving pressure (15.0 vs. 16.0 cm H2O, p = 0.001), MP (18.8 vs. 21.8 J/min, p < 0.001), LTCdyn-MP (7,371 vs. 8,780 cm H2O/min, p < 0.001), and power index (5,429 vs. 6,386 cm H2O/min, p = 0.005) between survivors and non-survivors. In adjusted models, MP (OR 1.03, 95% CI 1.01-1.05, p = 0.006), VR (OR 1.39, 95% CI 1.02-1.92, p = 0.040), and PBW-adjusted MP (OR 1.02, 95% CI 1.00-1.03, p = 0.009) were significant predictors of ICU mortality. Conclusion Our findings indicate that MP and VR were independently associated with ICU mortality in patients with ARDS undergoing pressure-controlled ventilation.
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Affiliation(s)
- Tae Wan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Miryeo Nam
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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15
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Kallet RH, Lipnick MS. Pressure Control Surrogate Formula for Estimating Mechanical Power in ARDS Is Associated With Mortality. Respir Care 2025; 70:427-433. [PMID: 39242173 DOI: 10.4187/respcare.12269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 09/01/2024] [Indexed: 09/09/2024]
Abstract
Background: Mechanical power (MP) applied to the respiratory system (MPRS) is associated with ventilator-induced lung injury (VILI) and ARDS mortality. Absent automated ventilator MPRS measurements, the alternative is clinically unwieldy equations. However, simplified surrogate formulas are now available and accurately reflect values produced by airway pressure-volume curves. This retrospective, observational study examined whether the surrogate pressure -control equation alone could accurately assess mortality risk in subjects with ARDS managed almost exclusively with volume control (VC) ventilation. Methods: Nine hundred and forty-eight subjects were studied in whom invasive mechanical ventilation and implementation of ARDS Network ventilator protocols commenced ≤ 24 h after ARDS onset and who survived > 24 h. MPRS was calculated as 0.098 x breathing frequency x tidal volume x (PEEP + driving pressure). MPRS was assessed as a risk factor for hospital mortality and compared between non-survivors and survivors across Berlin definition classifications. In addition, mortality was compared across 4 MPRS thresholds associated with VILI or mortality (ie, 15, 20, 25, and 30 J/min). Results: MPRS was associated with increased mortality risk: odds ratio (95% CI) of 1.06 (1.04-1.07) J/min (P < .001). Median MPRS differentiated non-survivors from survivors in mild (24.7 J/min vs 18.5 J/min, respectively, P = .034), moderate (25.7 J/min vs 21.3 J/min, respectively, P < .001), and severe ARDS (28.7 J/min vs 23.5 J/min, respectively, P < .001). Across 4 MPRS thresholds, mortality increased from 23-29% when MPRS was ≤ threshold versus 38-51% when MPRS was > threshold (P < .001). In the > cohort, the odds ratio (95% CI) increased from 2.03 (1.34-3.12) to 2.51 (1.87-3.33). Conclusion: The pressure control surrogate formula is sufficiently accurate to assess mortality in ARDS, even when using VC ventilation. In our subjects when MPRS exceeds established cutoff values for VILI or mortality risk, we found mortality risk consistently increased by a factor of > 2.0.
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Affiliation(s)
- Richard H Kallet
- Mr. Kallet and Dr. Lipnick are affiliated with Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California
| | - Michael S Lipnick
- Mr. Kallet and Dr. Lipnick are affiliated with Department of Anesthesia and Perioperative Care, University of California, San Francisco at San Francisco General Hospital, San Francisco, California
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16
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da Silva AL, Magalhaes RF, Conceicao PHL, Dos Santos ACM, Oliveira CM, Thorton LT, Crooke PS, Baldavira CM, Capelozzi VL, Cruz FF, Samary CS, Silva PL, Marini JJ, Rocco PRM. Effects of Similar Mechanical Power Resulting From Different Combinations of Respiratory Variables on Lung Damage in Experimental Acute Respiratory Distress Syndrome. Crit Care Med 2025:00003246-990000000-00506. [PMID: 40167363 DOI: 10.1097/ccm.0000000000006661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2025]
Abstract
OBJECTIVES Mechanical power is a crucial concept in understanding ventilator-induced lung injury (VILI). We adopted the null hypothesis that under the same mechanical power, resulting from combinations of different static and dynamic variables-some with high stress per cycle and others without-would inflict similar degrees of damage on lung epithelial and endothelial cells as well as on the extracellular matrix in experimental acute respiratory distress syndrome (ARDS). To test this hypothesis, we varied tidal volume (Vt), which correlates with the stretching force per cycle, while adjusting respiratory rate (RR) to yield similar mechanical power values for identical durations across all experimental groups. DESIGN Animal study. SETTING Laboratory investigation. SUBJECTS Thirty male Wistar rats (333 ± 26 g). INTERVENTIONS Twenty-four hours after intratracheal administration of Escherichia coli lipopolysaccharide, animals were anesthetized and mechanically ventilated (positive end-expiratory pressure = 3 cm H2O) with combination of Vt and RR sufficient to induce similar mechanical power (n = 8/group): Vt = 6 mL/kg, RR = 140 breaths/minute (low Vt-high RR [LVT-HRR]); Vt = 12 mL/kg, RR = 70 breaths/minute (high Vt-low RR [HVT-LRR]); and Vt = 18 mL/kg, RR = 50 breaths/minute (very-high Vt-very-low RR [VHVT-VLRR]). All groups were ventilated for 80 minutes. A control group, not subjected to mechanical ventilation (MV), was used for molecular biology analyses. MEASUREMENTS AND MAIN RESULTS After 80 minutes of MV, lung overdistension, alveolar/interstitial edema, fractional area of E-cadherin, and biomarkers of lung inflammation (interleukin-6), lung stretch (amphiregulin), damage to epithelial (surfactant protein B) and endothelial cells (vascular cell adhesion molecule 1 and angiopoietin-2), and extracellular matrix (versican and syndecan) were higher in group VHVT-VLRR than LVT-HRR. Plateau pressure and driving pressure increased progressively from LVT-HRR to HVT-LRR and VHVT-VLRR. CONCLUSIONS In the current experimental model of ARDS, mechanical power alone is insufficient to account for VILI. Instead, the manner in which its components are applied determines the extent of injury at a given mechanical power value.
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Affiliation(s)
- Adriana L da Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raquel F Magalhaes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro H L Conceicao
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Carolina M Dos Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Catharina M Oliveira
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lauren T Thorton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN
| | - Camila M Baldavira
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Vera L Capelozzi
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cynthia S Samary
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Cardiorespiratory and Musculoskeletal Physiotherapy, Faculty of Physiotherapy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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17
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Fosset M, von Wedel D, Redaelli S, Talmor D, Molinari N, Josse J, Baedorf-Kassis EN, Schaefer MS, Jung B. Subphenotyping prone position responders with machine learning. Crit Care 2025; 29:116. [PMID: 40087660 PMCID: PMC11909901 DOI: 10.1186/s13054-025-05340-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2024] [Accepted: 02/25/2025] [Indexed: 03/17/2025] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a heterogeneous condition with varying response to prone positioning. We aimed to identify subphenotypes of ARDS patients undergoing prone positioning using machine learning and assess their association with mortality and response to prone positioning. METHODS In this retrospective observational study, we enrolled 353 mechanically ventilated ARDS patients who underwent at least one prone positioning cycle. Unsupervised machine learning was used to identify subphenotypes based on respiratory mechanics, oxygenation parameters, and demographic variables collected in supine position. The primary outcome was 28-day mortality. Secondary outcomes included response to prone positioning in terms of respiratory system compliance, driving pressure, PaO2/FiO2 ratio, ventilatory ratio, and mechanical power. RESULTS Three distinct subphenotypes were identified. Cluster 1 (22.9% of whole cohort) had a higher PaO2/FiO2 ratio and lower Positive End-Expiratory Pressure (PEEP). Cluster 2 (51.3%) had a higher proportion of COVID-19 patients, lower driving pressure, higher PEEP, and higher respiratory system compliance. Cluster 3 (25.8%) had a lower pH, higher PaCO2, and higher ventilatory ratio. Mortality differed significantly across clusters (p = 0.03), with Cluster 3 having the highest mortality (56%). There were no significant differences in the proportions of responders to prone positioning for any of the studied parameters. Transpulmonary pressure measurements in a subcohort did not improve subphenotype characterization. CONCLUSIONS Distinct ARDS subphenotypes with varying mortality were identified in patients undergoing prone positioning; however, predicting which patients benefited from this intervention based on available data was not possible. These findings underscore the need for continued efforts in phenotyping ARDS through multimodal data to better understand the heterogeneity of this population.
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Affiliation(s)
- Maxime Fosset
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Medical Intensive Care Unit and PhyMedExp, Lapeyronie Montpellier University Hospital, Lapeyronie Teaching Hospital, University Montpellier, 1; 371 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, CEDEX 5, France
- Desbrest Institute of Epidemiology and Public Health, University of Montpellier, INRIA, Montpellier, France
| | - Dario von Wedel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simone Redaelli
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Anesthesiology, Perioperative and Pain Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Nicolas Molinari
- Desbrest Institute of Epidemiology and Public Health, University of Montpellier, INRIA, Montpellier, France
| | - Julie Josse
- Desbrest Institute of Epidemiology and Public Health, University of Montpellier, INRIA, Montpellier, France
| | - Elias N Baedorf-Kassis
- Department of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Boris Jung
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
- Medical Intensive Care Unit and PhyMedExp, Lapeyronie Montpellier University Hospital, Lapeyronie Teaching Hospital, University Montpellier, 1; 371 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, CEDEX 5, France.
- Department of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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18
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Gaver DP, Kollisch-Singule M, Nieman G, Satalin J, Habashi N, Bates JHT. Mechanical ventilation energy analysis: Recruitment focuses injurious power in the ventilated lung. Proc Natl Acad Sci U S A 2025; 122:e2419374122. [PMID: 40030025 PMCID: PMC11912383 DOI: 10.1073/pnas.2419374122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Accepted: 01/22/2025] [Indexed: 03/19/2025] Open
Abstract
The progression of acute respiratory distress syndrome (ARDS) from its onset due to disease or trauma to either recovery or death is poorly understood. Currently, there are no generally accepted treatments aside from supportive care using mechanical ventilation. However, this can lead to ventilator-induced lung injury (VILI), which contributes to a 30 to 40% mortality rate. In this study, we develop and demonstrate a technique to quantify forms of energy transport and dissipation during mechanical ventilation to directly evaluate their relationship to VILI. A porcine ARDS model was used, with ventilation parameters independently controlling lung overdistension and alveolar/airway recruitment/derecruitment (RD). Hourly measurements of airflow, tracheal and esophageal pressures, respiratory system impedance, and oxygen transport were taken for six hours following lung injury to track energy transfer and lung function. The final degree of injury was assessed histologically. Total and dissipated energies were quantified from lung pressure-volume relationships and subdivided into contributions from airflow, tissue viscoelasticity, and RD. Only RD correlated with physiologic recovery. Despite accounting for a very small fraction (2 to 5%) of the total energy dissipation, RD is damaging because it occurs quickly over a very small area. We estimate power intensity of RD energy dissipation to be 100 W/m2, equivalent to 10% of the Sun's luminance at the Earth's surface. Minimizing repetitive RD events may thus be crucial for mitigating VILI.
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Affiliation(s)
- Donald P. Gaver
- Department of Biomedical Engineering, Tulane University, New Orleans, LA70118
| | | | - Gary Nieman
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY13210
| | - Joshua Satalin
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY13210
| | - Nader Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD21201
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19
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LeTourneau WM, Gallo De Moraes A. Mechanical Power: Using Ideal Body Weight to Identify Injurious Mechanical Ventilation Thresholds. Respir Care 2025. [PMID: 40054852 DOI: 10.1089/respcare.11815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2025]
Abstract
Identifying the mechanisms of ventilator/ventilation-induced lung injury requires an understanding of the pulmonary physiology involved in the mechanical properties of the lung along with the involvement of the inflammatory cascade. Accurately measuring parameters that represent physiologic lung stress and lung strain at the bedside can be clinically challenging. Although surrogates for lung stress and strain have been proposed, such as plateau pressure and driving pressure, these values only represent a static variable in the ventilator breath. It has been proposed that a single variable could be used as a unifying parameter to identify a threshold for the safe application of mechanical ventilation. The concept of "mechanical power" applies an energy load transfer designation to the ventilator settings and output of tidal volume, airway pressures, and flow. However, there is a potential disconnect between the use of "absolute" mechanical power and the variability of body weight throughout a mixed medical population. Using ideal body weight as an influential factor to express mechanical power can potentially allow for a more accurate depiction of energy applied to the lungs and a potentially reliable injurious mechanical ventilation threshold indicator.
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Affiliation(s)
- William M LeTourneau
- Mr. LeTourneau is affiliated with Department of Respiratory Therapy, Mayo Clinic, Rochester, Minnesota, USA
| | - Alice Gallo De Moraes
- Dr. Gallo De Moraes is affiliated with Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota, USA
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Ma W, Tang S, Yao P, Zhou T, Niu Q, Liu P, Tang S, Chen Y, Gan L, Cao Y. Advances in acute respiratory distress syndrome: focusing on heterogeneity, pathophysiology, and therapeutic strategies. Signal Transduct Target Ther 2025; 10:75. [PMID: 40050633 PMCID: PMC11885678 DOI: 10.1038/s41392-025-02127-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 12/27/2024] [Accepted: 12/27/2024] [Indexed: 03/09/2025] Open
Abstract
In recent years, the incidence of acute respiratory distress syndrome (ARDS) has been gradually increasing. Despite advances in supportive care, ARDS remains a significant cause of morbidity and mortality in critically ill patients. ARDS is characterized by acute hypoxaemic respiratory failure with diffuse pulmonary inflammation and bilateral edema due to excessive alveolocapillary permeability in patients with non-cardiogenic pulmonary diseases. Over the past seven decades, our understanding of the pathology and clinical characteristics of ARDS has evolved significantly, yet it remains an area of active research and discovery. ARDS is highly heterogeneous, including diverse pathological causes, clinical presentations, and treatment responses, presenting a significant challenge for clinicians and researchers. In this review, we comprehensively discuss the latest advancements in ARDS research, focusing on its heterogeneity, pathophysiological mechanisms, and emerging therapeutic approaches, such as cellular therapy, immunotherapy, and targeted therapy. Moreover, we also examine the pathological characteristics of COVID-19-related ARDS and discuss the corresponding therapeutic approaches. In the face of challenges posed by ARDS heterogeneity, recent advancements offer hope for improved patient outcomes. Further research is essential to translate these findings into effective clinical interventions and personalized treatment approaches for ARDS, ultimately leading to better outcomes for patients suffering from ARDS.
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Affiliation(s)
- Wen Ma
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Institute for Disaster Management and Reconstruction, Sichuan University-The Hong Kong Polytechnic University, Chengdu, China
| | - Songling Tang
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Peng Yao
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tingyuan Zhou
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Institute for Disaster Management and Reconstruction, Sichuan University-The Hong Kong Polytechnic University, Chengdu, China
| | - Qingsheng Niu
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Peng Liu
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Shiyuan Tang
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yao Chen
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Gan
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yu Cao
- Department of Emergency Medicine, Institute of Disaster Medicine and Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China.
- Institute for Disaster Management and Reconstruction, Sichuan University-The Hong Kong Polytechnic University, Chengdu, China.
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21
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Dong Y, Yang C, Sun R, Fu J, Huang R, Yuan J, Wang Y, Wang J, Shen F. Influence of the mean airway pressure trajectory on the mortality and AKI occurrence in septic shock patients with mechanical ventilation: insights from the MIMIC-IV database. Front Med (Lausanne) 2025; 12:1552336. [PMID: 40109722 PMCID: PMC11919853 DOI: 10.3389/fmed.2025.1552336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2024] [Accepted: 02/20/2025] [Indexed: 03/22/2025] Open
Abstract
Background Mean airway pressure (Pmean) is a known prognostic marker for mortality and adverse outcomes in mechanically ventilated patients. However, most previous studies have relied on static measurements, leaving the impact of Pmean trajectory on clinical outcomes in septic shock patients unclear. This study aimed to investigate the effect of Pmean trajectory on survival rates and acute kidney injury (AKI) incidence in septic shock patients undergoing mechanical ventilation (MV). Methods A retrospective cohort study was implemented utilizing sepsis patient data from the MIMIC-IV database. Group-based trajectory modeling (GBTM) was applied to identify distinct Pmean trajectory groups among septic shock patients. Cox proportional hazards and logistic regression models were utilized to analyze associations between Pmean trajectory and both mortality and AKI incidence. A causal mediation analysis evaluated the intermediary effect of cumulative fluid balance over the first 72 h post-ICU admission. Results A total of 956 eligible patients were included. Based on model fitting criteria, five distinct Pmean trajectory groups were identified: group 1 (low-stable), group 2 (high-descend), group 3 (medium-ascend), group 4 (high-stable), and group 5 (higher-stable). Compared to the low-stable trajectory (group 1), trajectories in groups 3, 4, and 5 were associated with significantly higher 30-day mortality risks (HR = 1.40, 95% CI = 1.03-1.88; HR = 1.47, 95% CI = 1.01-2.13; HR = 2.54, 95% CI = 1.53-4.2, respectively), while group 2 exhibited similar mortality rates to group 1 (HR = 0.88, 95% CI = 0.60-1.30). Logistic regression analyses revealed that groups 3, 4, and 5 were also significant risk factors for AKI occurrence (p < 0.05), with group 1 as the reference. Mediation analysis revealed that 20.5% (95% CI = 0.106-0.40) of the Pmean trajectory effect on AKI occurrence was mediated through cumulative fluid balance. Conclusion Pmean trajectories were strongly associated with mortality and AKI incidence in septic shock patients receiving MV.
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Affiliation(s)
- Yukang Dong
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
- Department of Emergency, Guizhou Provincial People's Hospital, Guiyang, China
| | - Changyan Yang
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
| | - Run Sun
- Department of Emergency, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jiangquan Fu
- Department of Emergency Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
| | - Rui Huang
- Department of Emergency Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
| | - Jia Yuan
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
| | - Ying Wang
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
| | - Jinni Wang
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
| | - Feng Shen
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, China
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22
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Meza-Fuentes G, Delgado I, Barbé M, Sánchez-Barraza I, Retamal MA, López R. Machine learning-based identification of efficient and restrictive physiological subphenotypes in acute respiratory distress syndrome. Intensive Care Med Exp 2025; 13:29. [PMID: 40024962 PMCID: PMC11872963 DOI: 10.1186/s40635-025-00737-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 02/14/2025] [Indexed: 03/04/2025] Open
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) is a severe condition with high morbidity and mortality, characterized by significant clinical heterogeneity. This heterogeneity complicates treatment selection and patient inclusion in clinical trials. Therefore, the objective of this study is to identify physiological subphenotypes of ARDS using machine learning, and to determine ventilatory variables that can effectively discriminate between these subphenotypes in a bedside setting with high performance, highlighting potential utility for future clinical stratification approaches. METHODOLOGY A retrospective cohort study was conducted using data from our ICU, covering admissions from 2017 to 2021. The study included 224 patients over 18 years of age diagnosed with ARDS according to the Berlin criteria and undergoing invasive mechanical ventilation (IMV). Data on physiological and ventilatory variables were collected during the first 24 h IMV. We applied machine learning techniques to categorize subphenotypes in ARDS patients. Initially, we employed the unsupervised Gaussian Mixture Classification Model approach to group patients into subphenotypes. Subsequently, we applied supervised models such as XGBoost to perform root cause analysis, evaluate the classification of patients into these subgroups, and measure their performance. RESULTS Our models identified two ARDS subphenotypes with significant clinical differences and significant outcomes. Subphenotype Efficient (n = 172) was characterized by lower mortality, lower clinical severity and presented a less restrictive pattern with better gas exchange compared to Subphenotype Restrictive (n = 52), which showed the opposite. The models demonstrated high performance with an area under the ROC curve of 0.94, sensitivity of 94.2% and specificity of 87.5%, in addition to an F1 score of 0.85. The most influential variables in the discrimination of subphenotypes were distension pressure, respiratory frequency and exhaled carbon dioxide volume. CONCLUSION This study presents an approach to improve subphenotype categorization in ARDS. The generation of clustering and prediction models by machine learning involving clinical, ventilatory mechanics, and gas exchange variables allowed for more accurate stratification of patients. These findings have the potential to optimize individualized treatment selection and improve clinical outcomes in patients with ARDS.
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Affiliation(s)
- Gabriela Meza-Fuentes
- Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Iris Delgado
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Mario Barbé
- Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Ignacio Sánchez-Barraza
- Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Mauricio A Retamal
- Programa de Comunicación Celular en Cáncer, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - René López
- Grupo Intensivo, ICIM, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile.
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23
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von Wedel D, Redaelli S, Jung B, Baedorf-Kassis EN, Schaefer MS. Higher mortality in female versus male critically ill patients at comparable thresholds of mechanical power: necessity of normalization to functional lung size. Intensive Care Med 2025; 51:624-626. [PMID: 39849156 DOI: 10.1007/s00134-024-07761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2024] [Indexed: 01/25/2025]
Affiliation(s)
- Dario von Wedel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- Institute of Medical Informatics, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Simone Redaelli
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Boris Jung
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
- Medical Intensive Care Unit and PhyMedExp, Montpellier University Hospital, Montpellier, France
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Elias N Baedorf-Kassis
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA.
- Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA.
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany.
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Canbaz M, Şentürk E, Şentürk M. Mechanical Protective Ventilation: New Paradigms in Thoracic Surgery. J Clin Med 2025; 14:1674. [PMID: 40095694 PMCID: PMC11900560 DOI: 10.3390/jcm14051674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2025] [Revised: 02/18/2025] [Accepted: 02/27/2025] [Indexed: 03/19/2025] Open
Abstract
One-lung ventilation (OLV) in thoracic anesthesia poses dual challenges: preventing hypoxemia and minimizing ventilator-associated lung injury (VALI). Advances such as fiberoptic bronchoscopy and improved anesthetic techniques have reduced hypoxemia, yet optimal management strategies remain uncertain. Protective ventilation, involving low tidal volumes (4-6 mL/kg), individualized PEEP, and selective alveolar recruitment maneuvers (ARM), seek to balance oxygenation and lung protection. However, questions persist regarding the ideal application of PEEP and ARM, as well as their integration into clinical practice. As for PEEP and ARM, further research is needed to address key questions and establish new guidelines.
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Affiliation(s)
- Mert Canbaz
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, University of Istanbul, 34093 Istanbul, Turkey;
| | - Emre Şentürk
- Department of Anesthesiology, Acibadem Atasehir Hospital, 34758 Istanbul, Turkey;
| | - Mert Şentürk
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem University, 34758 Istanbul, Turkey
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25
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Gattarello S, Pozzi T, Galizia M, Busana M, Ghidoni V, Catozzi G, Donati B, Nocera D, Giovanazzi S, D'Albo R, Fioccola A, Velati M, Nicolardi R, Fratti I, Romitti F, Gatta A, Collino F, Herrmann P, Quintel M, Meissner K, Sonzogni A, Marini JJ, Camporota L, Moerer O, Gattinoni L. Impact of Fluid Balance on the Development of Lung Injury. Am J Respir Crit Care Med 2025; 211:331-338. [PMID: 39585957 DOI: 10.1164/rccm.202406-1240oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/21/2024] [Indexed: 11/27/2024] Open
Abstract
Rationale: The pathophysiological relationship among fluid administration, fluid balance, and mechanical ventilation in the development of lung injury is unclear. Objectives: To quantify the relative contributions of mechanical power and fluid balance in the development of lung injury. Methods: Thirty-nine healthy female pigs, divided into four groups, were ventilated for 48 hours with high (∼18 J/min) or low (∼6 J/min) mechanical power and high (∼4 L) or low (∼1 L) targeted fluid balance. Measurements and Main Results: We measured physiological variables (e.g., end-expiratory lung gas volume, respiratory system mechanics, gas exchange, hemodynamics) and pathological variables (i.e., lung weight, wet-to-dry ratio, and histology score of lung injury). End-expiratory lung gas volume, respiratory system elastance, strain, and oxygenation significantly worsened in the two groups assigned to receive high fluid balance, irrespective of the mechanical power received. All four groups had similar lung weights (i.e., lung edema), lung wet-to-dry ratios, and pathological variables. Animals with higher fluid balance developed more ascites, which was associated with a decrease in end-expiratory lung gas volume. Conclusions: Our study did not detect a significant difference in lung injury between high and low mechanical power. Some damage is directly attributable to mechanical power, while additional injury appears to result indirectly from high fluid balance, which reduces end-expiratory lung gas volume, with ascites playing an important role in this process.
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Affiliation(s)
- Simone Gattarello
- Department of Anesthesia and Intensive Care Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Mauro Galizia
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Valentina Ghidoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Science, Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
| | - Giulia Catozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Beatrice Donati
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Domenico Nocera
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Stefano Giovanazzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rosanna D'Albo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonio Fioccola
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Dipartimento di Anestesia e Rianimazione, ASST Santi Paolo e Carlo, Ospedale Universitario San Paolo, Milano, Italia
| | - Mara Velati
- Department of Anesthesia and Intensive Care Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Rosmery Nicolardi
- Department of Anesthesia and Intensive Care Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Alessandro Gatta
- Dipartimento di Anestesia e Rianimazione, Ospedale "Ceccarini", AUSL della Romagna, Riccione, Italia
| | - Francesca Collino
- Dipartimento di Anestesia e Rianimazione, AOU Città della Salute e della Scienza di Torino, Corso Bramante 88, Torino, Italia
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - John J Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, Minnesota
| | - Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, United Kingdom; and
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
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Bugedo G, Nin N, Estenssoro E, Machado FR. Thank you, Professor Gattinoni†, and have a good trip to eternity! CRITICAL CARE SCIENCE 2025; 37:e20250002. [PMID: 40053016 PMCID: PMC11869818 DOI: 10.62675/2965-2774.20250002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Accepted: 01/05/2025] [Indexed: 03/10/2025]
Affiliation(s)
- Guillermo Bugedo
- Pontificia Universidad Católica de ChileDepartamento de Medicina IntensivaSantiagoChileDepartamento de Medicina Intensiva, Pontificia Universidad Católica de Chile -Santiago, Chile.
| | - Nicolas Nin
- Unidad de Cuidados IntensivosHospital Español Juan Jose CrottogginiMontevideoUruguayUnidad de Cuidados Intensivos, Hospital Español Juan Jose Crottoggini - Montevideo, Uruguay.
- Universidad de MontevideoCentro de Ciencias BiomédicasMontevideoUruguayCentro de Ciencias Biomédicas, Universidad de Montevideo - Montevideo, Uruguay.
| | - Elisa Estenssoro
- Universidad Nacional de La PlataFacultad de Ciencias MédicasLa PlataArgentinaFacultad de Ciencias Médicas, Universidad Nacional de La Plata - La Plata, Argentina.
| | - Flavia Ribeiro Machado
- Universidade Federal de São PauloEscola Paulista de MedicinaDiscipline of AnesthesiologySão PauloSPBrazilDiscipline of Anesthesiology, Pain and Intensive Care, Escola Paulista de Medicina, Universidade Federal de São Paulo - São Paulo (SP), Brazil.
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27
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Wu C, Canakoglu A, Vine J, Mathur A, Nath R, Kashiouris M, Mathur P, Ercole A, Elbers P, Duggal A, Wong KK, Bhattacharyya A. Elucidating the causal relationship of mechanical power and lung injury: a dynamic approach to ventilator management. Intensive Care Med Exp 2025; 13:28. [PMID: 40019703 PMCID: PMC11871266 DOI: 10.1186/s40635-025-00736-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/14/2025] [Indexed: 03/01/2025] Open
Abstract
BACKGROUND Mechanical power (MP) serves as a crucial predictive indicator for ventilator-induced lung injury and plays a pivotal role in tailoring the management of mechanical ventilation. However, its application across different diseases and stages remains nuanced. METHODS Using AmsterdamUMCdb, we conducted a retrospective study to analyze the causal relationship between MP and outcomes of invasive mechanical ventilation, specifically SpO2/FiO2 ratio (P/F) and ventilator-free days at day 28 (VFD28). We employed causal inferential analysis with backdoor linear regression and double machine learning, guided by directed acyclic graphs, to estimate the average treatment effect (ATE) in the whole population and conditional average treatment effect (CATE) in the individual cohort. Additionally, to enhance interpretability and identify MP thresholds, we conducted a simulation analysis. RESULTS In the study, we included 11,110 unique admissions into analysis, of which 58.3% (6391) were surgical admissions. We revealed a negative and significant causal effect of median MP on VFD28, with estimated ATEs of -0.135 (95% confidence interval [CI]: -0.15 to -0.121). The similar effect was not observed in Maximal MP and minimal MP. The effect of MP was more pronounced in the medical subgroup, with a CATE of -0.173 (95% CI: -0.197 to -0.143) determined through backdoor linear regression. Patients with cardio, respiratory, and infection diagnoses, who required long-term intubation, sustained higher impact on CATEs across various admission diagnoses. Our simulations showed that there is no single MP threshold that can be applied to all patients, as the optimal threshold varies depending on the patient's condition. CONCLUSION Our study underscores the importance of tailoring MP adjustments on an individualized basis in ventilator management. This approach opens up new avenues for personalized treatment strategies and provides fresh insights into the real-time impact of MP in diverse clinical scenarios. It highlights the significance of median MP while acknowledging the absence of universally applicable thresholds.
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Affiliation(s)
- ChaoPing Wu
- Critical Care, Integrated Hospital Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Arif Canakoglu
- Department of Anestesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Jacob Vine
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, Boston, MA, 02215, USA
| | - Anya Mathur
- Western Reserve Academy, 115 College St, Hudson, OH, 44236, USA
| | - Ronit Nath
- Computer Science, University of California, Berkeley, 387 Soda Hall, Berkeley, CA, 94720, USA
| | - Markos Kashiouris
- Critical Care, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Piyush Mathur
- Anesthesiology, Integrated Hospital Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ari Ercole
- Cambridge Center for Artificial Intelligence in Medicine., 3rd Floor University Centre, Granta Pl, Mill Lane, Cambridge, CB2 1RU, UK
- Cambridge University Hospitals, NHS Foundation Trust, Hills Road, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Paul Elbers
- Intensive Care Medicine, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands
| | - Abhijit Duggal
- Critical Care, Integrated Hospital Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ken Koon Wong
- Infectious Diseases, Integrated Hospital Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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28
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Xu M, Chi Y, Yuan S, Gao Y, Sun X, Long Y, He H. Gravitational distribution of regional intrapulmonary shunt assessed by EIT in ARDS. Respir Res 2025; 26:66. [PMID: 39987063 PMCID: PMC11847383 DOI: 10.1186/s12931-025-03141-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 02/06/2025] [Indexed: 02/24/2025] Open
Abstract
BACKGROUND Regional ventilation/perfusion (V/Q) mismatch in intrapulmonary shunt in dependent regions has always been considered a hallmark of ARDS. However, little is known about the spatial distribution of shunt, and a clear definition has been lacking. The aim of the study was to propose two phenotypes for the spatial distribution of intrapulmonary shunt using electrical impedance tomography (EIT) and to investigate the clinical characteristics and outcomes in the two preset phenotypes. METHODS A total of 76 ARDS patients who received EIT saline contrast examination were included in this retrospective study. Deadspace(%), Shunt(%), and V/Qmismatch(%) were calculated based on the lung V/Q matching map. EIT maps were divided into two horizontal anterior-to-posterior regions of interest, ranging from gravity-independent regions to gravity-dependent regions. The dosal shunt proportion (Shuntdosal/Shuntglobal%) was defined as the percentage of shunt in gravity-dependent regions. Based on Shuntdosal/Shuntglobal%, the patients were divided into a dependent-shunt group (D-shunt, Shuntdosal/Shuntglobal% > 50%) and a nondependent-shunt group (ND-shunt, Shuntdosal/Shuntglobal% ≤ 50%). RESULTS The D-shunt group (n = 46) had lower dorsal ventilation, lower dorsal deadspace, and a higher Shuntdosal/Shuntglobal% than the ND-shunt group (n = 30). Multivariable Cox regression analysis showed that Shuntdosal/Shuntglobal% was an independent predictive factor for 28-day mortality (HR = 0.06; 95% CI, 0.01-0.36; P = 0.002). There was no significant difference in regional perfusion distribution, global shunt, global deadspace and global V/Q mismatch between the two groups. Moreover, a higher BMI (25.4 [22.9, 29.2] vs. 22.9 [20.8, 26.4], P = 0.04) and more extrapulmonary ARDS patients [65% (30/46) vs. 33% (10/30), P = 0.01] were found in the D-shunt group. A similar PaO2/FiO2 ratio was found between the two groups on Day 0, but the D-shunt group had a higher PaO2/FiO2 ratio on Day 4. A higher 28-day mortality (40% vs. 17%, P = 0.03) and fewer ventilation-free days (VFDs) on day 28 (11.0 [0, 21.8] vs. 20.5 [4.8, 24.0], P = 0.04) were found in the ND-shunt group. CONCLUSION Two phenotypes of regional shunt gravitational distribution can be revealed by EIT. Patients exhibiting a predominance of dependent shunt were characterized by a higher BMI and extrapulmonary ARDS and may experience faster improvement in oxygenation as well as better clinical outcomes. Further research is necessary to evaluate shunt distribution patterns to guide the individualized treatment of ARDS patients.
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Affiliation(s)
- Mengru Xu
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyi Yuan
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yelin Gao
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaotong Sun
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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Alkhalifah AS, Rumindo K, Brincat E, Blanchard F, Helleberg J, Clarke D, Popoff B, Duranteau O, Mohamed ZU, Senosy A. Optimizing mechanical ventilation: Personalizing mechanical power to reduce ICU mortality - a retrospective cohort study. PLoS One 2025; 20:e0318018. [PMID: 39946423 PMCID: PMC11825045 DOI: 10.1371/journal.pone.0318018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 01/08/2025] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND Mechanical ventilation, a crucial intervention for acute respiratory distress syndrome (ARDS), can lead to ventilator-induced lung injury (VILI). This study focuses on individualizing mechanical power (MP) in mechanically ventilated patients to minimize VILI and reduce ICU mortality. METHODS A retrospective analysis was conducted using the Amsterdam University Medical Centers Database (AmsterdamUMCdb) data. The study included patients aged 18 and older who needed at least 48 hours of pressure-controlled mechanical ventilation. Patients who died or were extubated within 48 hours and those with inadequate data were excluded. Patients were categorized into hypoxemia groups based on their PaO2/FiO2 ratio. MP was calculated using a surrogate formula and normalized to ideal body weight (IBW). Statistical analyses and machine learning models, including logistic regression and random forest, were used to predict ICU mortality and establish safe upper limits for IBW-adjusted MP. RESULTS Out of 23,106 admissions, 2,338 met the criteria. Nonsurvivors had a significantly higher time-weighted average MP (TWA-MP) than survivors. Safe upper limits for IBW-adjusted MP varied across hypoxemia groups. The XGBoost model showed the highest predictive accuracy for ICU mortality. An individualization method for mechanical ventilation settings, based on real-time physiological variables, demonstrated reduced predicted mortality in a subset of patients. DISCUSSION Elevated TWA-MP is associated with increased ICU mortality, underscoring the need for personalized mechanical ventilation strategies. The study highlights the complexity of VILI and the multifactorial nature of ICU mortality. Further studies to define a safe upper limit for IBW-adjusted MP may help clinicians optimize mechanical ventilation settings and decrease the risk of VILI and mortality. CONCLUSIONS Despite the fact that the study's retrospective design and reliance on a single-center database may limit the generalizability of findings, this study offers valuable insights into the relationship between mechanical power and ICU mortality, emphasizing the need for individualized mechanical ventilation strategies. The findings suggest a potential for more personalized, data-driven approach in managing mechanically ventilated patients, which could improve patient outcomes in critical care settings.
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Affiliation(s)
| | - Kenny Rumindo
- Research & Development, Getinge Acute Care Therapies, Solna, Sweden
| | - Edgar Brincat
- Pediatric Intensive Care Unit, Royal Hospital for Children, Glasgow, United Kingdom
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Florian Blanchard
- Department of Anesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hôpital, Paris, France
| | - Johan Helleberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - David Clarke
- Oxford Critical Care, Oxford University Healthcare Trust, Oxford, United Kingdom
| | - Benjamin Popoff
- Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | - Olivier Duranteau
- Anesthesiology Department, Erasmus Hospital, Brussels, Belgium
- Intensive Care Unit, Hôpital d’instruction des Armées Percy, Clamart, France
| | - Zubair Umer Mohamed
- Adult Critical Care Unit, King Faisal Specialist Hospital and Research Centre, Madinah, Saudi Arabia
- Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Abdelrahman Senosy
- Adult Intensive Care Unit, Hayat National Hospital, Medina, Saudi Arabia
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Ghiani A, Walcher S, Lutfi A, Gernhold L, Feige SF, Neurohr C. Mechanical power density, spontaneous breathing indexes, and weaning readiness following prolonged mechanical ventilation. Respir Med 2025; 237:107943. [PMID: 39788438 DOI: 10.1016/j.rmed.2025.107943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 12/07/2024] [Accepted: 01/03/2025] [Indexed: 01/12/2025]
Abstract
INTRODUCTION Evidence suggests that mechanical power (MP) normalized to dynamic compliance, which equals power density, may help identify prolonged ventilated patients at risk for spontaneous breathing trial (SBT) failure. This study compared MP density with traditional spontaneous breathing indexes to predict a patient's capacity to sustain a short trial of unassisted breathing. METHODS A prospective observational study on 186 prolonged ventilated, tracheotomized patients. We analyzed the first 30-min SBT upon weaning center admission, comparing MP density with spontaneous breathing indexes (e.g., predicted body weight normalized tidal volume (VT/PBW), rapid shallow breathing index (RSBI), and the integrative weaning index (IWI)) regarding SBT failure prediction, with diagnostic accuracy expressed as the area under the receiver operating characteristic curve (AUROC). RESULTS SBT failure occurred in 51 out of 186 patients (27 %), who demonstrated significantly lower dynamic compliance (median 29 mL/cmH2O [IQR 26-37] vs. 39 mL/cmH2O [33-45]) and higher MP density (5837 cmH2O2/min [4512-7758] vs. 2922 cmH2O2/min [2001-4094]) before SBT, as well as lower spontaneous VT/PBW (5.7 mL∗kg-1 [5.0-6.7] vs. 6.6 mL∗kg-1 [5.9-7.8]), higher RSBI (73 min-1∗L-1 [57-100] vs. 59 min-1∗L-1 [45-76]), and lower IWI (40 L2/cmH2O∗%∗min∗10-3 [27-50] vs. 63 L2/cmH2O∗%∗min∗10-3 [46-91]) after 5 min of unassisted breathing. MP density was more accurate at predicting SBT failures (AUROC 0.86 [95%CI 0.80-0.91]) than VT/PBW (0.58 [0.50-0.65]), RSBI (0.54 [0.47-0.61]), or IWI (0.66 [0.58-0.73])). CONCLUSIONS MP density as a readiness criterion was more accurate at predicting weaning trial failures in prolonged ventilated, tracheotomized patients than traditional indexes assessed during unassisted breathing.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Swenja Walcher
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Azal Lutfi
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Lukas Gernhold
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Sven Fabian Feige
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany; Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Munich, Germany
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von Düring S, Parhar KKS, Adhikari NKJ, Urner M, Kim SJ, Munshi L, Liu K, Fan E. Understanding ventilator-induced lung injury: The role of mechanical power. J Crit Care 2025; 85:154902. [PMID: 39241350 DOI: 10.1016/j.jcrc.2024.154902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/31/2024] [Accepted: 08/24/2024] [Indexed: 09/09/2024]
Abstract
Mechanical ventilation stands as a life-saving intervention in the management of respiratory failure. However, it carries the risk of ventilator-induced lung injury. Despite the adoption of lung-protective ventilation strategies, including lower tidal volumes and pressure limitations, mortality rates remain high, leaving room for innovative approaches. The concept of mechanical power has emerged as a comprehensive metric encompassing key ventilator parameters associated with the genesis of ventilator-induced lung injury, including volume, pressure, flow, resistance, and respiratory rate. While numerous animal and human studies have linked mechanical power and ventilator-induced lung injury, its practical implementation at the bedside is hindered by calculation challenges, lack of equation consensus, and the absence of an optimal threshold. To overcome the constraints of measuring static respiratory parameters, dynamic mechanical power is proposed for all patients, regardless of their ventilation mode. However, establishing a causal relationship is crucial for its potential implementation, and requires further research. The objective of this review is to explore the role of mechanical power in ventilator-induced lung injury, its association with patient outcomes, and the challenges and potential benefits of implementing a ventilation strategy based on mechanical power.
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Affiliation(s)
- Stephan von Düring
- Division of Critical Care Medicine, Department of Acute Medicine, Geneva University Hospitals (HUG) and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology & Pain Medicine, University of Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
| | - S Joseph Kim
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of Nephrology, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada.
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Robba C, Giardiello D, Almondo C, Asehnoune K, Badenes R, Cinotti R, Elhadi M, Graziano F, Helbok R, Jiang L, Chen W, Laffey JG, Messina A, Putensen C, Schultz MJ, Wahlster S, Rebora P, Galimberti S, Taccone FS, Citerio G. Ventilation practices in acute brain injured patients and association with outcomes: the VENTIBRAIN multicenter observational study. Intensive Care Med 2025; 51:318-331. [PMID: 39992441 PMCID: PMC11903615 DOI: 10.1007/s00134-025-07808-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Accepted: 01/19/2025] [Indexed: 02/25/2025]
Abstract
PURPOSE Current mechanical ventilation practices for patients with acute brain injury (ABI) are poorly defined. This study aimed to describe ventilator settings/parameters used in intensive care units (ICUs) and evaluate their association with clinical outcomes in these patients. METHODS An international, prospective, multicenter, observational study was conducted across 74 ICUs in 26 countries, including adult patients with ABI (e.g., traumatic brain injury, intracranial hemorrhage, subarachnoid hemorrhage, and acute ischemic stroke), who required ICU admission and invasive mechanical ventilation. Ventilatory settings were recorded daily during the first week and on days 10 and 14. ICU and 6-months mortality and 6-months neurological outcome were evaluated. RESULTS On admission, 2095 recruited patients (median age 58 [interquartile range 45-70] years, 66.1% male) had a median plateau pressure (Pplat) of 15 (13-18) cmH20, tidal volume/predicted body weight 6.5 (5.7-7.3) mL/Kg, driving pressure 9 (7-12) cmH20, and positive end-expiratory pressure 5 (5-8) cmH20, with no modifications in case of increased intracranial pressure (> 20 mmHg). Significant differences in practices were observed across different countries. The majority of these ventilatory settings were associated with ICU mortality, with the highest hazard ratio (HR) for Pplat (odds ratio 1.50; 95% confidence interval, CI: 1.27-1.78). The results demonstrated consistent association with 6-month mortality; less clear association was observed for neurological outcome. CONCLUSIONS Protective ventilation strategies are commonly used in ABI patients but with high variability across different countries. Ventilator settings during ICU stay were associated with an increased risk of ICU and 6-month mortality, but not an unfavorable neurological outcome.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy.
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Daniele Giardiello
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Chiara Almondo
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
| | | | - Francesca Graziano
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lidan Jiang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Wenjin Chen
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, University Hospital Galway, University of Galway, Galway, Ireland
| | - Antonio Messina
- Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Marcus J Schultz
- Department of Clinical Medicine, University of Oxford Nuffield, Oxford, UK
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Sarah Wahlster
- Departments of Neurology, Neurosurgery, and Anesthesiology, University of Washington, Seattle, USA
| | - Paola Rebora
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italia
| | - Stefania Galimberti
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italia
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italia
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Tschernko E, Geilen J, Wasserscheid T. The role of extracorporeal membrane oxygenation in thoracic anesthesia. Curr Opin Anaesthesiol 2025; 38:71-79. [PMID: 39670625 DOI: 10.1097/aco.0000000000001450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2024]
Abstract
PURPOSE OF REVIEW Circulatory and respiratory support with extracorporeal membrane oxygenation (ECMO) has gained widespread acceptance during high-end thoracic surgery. The purpose of this review is to summarize the recent knowledge and give an outlook for future developments. RECENT FINDINGS A personalized approach of ECMO use is state of the art for monitoring during surgery. Personalization is increasingly applied during anesthesia for high-end surgery nowadays. This is reflected in the point of care testing (POCT) for anticoagulation and cardiac function during surgery on ECMO combining specific patient data into tailored algorithms. For optimizing protective ventilation MP (mechanical power) is a promising parameter for the future. These personalized methods incorporating numerous patient data are promising for the improvement of morbidity and mortality in high-end thoracic surgery. However, clinical data supporting improvement are not available to date but can be awaited in the future. SUMMARY Clinical practice during surgery on ECMO is increasingly personalized. The effect of personalization on morbidity and mortality must be examined in the future. Undoubtedly, an increase in knowledge can be expected from this trend towards personalization.
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Affiliation(s)
- Edda Tschernko
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University Vienna, Vienna, Austria
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Chiu LC, Li HH, Juan YH, Ko HW, Kuo SCH, Lee CS, Chan TM, Lin YJ, Chuang LP, Hu HC, Kao KC, Hsu PC. Ventilatory variables and computed tomography features in COVID-19 ARDS and non-COVID-19-related ARDS: a prospective observational cohort study. Eur J Med Res 2025; 30:57. [PMID: 39875972 PMCID: PMC11773838 DOI: 10.1186/s40001-025-02303-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 01/16/2025] [Indexed: 01/30/2025] Open
Abstract
BACKGROUND This study compared the ventilatory variables and computed tomography (CT) features of patients with coronavirus disease 2019 (COVID-19) versus those of patients with pulmonary non-COVID-19-related acute respiratory distress syndrome (ARDS) during the early phase of ARDS. METHODS This prospective, observational cohort study of ARDS patients in Taiwan was performed between February 2017 and June 2018 as well as between October 2020 and January 2024. Analysis was performed on clinical characteristics, including consecutive ventilatory variables during the first week after ARDS diagnosis. Analysis was also performed on CT scans obtained within one week after ARDS onset. RESULTS A total of 222 ARDS patients were divided into a COVID-19 ARDS group (n = 44; 19.8%) and a non-COVID-19 group (all pulmonary origin) (n = 178; 80.2%). No significant difference was observed between the two groups in terms of all-cause hospital mortality (38.6% versus 47.8%, p = 0.277). Pulmonary non-COVID-19 patients presented higher values for mechanical power (MP), MP normalized to predicted body weight (MP/PBW), MP normalized to compliance (MP/compliance), ventilatory ratio (VR), peak inspiratory pressure (Ppeak), and dynamic driving pressure (∆P) as well as lower dynamic compliance from day 1 to day 7 after ARDS onset. In both groups, non-survivors exceeded survivors and presented higher values for MP, MP/PBW, MP/compliance, VR, Ppeak, and dynamic ∆P with lower dynamic compliance from day 1 to day 7 after ARDS onset. The CT severity score for each of the five lung lobes and total CT scores were all significantly higher in the non-COVID-19 group (all p < 0.05). Multivariable logistic regression models revealed that Sequential Organ Failure Assessment (SOFA) score was independently associated with mortality in the COVID-19 group. In the non-COVID-19 group, body mass index, immunocompromised status, SOFA score, MP/PBW and total CT severity scores were independently associated with mortality. CONCLUSIONS In the early course of ARDS, physicians should be aware of the distinctions between COVID-19-related ARDS and non-COVID-19-related ARDS in terms of ventilatory variables and CT imaging presentations. It is also important to tailor the mechanical ventilation settings according to these distinct subsets of ARDS.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Hsien Li
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Hsiang Juan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Imaging and Intervention, Institute for Radiological Research, Chang Gung Memorial Hospital at Linkou and Taoyuan, Chang Gung University, Taoyuan, Taiwan
| | - How-Wen Ko
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Scott Chih-Hsi Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Shu Lee
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Tien-Ming Chan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Yu-Jr Lin
- Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
| | - Li-Pang Chuang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ping-Chih Hsu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Chang KW, Leu SW, Hu HC, Chan MC, Liang SJ, Yang KY, Chiu LC, Fang WF, Sheu CC, Chien YC, Peng CK, Huang CT, Kao KC. The Mechanical Power in Patients with Acute Respiratory Distress Syndrome Undergoing Prone Positioning Can Predict Mortality. Diagnostics (Basel) 2025; 15:158. [PMID: 39857042 PMCID: PMC11763726 DOI: 10.3390/diagnostics15020158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Revised: 12/29/2024] [Accepted: 01/10/2025] [Indexed: 01/27/2025] Open
Abstract
Background/Objectives: Mechanical power (MP) refers to ventilator-delivered energy to the lungs, which may induce lung injury. We examined the relationship between MP and mortality in patients with acute respiratory distress syndrome (ARDS) who underwent prone positioning. Methods: This multicenter retrospective study included data on all patients admitted to the intensive care units of eight referral hospitals in Taiwan from October 2015 to March 2016, and in Chang Gung Memorial Hospital Linkou branch from January 2017 to October 2023. The data were obtained from the electronic medical records of each hospital by using a standard case report form. MP was calculated as follows: MP (J/min) = 0.098 × VT × RR × (Ppeak - 1/2 × ΔP). Results: We included 135 patients who underwent prone positioning. Among them, 28-day survivors had significantly lower MP (22.6 ± 6.5 vs. 25.3 ± 6.2 J/min, p = 0.024), MP/predicted body weight (PBW) (396.9 ± 118.9 vs. 449.3 ± 118.8 10-3 J/min/kg, p = 0.018), MP/compliance values (0.8 ± 0.3 vs. 1.1 ± 0.4 J/min/mL/cmH2O, p = 0.048) after prone positioning, and significantly lower changes in MP, MP/PBW, and MP/compliance (-0.6 ± 5.7 vs. 2.5 ± 7.4 J/min, p = 0.007; -9.2 ± 97.5 vs. 42.1 ± 127.9 10-3 J/min/kg, p = 0.010; -0.1 ± 0.3 vs. 0.2 ± 0.3 J/min/mL/cmH2O, p < 0.001, respectively). Multivariate Cox regression revealed that the change in MP/compliance (HR: 7.972, p < 0.001) was an independent predictive factor for 28-day mortality. Conclusions: In ARDS patients treated with prone positioning, MP/compliance, and change in MP, MP/PBW, and MP/compliance after prone positioning differed significantly between 28-day survivors and nonsurvivors. Further randomized controlled research is required to elucidate the potential causality of decreased MP and improved clinical outcomes.
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Affiliation(s)
- Ko-Wei Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-W.C.); (S.-W.L.); (H.-C.H.); (L.-C.C.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- School of Medicine, National Tsing Hua University, Hsinchu 300, Taiwan
| | - Shaw-Woei Leu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-W.C.); (S.-W.L.); (H.-C.H.); (L.-C.C.)
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-W.C.); (S.-W.L.); (H.-C.H.); (L.-C.C.)
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan;
- College of Science, Tunghai University, Taichung 407, Taiwan
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan;
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan;
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei 112, Taiwan
| | - Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-W.C.); (S.-W.L.); (H.-C.H.); (L.-C.C.)
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan;
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan;
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Ying-Chun Chien
- Division of Chest Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Ching-Tzu Huang
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (K.-W.C.); (S.-W.L.); (H.-C.H.); (L.-C.C.)
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
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Liu HJ, Lin Y, Li W, Yang H, Kang WY, Guo PL, Guo XH, Cheng NN, Tan JC, He YN, Chen SS, Mu Y, Liu XW, Zhang H, Chen MF. Clinical practice of one-lung ventilation in mainland China: a nationwide questionnaire survey. BMC Anesthesiol 2025; 25:7. [PMID: 39773104 PMCID: PMC11706103 DOI: 10.1186/s12871-024-02879-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2024] [Accepted: 12/25/2024] [Indexed: 01/11/2025] Open
Abstract
BACKGROUND Limited information is available regarding the application of lung-protective ventilation strategies during one-lung ventilation (OLV) across mainland China. A nationwide questionnaire survey was conducted to investigate this issue in current clinical practice. METHODS The survey covered various aspects, including respondent demographics, the establishment and maintenance of OLV, intraoperative monitoring standards, and complications associated with OLV. RESULTS Five hundred forty-three valid responses were collected from all provinces in mainland China. Volume control ventilation mode, 4 to 6 mL per kilogram of predictive body weight, pure oxygen inspiration, and a low-level positive end-expiratory pressure ≤ 5 cm H2O were the most popular ventilation parameters. The most common thresholds of intraoperative respiration monitoring were peripheral oxygen saturation (SpO2) of 90-94%, end-tidal CO2 of 45 to 55 mm Hg, and an airway pressure of 30 to 34 cm H2O. Recruitment maneuvers were traditionally performed by 94% of the respondents. Intraoperative hypoxemia and laryngeal injury were experienced by 75% and 51% of the respondents, respectively. The proportions of anesthesiologists who frequently experienced hypoxemia during OLV were 19%, 24%, and 7% for lung, cardiovascular, and esophageal surgeries, respectively. Up to 32% of respondents were reluctant to perform lung-protective ventilation strategies during OLV. Multiple regression analysis revealed that the volume-control ventilation mode and an SpO2 intervention threshold of < 85% were independent risk factors for hypoxemia during OLV in lung and cardiovascular surgeries. In esophageal surgery, working in a tier 2 hospital and using traditional ventilation strategies were independent risk factors for hypoxemia during OLV. Subgroup analysis revealed no significant difference in intraoperative hypoxemia during OLV between respondents who performed lung-protective ventilation strategies and those who did not. CONCLUSIONS Lung-protective ventilation strategies during OLV have been widely accepted in mainland China and are strongly recommended for esophageal surgery, particularly in tier 2 hospitals. Implementing volume control ventilation mode and early management of oxygen desaturation might prevent hypoxemia during OLV.
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Affiliation(s)
- Hong-Jin Liu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, Fujian, 350001, PR China
| | - Yong Lin
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, Fujian, 350001, PR China
| | - Wang Li
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Hai Yang
- Department of Anesthesiology, The First People's Hospital of Yulin, Yulin, China
| | - Wen-Yue Kang
- Department of Anesthesiology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Pei-Lei Guo
- Department of Anesthesiology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao-Hui Guo
- Department of Anesthesia and Surgery, The Third People's Hospital of Henan Province, Zhengzhou, China
| | - Ning-Ning Cheng
- Department of Anesthesiology, Binzhou People's Hospital, Binzhou, China
| | - Jie-Chao Tan
- Department of Anesthesiology, Shunde Hospital of South Medical University, Foshan, China
| | - Yi-Na He
- Department of Anesthesiology, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Sichuan, Nanchong, China
| | - Si-Si Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yan Mu
- Department of Anesthesiology, The Second Central Hospital of Baoding, Baoding, China
| | - Xian-Wen Liu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Hui Zhang
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, Fujian, 350001, PR China.
| | - Mei-Fang Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, Fujian, 350001, PR China.
- Department of Physical Examination Center, Fujian Medical University Union Hospital, Xinquan Road 29, Fuzhou, Fujian, 350001, PR China.
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Tonetti T, Marini JJ. Mechanical power and VILI: modeling limits and unknowns. Intensive Care Med Exp 2025; 13:1. [PMID: 39760961 PMCID: PMC11704099 DOI: 10.1186/s40635-024-00712-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 12/27/2024] [Indexed: 01/07/2025] Open
Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, St Paul, Minneapolis, MN, USA
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Paternoster G, Bertini P, Sangalli F, Scolletta S. Awake veno-venous extracorporeal membrane oxygenation: practical aspects and considerations. Minerva Anestesiol 2025; 91:92-100. [PMID: 39656144 DOI: 10.23736/s0375-9393.24.18228-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2025]
Abstract
Veno-venous extracorporeal membrane oxygenation (ECMO) is a life-saving technique in the armamentarium of critical care medicine. It involves extracorporeal blood circulation outside the body, providing temporary respiratory support while allowing the lungs to heal. Traditionally, patients undergoing ECMO require sedation to minimize discomfort and facilitate mechanical ventilation. The "awake ECMO" concept emerged as a promising strategy to mitigate sedation-related complications and facilitate early mobilization in critically ill patients. In this article, we describe the potential advantages of awake ECMO and its role in preserving respiratory muscle function, enhancing rehabilitation prospects, and improving patient outcomes.
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Affiliation(s)
- Gianluca Paternoster
- Department of Health Science Anesthesia and ICU, School of Medicine, San Carlo Hospital, University of Basilicata, Potenza, Italy -
| | - Pietro Bertini
- Department of Anesthesia and Intensive Care, Casa di Cura San Rossore, Pisa, Italy
| | - Fabio Sangalli
- Department of Anesthesia and Intensive Care, ASST Valtellina e Alto Lario, University of Milano-Bicocca, Sondrio, Italy
| | - Sabino Scolletta
- Department of Medical Science, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Siena, Italy
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Wallbank A, Sosa A, Colson A, Farooqi H, Kaye E, Warner K, Albers DJ, Sottile PD, Smith BJ. Dynamic driving pressure predicts ventilator-induced lung injury in mice with and without endotoxin-induced acute lung injury. Am J Physiol Lung Cell Mol Physiol 2025; 328:L159-L175. [PMID: 39601347 DOI: 10.1152/ajplung.00176.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 11/13/2024] [Accepted: 11/14/2024] [Indexed: 11/29/2024] Open
Abstract
Mechanical ventilation (MV) is a necessary lifesaving intervention for patients with acute respiratory distress syndrome (ARDS) but it can cause ventilator-induced lung injury (VILI), which contributes to the high ARDS mortality rate (∼40%). Bedside determination of optimally lung-protective ventilation settings is challenging because the evolution of VILI is not immediately reflected in clinically available, patient-level, data. The goal of this work was therefore to test ventilation waveform-derived parameters that represent the degree of ongoing VILI and can serve as targets for ventilator adjustments. VILI was generated at three different positive end-expiratory pressures in a murine inflammation-mediated (lipopolysaccharide, LPS) acute lung injury model and in initially healthy controls. LPS injury increased the expression of proinflammatory cytokines and caused widespread atelectasis, predisposing the lungs to VILI as measured in structure, mechanical function, and inflammation. Changes in lung function were used as response variables in an elastic net regression model that predicted VILI severity from tidal volume, dynamic driving pressure (PDDyn), mechanical power calculated by integration during inspiration or the entire respiratory cycle, and power calculated according to Gattinoni' s equation. Of these, PDDyn best predicted functional outcomes of injury using either data from the entire dataset or from 5-min time windows. The windowed data show higher predictive accuracy after an ∼1-h "run in" period and worse accuracy immediately following recruitment maneuvers. This analysis shows that low driving pressure is a computational biomarker associated with better experimental VILI outcomes and supports the use of driving pressure to guide ventilator adjustments to prevent VILI.NEW & NOTEWORTHY Elastic net regression analysis of ventilation waveforms recorded during mechanical ventilation of initially healthy and lung-injured mice shows that low driving pressure is a computational biomarker associated with better ventilator-induced lung injury (VILI) outcomes and supports the use of driving pressure to guide ventilator adjustments to prevent VILI.
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Affiliation(s)
- Alison Wallbank
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Alexander Sosa
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Andrew Colson
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Huda Farooqi
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Elizabeth Kaye
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Katharine Warner
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - David J Albers
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Biomedical Informatics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Aurora, Colorado, United States
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States
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40
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González-Castro A, Fajardo Campoverdi A. From geometric equations to dynamic strategies: advances in the personalization of mechanical ventilation through mechanical power. Med Intensiva 2025; 49:59-60. [PMID: 39567348 DOI: 10.1016/j.medine.2024.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Revised: 10/06/2024] [Accepted: 10/08/2024] [Indexed: 11/22/2024]
Affiliation(s)
- Alejandro González-Castro
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Spain; Grupo Internacional de Ventilación Mecánica, WeVent, Spain.
| | - Aurio Fajardo Campoverdi
- Critical Care Unit, Hospital Biprovincial Quillota-Petorca, Chile; Grupo Internacional de Ventilación Mecánica, WeVent, Spain
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Kingsley J, Kandil O, Satalin J, Bary AA, Coyle S, Nawar MS, Groom R, Farrag A, Shah J, Robedee BR, Darling E, Shawkat A, Chaudhuri D, Nieman GF, Aiash H. The use of protective mechanical ventilation during extracorporeal membrane oxygenation for the treatment of acute respiratory failure. Perfusion 2025; 40:69-82. [PMID: 38240747 DOI: 10.1177/02676591241227167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
Abstract
Acute respiratory failure (ARF) strikes an estimated two million people in the United States each year, with care exceeding US$50 billion. The hallmark of ARF is a heterogeneous injury, with normal tissue intermingled with a large volume of low compliance and collapsed tissue. Mechanical ventilation is necessary to oxygenate and ventilate patients with ARF, but if set inappropriately, it can cause an unintended ventilator-induced lung injury (VILI). The mechanism of VILI is believed to be overdistension of the remaining normal tissue known as the 'baby' lung, causing volutrauma, repetitive collapse and reopening of lung tissue with each breath, causing atelectrauma, and inflammation secondary to this mechanical damage, causing biotrauma. To avoid VILI, extracorporeal membrane oxygenation (ECMO) can temporally replace the pulmonary function of gas exchange without requiring high tidal volumes (VT) or airway pressures. In theory, the lower VT and airway pressure will minimize all three VILI mechanisms, allowing the lung to 'rest' and heal in the collapsed state. The optimal method of mechanical ventilation for the patient on ECMO is unknown. The ARDSNetwork Acute Respiratory Management Approach (ARMA) is a Rest Lung Approach (RLA) that attempts to reduce the excessive stress and strain on the remaining normal lung tissue and buys time for the lung to heal in the collapsed state. Theoretically, excessive tissue stress and strain can also be avoided if the lung is fully open, as long as the alveolar re-collapse is prevented during expiration, an approach known as the Open Lung Approach (OLA). A third lung-protective strategy is the Stabilize Lung Approach (SLA), in which the lung is initially stabilized and gradually reopened over time. This review will analyze the physiologic efficacy and pathophysiologic potential of the above lung-protective approaches.
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Affiliation(s)
| | | | | | - Akram Abdel Bary
- Critical Care Department, Faculty of Medicine Cairo University, Cairo, Egypt
| | - Sierra Coyle
- SUNY Upstate Medical University, Syracuse, NY, USA
| | - Mahmoud Saad Nawar
- Critical Care Department, Faculty of Medicine Cairo University, Cairo, Egypt
| | - Robert Groom
- SUNY Upstate Medical University, Syracuse, NY, USA
| | - Amr Farrag
- Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | | | | | | | | | | | | | - Hani Aiash
- SUNY Upstate Medical University, Syracuse, NY, USA
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Pearson-Lemme J, Halibullah I, Becher T, Tingay HD, Douglas E, Fatmous M, Kenna KR, Pereira-Fantini PM, Tingay DG, Sett A. Mechanical power made simple: validating a simplified calculation of mechanical power in preterm lungs. Pediatr Res 2025; 97:178-183. [PMID: 38886507 PMCID: PMC11798860 DOI: 10.1038/s41390-024-03339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/15/2024] [Accepted: 06/04/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The incidence of chronic lung disease is increasing, suggesting a need to explore novel ways to understand ventilator induced lung injury (VILI) in preterm infants. Mechanical power (MP) is a unifying measure of energy transferred to the respiratory system and a proposed determinant of VILI. The gold-standard method for calculating MP (geometric method) is not feasible in the clinical setting. This has prompted the derivation of simplified equations for calculating MP. OBJECTIVE To validate the agreement between a simplified calculation of MP (MPSimple) and the true MP calculated using the geometric method (MPRef). METHODS MPSimple and MPRef was calculated in mechanically ventilated preterm lambs (n = 71) and the agreement between both measures was determined using intraclass correlation coefficients (ICC), linear regression, and Bland-Altman analysis. RESULTS A strong linear relationship (adjusted R2 = 0.98), and excellent agreement (ICC = 0.99, 95% CI = 0.98-0.99) between MPSimple and MPRef was demonstrated. Bland-Altman analysis demonstrated a negligible positive bias (mean difference = 0.131 J/min·kg). The 95% limits of agreement were -0.06 to 0.32 J/min·kg. CONCLUSIONS In a controlled setting, there was excellent agreement between MPSimple and gold-standard calculations. MPSimple should be validated and explored in preterm neonates to assess the cause-effect relationship with VILI and neonatal outcomes. IMPACT STATEMENT Mechanical power (MP) unifies the individual components of ventilator induced lung injury (VILI) and provides an estimate of total energy transferred to the respiratory system during mechanical ventilation. As gold-standard calculations of mechanical power at the bedside are not feasible, alternative simplified equations have been proposed. In this study, MP calculated using a simplified equation had excellent agreement with true MP in mechanically ventilated preterm lambs. These results lay foundations to explore the role of MP in neonatal VILI and determine its relationship with short and long term respiratory outcomes.
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Affiliation(s)
- Jack Pearson-Lemme
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Newborn Services, Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ikhwan Halibullah
- Newborn Services, Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tobias Becher
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Schleswig-Holstein, Germany
| | - Hamish D Tingay
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ellen Douglas
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Monique Fatmous
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Kelly R Kenna
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Prue M Pereira-Fantini
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David G Tingay
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Arun Sett
- Newborn Services, Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, VIC, Australia.
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Melbourne, Victoria, Australia.
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Monet C, Renault T, Aarab Y, Pensier J, Prades A, Lakbar I, Le Bihan C, Capdevila M, De Jong A, Molinari N, Jaber S. Feasibility and safety of ultra-low volume ventilation (≤ 3 ml/kg) combined with extra corporeal carbon dioxide removal (ECCO 2R) in acute respiratory failure patients. Crit Care 2024; 28:433. [PMID: 39731126 PMCID: PMC11674201 DOI: 10.1186/s13054-024-05168-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Accepted: 11/11/2024] [Indexed: 12/29/2024] Open
Abstract
BACKGROUND Ultra-protective ventilation is the combination of low airway pressures and tidal volume (Vt) combined with extra corporeal carbon dioxide removal (ECCO2R). A recent large study showed no benefit of ultra-protective ventilation compared to standard ventilation in ARDS (Acute Respiratory Distress Syndrome) patients. However, the reduction in Vt failed to achieve the objective of less than or equal to 3 ml/kg predicted body weight (PBW). The main objective of our study was to assess the feasibility of the ultra-low volume ventilation (Vt ≤ 3 ml/kg PBW) facilitated by ECCO2R in acute respiratory failure patients. METHODS Retrospective analysis of a prospective cohort of patients with either high or low blood flow veno-venous ECCO2R devices. A session was defined as a treatment of ECCO2R from the start to the removal of the device (one patient could have one more than one session). Primary endpoint was the proportion of sessions during which a Vt less or equal to 3 ml/kg PBW at 24 h after the start of ECCO2R was successfully achieved for at least 12 h. Secondary endpoints were respiratory variables, rate of adverse events and outcomes. RESULTS Forty-five ECCO2R sessions were recorded among 41 patients. Ultra-low volume ventilation (tidal volume ≤ 3 ml/kg PBW, success group) was successfully achieved at 24 h in 40.0% sessions (18 out of 45 sessions, confidence interval 25.3-54.6%). At 24 h, tidal volume in the failure group was 4.1 [3.8-4.5] ml/kg PBW compared to 2.1 [1.9-2.5] in the success group (p < 0.001). After multivariate analysis, blood flow rate was significantly associated with success of ultra-low volume ventilation (adjusted OR per 100 ml/min increase 1.51 (95%CI 1.21-1.90, p = 0.0003). CONCLUSION Ultra-low volume ventilation (≤ 3 ml/kg PBW) was feasible in 18 out of 45 sessions. Higher blood flow rates were associated with the success of ultra-low volume ventilation.
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Affiliation(s)
- Clément Monet
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
- PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier, France
| | - Thomas Renault
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
| | - Yassir Aarab
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
- PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier, France
| | - Joris Pensier
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
- PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier, France
| | - Albert Prades
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
| | - Ines Lakbar
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
- PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier, France
| | - Clément Le Bihan
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
| | - Mathieu Capdevila
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France
- PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier, France
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France.
- PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier, France.
| | - Nicolas Molinari
- Medical Information, IMAG, CNRS, Centre Hospitalier Regional Universitaire de Montpellier, Univ Montpellier, Montpellier, France
- Département d'informatique Médicale, CHRU Montpellier, Institut Desbrest de Santé Publique (IDESP) INSERM, Université de Montpellier, Montpellier, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier Cedex 5, France.
- PhyMedExp, INSERM U1046, CNRS UMR, University of Montpellier, 9214, Montpellier, France.
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44
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Fabry B. How to minimize mechanical power during controlled mechanical ventilation. Intensive Care Med Exp 2024; 12:114. [PMID: 39652195 PMCID: PMC11628461 DOI: 10.1186/s40635-024-00699-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Accepted: 11/26/2024] [Indexed: 12/12/2024] Open
Abstract
High intrapulmonary pressures, large tidal volumes, and elevated respiratory rates during controlled mechanical ventilation can lead to barotrauma, volutrauma, and atelectrauma. Mechanical power-defined as the product of the pressure-volume integral and respiratory rate-consolidates these three risk factors into a single, intuitive parameter. Several studies have demonstrated that higher mechanical power correlates with an increased risk of lung injury and mortality, prompting the suggestion that mechanical power should be minimized. However, under the constraint of maintaining a fixed alveolar minute ventilation and positive end-expiratory pressure (PEEP), it remains unclear how to adjust respiratory rate and tidal volume to minimize mechanical power. This study provides an analytical solution to this optimization problem. Accordingly, only the elastic component of mechanical power should be targeted for minimization. Regardless of lung elastance or resistance, or the mode and settings of the ventilator, the elastic power is minimized at a tidal volume equal to twice the anatomic dead space, or approximately 4.4 ml/kg of body weight.
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Affiliation(s)
- Ben Fabry
- Department of Physics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.
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45
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Giosa L, Collins PD, Shetty S, Lubian M, Del Signore R, Chioccola M, Pugliese F, Camporota L. Bedside Assessment of the Respiratory System During Invasive Mechanical Ventilation. J Clin Med 2024; 13:7456. [PMID: 39685913 DOI: 10.3390/jcm13237456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2024] [Revised: 11/21/2024] [Accepted: 11/28/2024] [Indexed: 12/18/2024] Open
Abstract
Assessing the respiratory system of a patient receiving mechanical ventilation is complex. We provide an overview of an approach at the bedside underpinned by physiology. We discuss the importance of distinguishing between extensive and intensive ventilatory variables. We outline methods to evaluate both passive patients and those making spontaneous respiratory efforts during assisted ventilation. We believe a comprehensive assessment can influence setting mechanical ventilatory support to achieve lung and diaphragm protective ventilation.
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Affiliation(s)
- Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
- Center for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London WC2R 2LS, UK
| | - Patrick D Collins
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
- Center for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London WC2R 2LS, UK
| | - Sridevi Shetty
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Marta Lubian
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Riccardo Del Signore
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Mara Chioccola
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Francesca Pugliese
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
- Center for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London WC2R 2LS, UK
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46
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Percy AG, Keim G, Bhalla AK, Yehya N. Mechanical Power in Decelerating Flow versus Square Flow Ventilation in Pediatric Acute Respiratory Distress Syndrome. Anesthesiology 2024; 141:1095-1104. [PMID: 39190682 PMCID: PMC11560697 DOI: 10.1097/aln.0000000000005209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Mechanical power is a summary variable quantifying the risk of ventilator-induced lung injury. The original mechanical power equation was developed using square flow ventilation. However, most children are ventilated using decelerating flow. It is unclear whether mechanical power differs according to mode of flow delivery. This study compared mechanical power in children with acute respiratory distress syndrome who received both square and decelerating flow ventilation. METHODS This was a secondary analysis of a prospectively enrolled cohort of pediatric acute respiratory distress syndrome. Patients were ventilated on decelerating flow and then placed in square flow and allowed to stabilize. Ventilator metrics from both modes were collected within 24 h of acute respiratory distress syndrome onset. Paired t tests were used to compare differences in mechanical power between the modes. RESULTS This study enrolled 185 subjects with a median oxygenation index of 9.5 (interquartile range, 7 to 13) and median age of 8.3 yr (interquartile range, 1.8 to 14). Mechanical power was lower in square flow mode (mean, 0.46 J · min-1 · kg-1; SD, 0.25; 95% CI, 0.42 to 0.50) than in decelerating flow mode (mean, 0.49 J · min-1 · kg-1; SD, 0.28; 95% CI, 0.45 to 0.53) with a mean difference of 0.03 J · min-1 · kg-1 (SD, 0.08; 95% CI, 0.014 to 0.038; P < 0.001). This result remained statistically significant when stratified by age of less than 2 yr in square flow compared to decelerating flow and also when stratified by age of 2 yr or greater in square flow compared to decelerating flow. The elastic contribution in square flow was 70%, and the resistive contribution was 30%. CONCLUSIONS Mechanical power was marginally lower in square flow than in decelerating flow, although the clinical significance of this is unclear. Upward of 30% of mechanical power may go toward overcoming resistance, regardless of age. This is nearly three-fold greater resistance compared to what has been reported in adults. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Andrew G Percy
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Anoopindar K Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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47
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Greendyk R, Abrams D, Agerstrand C, Parekh M, Brodie D. Extracorporeal Support for Acute Respiratory Distress Syndrome. Clin Chest Med 2024; 45:905-916. [PMID: 39443007 DOI: 10.1016/j.ccm.2024.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2024]
Abstract
Extracorporeal life support (ECLS) has a long history in the management of the acute respiratory distress syndrome (ARDS). The objectives of this review are to summarize the rationale and evidence for ECLS in ARDS including its role in reducing ventilator-induced lung injury (VILI), suggest best practice management strategies during ECLS, and identify areas that require additional research to better inform patient care.
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Affiliation(s)
- Richard Greendyk
- Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons, 622 W168th Street, PH 8E, 101, New York, NY 10032, USA
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons, 622 W168th Street, PH 8E, 101, New York, NY 10032, USA.
| | - Cara Agerstrand
- Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons, 622 W168th Street, PH 8E, 101, New York, NY 10032, USA
| | - Madhavi Parekh
- Division of Pulmonary, Allergy and Critical Care, Columbia University College of Physicians and Surgeons, 622 W168th Street, PH 8E, 101, New York, NY 10032, USA
| | - Daniel Brodie
- Division of Pulmonary & Critical Care Medicine, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 5000, Baltimore, MD 21205, USA
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48
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Goedegebuur J, Smits FE, Snoep JWM, Rietveld PJ, van der Velde F, de Jonge E, Schoe A. Mechanical Power Is Associated With Mortality in Pressure-Controlled Ventilated Patients: A Dutch, Single-Center Cohort Study. Crit Care Explor 2024; 6:e1190. [PMID: 39699550 DOI: 10.1097/cce.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2024] Open
Abstract
IMPORTANCE Mechanical power (MP) could serve as a valuable parameter in clinical practice to estimate the likelihood of adverse outcomes. However, the safety thresholds for MP in mechanical ventilation remain underexplored and contentious. OBJECTIVES This study aims to investigate the association between MP and hospital mortality across varying degrees of lung disease severity, classified by Pao2/Fio2 ratios. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study using automatically extracted data. Patients admitted to the ICU of a tertiary referral hospital in The Netherlands between 2018 and 2024 and ventilated in pressure-controlled mode were included. MAIN OUTCOMES AND MEASURES Logistic regression, adjusted for age, sex, Acute Physiology and Chronic Health Evaluation-IV score, and Pao2/Fio2 ratio, was used to calculate the odds ratio (OR) for all-cause in-hospital mortality. RESULTS A total of 2184 patients were analyzed, with a mean age of 62.5 ± 13.8 years, of whom 1508 (70.2%) were male. The mean MP was highest in patients with the lowest Pao2/Fio2 ratios (21.5 ± 6.5 J/min) compared with those with the highest ratios (12.0 ± 3.8 J/min; p < 0.001). Adjusted analyses revealed that increased MP was associated with higher mortality (OR, 1.06; 95% CI, 1.03-1.09 per J/min increase). Similarly, MP normalized for body weight showed a stronger association with mortality (OR, 1.004; 95% CI, 1.002-1.006 per J/min/kg increase). An increase in mortality was seen when MP exceeded 16-18 J/min. CONCLUSIONS AND RELEVANCE Our findings demonstrate a significant association between MP and hospital mortality, even after adjusting for key confounders. Mortality increases notably when MP exceeds 16-18 J/min. Normalized MP presents an even stronger association with mortality. These results underscore the need for further research into ventilation strategies that consider MP adjustments.
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Affiliation(s)
- Jamilla Goedegebuur
- Department of Thrombosis and Hemostastis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Floor E Smits
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jacob W M Snoep
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Petra J Rietveld
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Abraham Schoe
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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49
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Ter Horst J, Rimensberger PC, Kneyber MCJ. What every paediatrician needs to know about mechanical ventilation. Eur J Pediatr 2024; 183:5063-5070. [PMID: 39349751 PMCID: PMC11527898 DOI: 10.1007/s00431-024-05793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 09/16/2024] [Accepted: 09/20/2024] [Indexed: 11/01/2024]
Abstract
Invasive mechanical ventilation (MV) is one of the most practiced interventions in the intensive care unit (ICU) and is unmistakably lifesaving for children with acute respiratory failure (ARF). However, if delivered inappropriately (i.e. ignoring the respiratory system mechanics and not targeted to the need of the individual patient at a specific time point in the disease trajectory), the side effects will outweigh the benefits. Decades of experimental and clinical investigations have resulted in a better understanding of three important detrimental effects of MV. These are ventilation-induced lung injury (VILI), patient self-inflicted lung injury (P-SILI), and ventilation-induced diaphragmatic injury (VIDD). VILI, P-SILI, and VIDD have in common that they occur when there is either too much or too little ventilatory assistance.Conclusion: The purpose of this review is to give the paediatrician an overview of the challenges to prevent these detrimental effects and titrate MV to the individual patient needs.
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Affiliation(s)
- Jeroen Ter Horst
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, University of Geneva, Geneva, Switzerland
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA62, P.O. Box 30.001, 9700 RB, Groningen, the Netherlands.
- Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, the Netherlands.
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50
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Ferraz IDS, Carioca FDL, Junqueira FMD, Oliveira MS, Duarte GL, Foronda FK, Matsumoto T, Brandão MB, De Souza TH. The impact of PEEP on mechanical power and driving pressure in children with pediatric acute respiratory distress syndrome. Pediatr Pulmonol 2024; 59:3593-3600. [PMID: 39267444 DOI: 10.1002/ppul.27266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 07/23/2024] [Accepted: 09/03/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) is widely used to improve oxygenation and avoid alveolar collapse in mechanically ventilated patients with pediatric acute respiratory distress syndrome (PARDS). However, its improper use can be harmful, impacting variables associated with ventilation-induced lung injury, such as mechanical power (MP) and driving pressure (∆P). Our main objective was to assess the impact of increasing PEEP on MP and ∆P in children with PARDS. INTERVENTIONS Mechanically ventilated children on pressure-controlled volume-guaranteed mode were prospectively assessed for inclusion. PEEP was sequentially changed to 5, 12, 10, 8, and again to 5 cm H2O. After 10 min at each PEEP level, ventilatory data were collected and then variables of interest were determined. Respiratory system mechanics were measured using the least squares fitting method. RESULTS Thirty-one patients were included, with median age and weight of 6 months and 6.3 kg. Most subjects were admitted for acute viral bronchiolitis (45%) or community-acquired pneumonia (32%) and were diagnosed with mild (45%) or moderate (42%) PARDS. There was a significant increase in MP and ∆P at PEEP levels of 10 and 12 cm H2O. When PEEP was increased from 5 to 12 cm H2O, there was a relative increase in MP of 60.7% (IQR 49.3-82.9) and in ΔP of 33.3% (IQR 17.8-65.8). A positive correlation was observed between MP and ΔP (ρ = 0.59). CONCLUSIONS Children with mild or moderate PARDS may experience a significant increase in MP and ∆P with increased PEEP. Therefore, respiratory system mechanics and lung recruitability must be carefully evaluated during PEEP titration.
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Affiliation(s)
- Isabel de Siqueira Ferraz
- Department of Pediatrics, Pediatric Intensive Care Unit, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernando de Lima Carioca
- Department of Pediatrics, Pediatric Intensive Care Unit, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernanda Monteiro Diniz Junqueira
- Department of Pediatrics, Pediatric Intensive Care Unit, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Marina Simões Oliveira
- Department of Pediatrics, Pediatric Intensive Care Unit, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Gregory Lui Duarte
- Department of Pediatrics, Pediatric Intensive Care Unit, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | | | - Toshio Matsumoto
- Intensive Care Society of Sao Paulo, Sao Paulo, São Paulo, Brazil
| | - Marcelo Barciela Brandão
- Department of Pediatrics, Pediatric Intensive Care Unit, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Tiago Henrique De Souza
- Department of Pediatrics, Pediatric Intensive Care Unit, Clinics Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
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