Effect of different seated positions on lung volume and oxygenation in acute respiratory distress syndrome

Dellamonica, Jean; Lerolle, Nicolas; Sargentini, Cyril; Hubert, S.; Béduneau, G.; Marco, Fabiano Di; Mercat, Alain; Diehl, Jean‐Luc; Richard, Jean Christophe; Bernardin, G.; Brochard, Laurent

doi:10.1007/s00134-013-2827-x

Cited by 56 publications

(68 citation statements)

References 31 publications

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“…Goldman et al [11] found that the abdominal wall in tetraplegic patients is twice as compliant as in normal subjects. There is recent evidence of the benefits of a semiseated position to the weaning process of patients dependent on a respirator [12] and the effect of the seated position on lung volume and oxygenation in acute respiratory distress syndrome [13]. However, it must be noted that quadriplegics have better pulmonary mechanics in the supine position than when upright [14].…”

Section: Respiratory Pathophysiologymentioning

confidence: 99%

Respiratory Management in the Patient with Spinal Cord Injury

Galeiras

Sedes

Fariña

et al. 2013

BioMed Research International

132

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Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriate candidates can sometimes be freed from mechanical ventilation by electrical stimulation. Respiratory muscle training regimens may improve patients' inspiratory function following a SCI.

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Section: Respiratory Pathophysiologymentioning

confidence: 99%

Respiratory Management in the Patient with Spinal Cord Injury

Galeiras

Sedes

Fariña

et al. 2013

BioMed Research International

132

View full text Add to dashboard Cite

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“…increase the size of the baby lung [102]) next to the true atelectatic areas without RV afterloading as opposed to re-expanding all atelectatic areas at once ( 1) Ascertain severe ARDS: P/F < 100 after 30 min (Vt ~7 mL kg −1 , PEEP = 10 cm H 2 O, FiO 2 = 1) [60] 2) Optimize circulation (cardiological strategy): a) rule out patent foramen ovale, especially if no oxygenation response to PEEP elevation (Dessap 2010 in part I) b) avoid a "low PvO 2 effect" [7] and RV dysfunction 3) Use an upright position [81] and lower intra-abdominal pressure (gastric, bladder and colonic drainage: early facilitation of bowel movements) 4) Normalize the temperature (≈36°C) to lower the VO 2 [16,45,70] and VCO 2 , leading to a low Vt (≤ 5 mL kg −1 ; consider veno-venous CO 2 removal 5) Normalize acidosis (optimized cardiac output: CO 2 gap < 5−6 mm Hg; SscvO 2 > 70−75%; early EER therapy to lower lactates ≤ 2; infection control; rare administration of buffer) in order to lower the RR. This is the pathophysiological cornerstone of this alternative strategy because ARDS occurs rarely as single-organ failure but most often within the context of septic shock and early MOF 6) CO 2 : avoid major hypercapnia [55] in order to lower the risk of RV failure and increased RR 7) O 2 : a high FiO 2 will lower RR in SV [40] 8) SV should be set stringently only following control of ventilatory demands and metabolic demands…”

Section: Ps Vs Aprvmentioning

confidence: 99%

Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

Petitjeans

Pichot

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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The second part of this overview on early severe ARDS delineates the pros and cons of the following: a) controlled mechanical ventilation (CMV: lowered oxygen consumption and perfect patient-to-ventilator synchrony), to be used during acute cardio-ventilatory distress in order to "buy time" and correct circulatory insufficiency and metabolic defects (acidosis, etc.); b) spontaneous ventilation (SV: improved venous return, lowered intrathoracic pressure, absence of muscle atrophy). Given a stabilized early severe ARDS, as soon as the overall clinical situation improves, spontaneous ventilation will be used with the following stringent conditionalities: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone, as well as high PEEP (titrated on transpulmonary pressure, or as a second best: "trial"-PEEP) with spontaneous ventilation + pressure support (or newer modes of ventilation). As these propositions require evidence-based demonstration, the reader is reminded that the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation and prone position. Anestezjologia Intensywna Terapia 2016, tom 48, nr 5, 354-366Key words: acute respiratory distress syndrome, ARDS, severe ARDS; acute hypoxic non-hypercapnic respiratory failure; driving pressure; tidal volume, Vt, low tidal volume, ultra-low tidal volume; positive end-expiratory pressure, PEEP; transpulmonary pressure; controlled mechanical ventilation; spontaneous ventilation; spontaneous breathing; pressure support, airway pressure release ventilation; sedation, cooperative sedation; alpha-2 adrenergic agonist, clonidine, dexmedetomidineThe previous chapter overviewed, for residents rotating through the critical care unit (CCU), basic pathophysiology required to analyze early severe acute respiratory distress syndrome (ARDS). An emphasis was placed on spontaneous ventilation both in the setting of the healthy volunteer and of severe ARDS. This chapter will address the pros and cons of controlled mechanical ventilation, with the help of muscle relaxation, as opposed to the putative advantages of spontaneous ventilation. So far, spontaneous ventilation has not achieved evidence-based demonstration: thus, as in part I, conjectures are within [….], following [1]. i. MUSCLE RELAXATiON VERSUS SPONTANEOUS VENTiLATiON?When muscle relaxation is considered, the overall picture appears to be simplified with 48 h of muscle relaxation [2]. A sober interpretation may be considered. a. Muscle relaxationIn severe ARDS (P/F < 120), muscle relaxation [2] lowered the mortality (45 to 31%; difference of −32%; P = 0.04), multiple organ failure (MOF), and barotrauma and led to more ventilator-free days and identical CCU-acquired paresis. Muscle relaxation was hypothesized to minimize excessive transpulmonary pressure, patient-to-ventilator asynchrony [2], ventilator-induced lung injury (VILI), atelectrauma, overdistension,...

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“…Upright position: Moving from a supine to an upright position (reverse Trendelenburg, trunk at + 60°, and legs down at 45°) [107,108] increases the P/F in 32% of ARDS patients, "especially for… severe ARDS" [109], and in 5 out of 7 patients presenting with severe ARDS [110].…”

Section: ) or < 26 CM H 2 O [41] When The Rv Is Considered ( § I A 2)mentioning

confidence: 99%

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Severe acute respiratory distress syndrome (ARDS, PaO 2 /FiO 2 < 100 on PEEP ≥ 5 cm H 2 O) is treated using controlled mechanical ventilation (CMV), recently combined with muscle relaxation for 48 h and prone positioning. While the amplitude of tidal volume appears set £ 6 mL kg -1 , the level of positive end-expiratory pressure (PEEP) remains controversial. This overview summarizes several salient points, namely: a) ARDS is an oxygenation defect: consolidation/difuse alveolar damage is reversed by PEEP and/or prone positioning, at least during the early phase of ARDS b) ARDS is a dynamic disease and partially iatrogenic. This implies that the management of the ventilator may be a life-saver by reducing the duration of mechanical ventilation, or detrimental by extending this duration, leading into critical care-acquired diseases. Indeed, a high PEEP (10−24 cm H 2 O) appears to be a life-saver in the context of early severe diffuse ARDS; c) tidal volume and plateau pressure cannot be identical for all patients; d) the only remaining rationale for CMV and muscle relaxation is to suppress patient-ventilator asynchrony and to lower VO 2 , during the acute cardio-ventilatory distress. Therefore, in early severe diffuse ARDS, this review argues for a combination of a high PEEP (preferably titrated on transpulmonary pressure) with spontaneous ventilation + pressure support (or newer modes of ventilation). However, conditionalities are stringent: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone. As these propositions require evidence-based demonstration, the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation, and prone position.

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Effect of different seated positions on lung volume and oxygenation in acute respiratory distress syndrome

Abstract: Verticalization is easily achieved and improves oxygenation in approximately 32 % of the patients together with an increase in EELV. Nonetheless, effect of verticalization on EELV/PBW is not predictable by PaO₂/FiO₂ increase, its monitoring may be helpful for strain optimization.

Cited by 56 publications

References 31 publications

Respiratory Management in the Patient with Spinal Cord Injury

Respiratory Management in the Patient with Spinal Cord Injury

Early severe acute respiratory distress syndrome: What’s going on? Part II: controlled vs. spontaneous ventilation?

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

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