High Positive End-Expiratory Pressure Renders Spontaneous Effort Noninjurious

Morais, Caio C. A.; Koyama, Yusuke; Yoshida, Toyohiko; Plens, Glauco M.; Gomes, Susimeire; Lima, Cárita Portilho de; Ramos, Ozires; Pereira, S.; Kawaguchi, Naomasa; Yamamoto, Hirofumi; Uchiyama, Akinori; Borges, João Batista; Melo, Marcos F. Vidal; Tucci, Mauro R.; Amato, Marcelo B. P.; Kavanagh, Brian P.; Costa, Eduardo F.; Fujino, Yuji

doi:10.1164/rccm.201706-1244oc

Cited by 174 publications

(192 citation statements)

References 40 publications

(52 reference statements)

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“…The amount of inspiratory effort is usually measured more than once per day, by means of p0.1 and PMI. PEEP is typically set by the clinician based both on respiratory system compliance and oxygenation response [36], taking also into account that the level of PEEP itself can modify the respiratory effort of the patient [37]. Therefore, it is very uncommon that patients' endurance is tested causing strenuous levels of inspiratory effort, as also witnessed by the low median Rapid Shallow Breathing Index in all the patients.…”

Section: Discussionmentioning

confidence: 99%

Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study

et al. 2020

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Background: Diaphragm atrophy and dysfunction are consequences of mechanical ventilation and are determinants of clinical outcomes. We hypothesize that partial preservation of diaphragm function, such as during assisted modes of ventilation, will restore diaphragm thickness. We also aim to correlate the changes in diaphragm thickness and function to outcomes and clinical factors. Methods: This is a prospective, multicentre, observational study. Patients mechanically ventilated for more than 48 h in controlled mode and eventually switched to assisted ventilation were enrolled. Diaphragm ultrasound and clinical data collection were performed every 48 h until discharge or death. A threshold of 10% was used to define thinning during controlled and recovery of thickness during assisted ventilation. Patients were also classified based on the level of diaphragm activity during assisted ventilation. We evaluated the association between changes in diaphragm thickness and activity and clinical outcomes and data, such as ventilation parameters. Results: Sixty-two patients ventilated in controlled mode and then switched to the assisted mode of ventilation were enrolled. Diaphragm thickness significantly decreased during controlled ventilation (1.84 ± 0.44 to 1.49 ± 0.37 mm, p < 0.001) and was partially restored during assisted ventilation (1.49 ± 0.37 to 1.75 ± 0.43 mm, p < 0.001). A diaphragm thinning of more than 10% was associated with longer duration of controlled ventilation (10 [5, 15] versus 5 [4, 8.5] days, p = 0.004) and higher PEEP levels (12.6 ± 4 versus 10.4 ± 4 cmH 2 O, p = 0.034). An increase in diaphragm thickness of more than 10% during assisted ventilation was not associated with any clinical outcome but with lower respiratory rate (16.7 ± 3.2 versus 19.2 ± 4 bpm, p = 0.019) and Rapid Shallow Breathing Index (37 ± 11 versus 44 ± 13, p = 0.029) and with higher Pressure Muscle Index (2 [0.5, 3] versus 0.4 [0, 1.9], p = 0.024). Change in diaphragm thickness was not related to diaphragm function expressed as diaphragm thickening fraction. Conclusion: Mode of ventilation affects diaphragm thickness, and preservation of diaphragmatic contraction, as during assisted modes, can partially reverse the muscle atrophy process. Avoiding a strenuous inspiratory work, as measured by Rapid Shallow Breathing Index and Pressure Muscle Index, may help diaphragm thickness restoration.

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Section: Discussionmentioning

confidence: 99%

Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study

et al. 2020

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“…In the setting of heterogeneous lung injury, the potential for very high local transpulmonary pressures, raises the potential for more lung injury (19). Perhaps these swings can be ameliorated with some ventilator strategies (20,21), but the method has yet to be determined. Another important issue is the intensity and amount of minute ventilation supported by spontaneous breathes.…”

Section: Physiological Premisesmentioning

confidence: 99%

APRV for ARDS: the complexities of a mode and how it affects even the best trials

2018

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“…However, it is important to note that this protective role of spontaneous effort has been shown in less severe ARDS and with mild spontaneous effort. Recent studies indicate that spontaneous effort may injure and/or worsen already injured lung and diaphragm in severe ARDS, especially when spontaneous effort is vigorous [8][9][10][11][12]. First, vigorous effort may present injuriously high P L (static and/or dynamic) by lowering P pl despite a limitation of plateau pressure, causing patient self-inflicted lung injury [13].…”

Section: How Transpulmonary Pressure Could Guide Spontaneous Breathinmentioning

confidence: 99%

Guiding ventilation with transpulmonary pressure

2018

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High Positive End-Expiratory Pressure Renders Spontaneous Effort Noninjurious

Abstract: Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.

Cited by 174 publications

References 40 publications

Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study

Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study

APRV for ARDS: the complexities of a mode and how it affects even the best trials

Guiding ventilation with transpulmonary pressure

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