Mechanical power during mechanical ventilation of critically ill patients

Neto, Ary Serpa; Deliberato, Rodrigo Octávio; Johnson, Alistair E. W.; Amorim, Pedro; Pereira, Silvio Moreto; Cazati, Denise Carnieli; Cordioli, Ricardo Luiz; Corrêa, Thiago Domingos; Coutinho, Eduardo; Schettino, Guilherme de Paula Pinto; Timenetsky, Karina Tavares; Pelosi, Paolo; Abreu, Marcelo Gama de; Schultz, Marcus J.

doi:10.1016/j.jcrc.2017.09.067

Cited by 5 publications

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“…Retrospective studies in mechanically ventilated patients suffering from acute respiratory distress syndrome (ARDS) reported a greater mortality when a higher mechanical power was applied. [17][18][19] However, its role in the development of respiratory failure in patients without lung injury is poorly understood. It is unclear whether the evidence from patients with ARDS is translatable to patients undergoing general anesthesia, which typically show fundamentally different pulmonary mechanics and a higher lung volume available for aeration.…”

Section: What This Article Tells Us That Is Newmentioning

confidence: 99%

Mechanical Power during General Anesthesia and Postoperative Respiratory Failure: A Multicenter Retrospective Cohort Study

et al. 2022

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Background Mechanical power during ventilation estimates the energy delivered to the respiratory system through integrating inspiratory pressures, tidal volume, and respiratory rate into a single value. It has been linked to lung injury and mortality in the acute respiratory distress syndrome, but little evidence exists regarding whether the concept relates to lung injury in patients with healthy lungs. This study hypothesized that higher mechanical power is associated with greater postoperative respiratory failure requiring reintubation in patients undergoing general anesthesia. Methods In this multicenter, retrospective study, 230,767 elective, noncardiac adult surgical out- and inpatients undergoing general anesthesia between 2008 and 2018 at two academic hospital networks in Boston, Massachusetts, were included. The risk-adjusted association between the median intraoperative mechanical power, calculated from median values of tidal volume (Vt), respiratory rate (RR), positive end-expiratory pressure (PEEP), plateau pressure (Pplat), and peak inspiratory pressure (Ppeak), using the following formula: mechanical power (J/min) = 0.098 × RR × Vt × (PEEP + ½[Pplat – PEEP] + [Ppeak − Pplat]), and postoperative respiratory failure requiring reintubation within 7 days, was assessed. Results The median intraoperative mechanical power was 6.63 (interquartile range, 4.62 to 9.11) J/min. Postoperative respiratory failure occurred in 2,024 (0.9%) patients. The median (interquartile range) intraoperative mechanical power was higher in patients with postoperative respiratory failure than in patients without (7.67 [5.64 to 10.11] vs. 6.62 [4.62 to 9.10] J/min; P < 0.001). In adjusted analyses, a higher mechanical power was associated with greater odds of postoperative respiratory failure (adjusted odds ratio, 1.31 per 5 J/min increase; 95% CI, 1.21 to 1.42; P < 0.001). The association between mechanical power and postoperative respiratory failure was robust to additional adjustment for known drivers of ventilator-induced lung injury, including tidal volume, driving pressure, and respiratory rate, and driven by the dynamic elastic component (adjusted odds ratio, 1.35 per 5 J/min; 95% CI, 1.05 to 1.73; P = 0.02). Conclusions Higher mechanical power during ventilation is statistically associated with a greater risk of postoperative respiratory failure requiring reintubation. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Section: What This Article Tells Us That Is Newmentioning

confidence: 99%

Mechanical Power during General Anesthesia and Postoperative Respiratory Failure: A Multicenter Retrospective Cohort Study

et al. 2022

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“…These findings advance our understanding of ventilator-induced lung injury, and are generally consistent with critical care studies suggesting that mechanical power is associated with adverse outcomes, including death. 6 Santer et al 5 used an equation developed 2021 for epidemiologic studies, 7 which includes three basic terms. One term expresses a "static" component-that is, the contribution of positive end-expiratory pressure (PEEP) or stored energy.…”

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confidence: 99%

Mechanical Power: Correlate or Cause of Ventilator-induced Lung Injury?

Abreu

Sessler

2022

Anesthesiology

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“…33 Our rationale was that RR represents an important component in the mechanical power formula, because it is not directly related to cumulative energy load over the span of multiple cycles. 2,5,34 Although RR has received less attention, it has been associated experimentally with ventilator-induced lung injury. 5,35 During protective ventilatory strategies in ARDS patients (e.g., V T ~6 ml/kg), it is usual practice to increase RR abruptly to control hypercapnia.…”

Section: Discussionmentioning

confidence: 99%

“…Thus, fast alveolar units that better accommodate strain tend to overdistend. 2,7,34,40 After recruitment maneuver application, the fraction of slow alveolar units tends to decrease, 41 as does the propensity of alveolar units to become atelectatic, which may decrease regional tidal strains and heterogeneity. Although the injurious biologic impact of abruptly increasing RR was observed in a heterogeneous lung, it was not detected when the lungs were previously subjected to recruitment maneuver.…”

Section: Discussionmentioning

confidence: 99%

Lung Injury Is Induced by Abrupt Increase in Respiratory Rate but Prevented by Recruitment Maneuver in Mild Acute Respiratory Distress Syndrome in Rats

et al. 2022

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Background Gradually changing respiratory rate (RR) over time to reduce ventilation-induced lung injury (VILI) has not been investigated. We hypothesized that gradual, compared to abrupt, increments in RR would mitigate VILI and that recruitment maneuver (RM) prior to abrupt increasing RR may prevent injurious biological impact. Methods Twenty-four hours after intratracheal administration of Escherichia coli lipopolysaccharide, 49 male Wistar rats were anesthetized and mechanically ventilated (VT=6ml/kg, PEEP=3cmH2O) with RR increase patterns as follows (n=7/group): (1)control-1, RR=70bpm for 2h; (2) and (3)abrupt increases of RR for 1h and 2h, respectively, both for 2h; (4)shorter RR adaptation, gradually increasing RR (from 70 to 130bpm over 30min); (5)longer RR adaptation, more gradual increase in RR (from 70 to 130bpm over 60min), both for 2h; (6)control-2, abrupt increase of RR maintained for 1h; and (7)control-3, RM [CPAP=30cmH2O for 30s] followed by control-2 protocol. Results At the end of 1h of mechanical ventilation, cumulative diffuse alveolar damage scores were lower in shorter (11.0 [8.0–12.0]) and longer (13.0 [11.0–14.0]) RR adaptation groups than in animals with abrupt increase of RR for 1 h (25.0 [22.0–26.0] p=0.035, and p=0.048, respectively) and 2 h (35.0 [32.0–39.0], p=0.003, and p=0.040, respectively); mechanical power and lung heterogeneity were lower, and alveolar integrity was higher, in the longer RR adaptation group compared with abruptly adjusted groups; markers of lung inflammation (IL-6), epithelial (CC-16) and endothelial cell damage (VCAM-1) were higher in both abrupt groups, but not in either RR adaptation group, compared with controls. RM prevented the increase in VCAM-1 and CC-16 gene expressions in the abruptly increased RR groups. Conclusion In mild experimental ARDS in rats, gradually increasing RR, compared with abruptly doing so, can mitigate the development of VILI. In addition, recruitment maneuver prevented the injurious biological impact of abrupt increases in RR.

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Mechanical power during mechanical ventilation of critically ill patients

Cited by 5 publications

References 0 publications

Mechanical Power during General Anesthesia and Postoperative Respiratory Failure: A Multicenter Retrospective Cohort Study

Mechanical Power during General Anesthesia and Postoperative Respiratory Failure: A Multicenter Retrospective Cohort Study

Mechanical Power: Correlate or Cause of Ventilator-induced Lung Injury?

Lung Injury Is Induced by Abrupt Increase in Respiratory Rate but Prevented by Recruitment Maneuver in Mild Acute Respiratory Distress Syndrome in Rats

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