Paradoxically Improved Respiratory Compliance With Abdominal Compression in COVID-19 ARDS

Kummer, Rebecca L.; Shapiro, Robert; Marini, John J.; Huelster, Joshua; Leatherman, James W.

doi:10.1016/j.chest.2021.05.012

Cited by 22 publications

(42 citation statements)

References 9 publications

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“…However, unresolving late phase C-ARDS may be characterized by impressive loss of aeratable lung units, in part due to fibroblastic proliferation and organization within the parenchyma. In this latter setting, recent reports indicate that late phase patients unexpectedly experienced improved respiratory system compliance and gas exchange in response to compressive sternal [ 28 ] or abdominal [ 27 ] pressures that were applied steadily (Fig. 1 ).…”

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 95%

“…Indeed, such assumptions do usually apply. However, extensive recent experience with one specialized form of ARDS, COVID-19 pneumonia (CARDS), has demonstrated that violations of that expectation do occur under some conditions, with important implications for ventilator management [ 27 , 28 ].…”

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

“…1 ). In a report by Kummer and colleagues [ 27 ], lung protective tidal volumes and modest PEEP were applied using volume control ventilation during both phases of multiple tidal cycles for about ten seconds. No end-expiratory gas trapping (auto-PEEP) was detected with or without loading, even though compression during loading increased resistance detectably in some patients (Fig.…”

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

“…By this explanatory hypothesis, descent along the lung’s altered pressure–volume curve caused by the enforced volume reduction consequent to abdominal or sternal compression disproportionally improves the lung’s tidal compliance as well as that of the integrated respiratory system. In other words, abdominal or sternal compression simultaneously reduces the end-expiratory volumes of the limited number of aeratable lung units but by relieving end-inspiratory overinflation, also improves their tidal distensibility [ 27 ]. Lung units previously over-distended near end-tidal inflation would then operate on a more linear portion of their sigmoidal pressure–volume (P–V) curves (Fig.…”

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

“…3 ). As detailed in the reported case series, reduction of low-level PEEP improved tidal compliance and driving pressure, as did assuming a more horizontal position [ 27 , 28 ]. Taken together, these observations indicate that lung volume reduction by local chest wall compression, lowering PEEP, changing position or (when possible) dropping tidal volume is key to avoiding end-tidal overdistention and, paradoxically, to improving tidal mechanics and lung protection.…”

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

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Improving lung compliance by external compression of the chest wall

Marini

Gattinoni

2021

Crit Care

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As exemplified by prone positioning, regional variations of lung and chest wall properties provide possibilities for modifying transpulmonary pressures and suggest that clinical interventions related to the judicious application of external pressure may yield benefit. Recent observations made in late-phase patients with severe ARDS caused by COVID-19 (C-ARDS) have revealed unexpected mechanical responses to local chest wall compressions over the sternum and abdomen in the supine position that challenge the clinician’s assumptions and conventional bedside approaches to lung protection. These findings appear to open avenues for mechanism-defining research investigation with possible therapeutic implications for all forms and stages of ARDS.

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Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 95%

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

Section: Potential Diagnostic and Therapeutic Applications Of External Chest Wall Compressionmentioning

confidence: 99%

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Improving lung compliance by external compression of the chest wall

Marini

Gattinoni

2021

Crit Care

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Detecting end-tidal hyperinflation

Marini

2024

Intensive Care Med

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Lung Response to a Higher Positive End-Expiratory Pressure in Mechanically Ventilated Patients With COVID-19

Protti

Santini

Pennati

et al. 2022

Chest

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Background International guidelines suggest using a higher (>10 cmH 2 O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) due to the novel coronavirus disease (COVID-19). However, even if oxygenation generally improves with a higher PEEP, compliance and arterial carbon dioxide tension (PaCO 2 ) frequently do not, as if recruitment was small. Research question Is the potential for lung recruitment small in patients with early ARDS due to COVID-19? Study design and methods Forty patients with ARDS due to COVID-19 were studied in the supine position within three days of endotracheal intubation. They all underwent a PEEP trial, where oxygenation, compliance, and PaCO 2 were measured with 5, 10, and 15 cmH 2 O of PEEP and all other ventilatory settings unchanged. Twenty underwent a whole-lung static computed tomography at 5 and 45 cmH 2 O, and the other twenty at 5 and 15 cmH 2 O of airway pressure. Recruitment and hyperinflation were defined as a decrease in the volume of the non-aerated (density above -100 HU) and an increase in the volume of the over-aerated (density below -900 HU) lung compartments, respectively. Results From 5 to 15 cmH 2 O, oxygenation improved in thirty-six (90%) patients but compliance only in eleven (28%) and PaCO 2 only in fourteen (35%). From 5 to 45 cmH 2 O, recruitment was 351 (161-462) ml and hyperinflation 465 (220-681) ml. From 5 to 15 cmH 2 O, recruitment was 168 (110-202) ml and hyperinflation 121 (63-270) ml. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them. Interpretation Patients with early ARDS due to COVID-19, ventilated in the supine position, present with a large potential for lung recruitment. Even so, their compliance and PaCO 2 do not generally improve with a higher PEEP, possibly due to hyperinflation.

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Paradoxically Improved Respiratory Compliance With Abdominal Compression in COVID-19 ARDS

Cited by 22 publications

References 9 publications

Improving lung compliance by external compression of the chest wall

Improving lung compliance by external compression of the chest wall

Detecting end-tidal hyperinflation

Lung Response to a Higher Positive End-Expiratory Pressure in Mechanically Ventilated Patients With COVID-19

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