Patient–ventilator interaction in ARDS patients with extremely low compliance undergoing ECMO: a novel approach based on diaphragm electrical activity

Mauri, Tommaso; Bellani, Giacomo; Grasselli, Giacomo; Confalonieri, A; Rona, Roberto; Patroniti, Nicolò; Pesenti, Antonio

doi:10.1007/s00134-012-2755-1

Cited by 91 publications

(64 citation statements)

References 37 publications

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“…Nevertheless, the accessory muscles should be at rest all the time: automatic tube compensation [56] will perform nearly all WOB: no sternal notch retraction, no use of accessory muscles, etc. Therefore, PS had to be set to a surprisingly low level (3−10 cm H 2 O, low inspiratory trigger, low expiratory trigger [59], high pressure rise time, automatic tube compensation 100%) in patients presenting with early severe ARDS undergoing moderate permissive hypercapnia (PaCO 2 £ 60 mm Hg) [55] under high PEEP (15−24 cm H 2 O) [30,71]. These observations agree with earlier findings [18,35,36].…”

Section: Analysis Of the Blood Gasessupporting

confidence: 75%

“…Select a low PS to avoid large transpulmonary pressure and volotrauma [35] Set low inspiratory trigger, high pressure rise time [57], low expiratory trigger [59], automatic tube compensation = 100% [56] 9) Sedation: an absence of respiratory depression [94] should be considered as the pharmacological cornerstone of all of the cardio-ventilatory physiology discussed throughout ms. If necessary, alpha-2 agonists should be combined with neuroleptics, to −3 < RASS < −2 [13] a) all the optimization of the cardio-ventilatory physiology, delineated in these two chapters, is useless if the respiratory generator is not free of any depressing influence [94] b) conversely, alpha-2 agonists, without optimized cardio-ventilatory physiology, are useless.…”

Section: Ps Vs Aprvmentioning

confidence: 99%

“…[Then, a minimized VO 2 ( Table 2, part II), an acceptable hypercapnia [55], a relatively high PO 2 evoking a low RR [40], and a PS set to the minimum [30] will generate the lowest Vt (≤ 5− -6 mL kg −1 ) and minimize firstly: i) the use of respiratory muscles (palpation of SCM; Fig. 3 in [18]) with a low inspiratory trigger, automatic tube compensation [56], rapid pressure rise time [57,58]; and ii) the inspiratory transpulmonary pressure (low expiratory trigger [59]; Figs 1 and 2 in [33]; Fig. 1 in [37])].…”

Section: Extubationmentioning

confidence: 99%

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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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Section: Analysis Of the Blood Gasessupporting

confidence: 75%

Section: Ps Vs Aprvmentioning

confidence: 99%

Section: Extubationmentioning

confidence: 99%

See 1 more Smart Citation

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

View full text Add to dashboard Cite

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“…However, the optimum PEEP value is currently unknown. Various other treatment concepts such as driving pressure, transpulmonary pressure, and electrical activity of the diaphragm have been proposed in addition to these, and future research attention is anticipated 197, 198, 199…”

Section: Introductionmentioning

confidence: 99%

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

Nishida

Ogura

Egi

et al. 2018

Acute Medicine & Surgery

157

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Background and PurposeThe Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG 2016), a Japanese‐specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English‐language version of these guidelines was created based on the contents of the original Japanese‐language version.MethodsMembers of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two‐thirds (>66.6%) majority vote of each of the 19 committee members.ResultsA total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J‐SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta‐analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.ConclusionsBased on the evidence gathered, we were able to formulate Japanese‐specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non‐specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

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“…Additionally, it could optimize other intensive care-based management strategies, including minimization of sedation, reductions in nosocomial infections (particularly ventilator-associated pneumonia) and maximization of mobilization and enteral nutrition. However, there is potential concern over exacerbating mechanical stress with spontaneous breathing in ARDS (61)(62)(63)(64)(65). Although ECCO 2 R has been shown to have the ability to control ventilatory drive in select patients with severe, chronic respiratory failure (e.g., COPD), data suggests that it may not be able to sufficiently control the spontaneous and potentially injurious respiratory efforts of patients with severe ARDS (66,67).…”

Section: Extubation During Extracorporeal Supportmentioning

confidence: 99%

Extracorporeal techniques in acute respiratory distress syndrome

2017

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Extracorporeal membrane oxygenation (ECMO) was first introduced for patients with acute respiratory distress syndrome (ARDS) in the 1970s. However, enthusiasm was tempered due to the high mortality seen at that time. The use of ECMO has grown considerably in recent years due to technological advances and the evidence suggesting potential benefit. While the efficacy of ECMO has yet to be rigorously demonstrated with high-quality evidence, it has the potential not only to have a substantial impact on outcomes, including mortality, but also to change the paradigm of ARDS management.

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Patient–ventilator interaction in ARDS patients with extremely low compliance undergoing ECMO: a novel approach based on diaphragm electrical activity

Abstract: EAdi allows accurate analysis of asynchrony patterns and magnitude in ARDS patients with very low Cst(rs) undergoing ECMO. In these patients, NAVA is associated with reduced asynchrony.

Cited by 91 publications

References 37 publications

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 II: controlled vs. spontaneous ventilation?

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

Extracorporeal techniques in acute respiratory distress syndrome

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