Protecting lungs during spontaneous breathing: what can we do?

Li, Hongliang; Chen, Lu; Brochard, Laurent

doi:10.21037/jtd.2017.08.25

Cited by 13 publications

(11 citation statements)

References 24 publications

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“…The mean age of our cohort was 63 + 11 yrs with 65% patients being males (Table 1). The duration for the development of barotrauma was 18.5 (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) days from symptom onset and 11 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) days from hospital admission. Interestingly, despite a high incidence of barotrauma, we did not observe CT-based evidence of emphysema, cysts, or bullae.…”

Section: Resultsmentioning

confidence: 99%

“…5,16,22 Another concerning factor is patient self-inflicted lung injury (P-SILI), which can induce lung injury as a consequence of intense inspiratory efforts. 23,24 The idea has been backed-up by animal models that showed that high tidal volume generated by negative pressure ventilation resulted in pulmonary edema, in a manner similar to positive pressure ventilation. 25 In patients with ARDS and acute hypoxemic respiratory failure, respiratory drive is increased.…”

Section: Discussionmentioning

confidence: 99%

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Pulmonary Barotrauma in COVID-19 Patients With ARDS on Invasive and Non-Invasive Positive Pressure Ventilation

Rajdev

Spanel

McMillan

et al. 2021

J Intensive Care Med

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Background: We experienced a high incidence of pulmonary barotrauma among patients with coronavirus disease-2019 (COVID-19) associated acute respiratory distress syndrome (ARDS) at our institution. In current study, we sought to estimate the incidence, clinical outcomes, and characteristics of barotrauma among COVID-19 patients receiving invasive and non-invasive positive pressure ventilation. Methodology: We conducted this retrospective cohort study of adult patients diagnosed with COVID-19 pneumonia and requiring oxygen support or positive airway pressure for ARDS who presented to our tertiary care center from March through November, 2020. Results: A total of 353 patients met our inclusion criteria, of which 232patients who required heated high-flow nasal cannula, continuous or bilevel positive airway pressure were assigned to non-invasive group. The remaining 121 patients required invasive mechanical ventilation and were assigned to invasive group. Of the 353 patients, 32 patients (65.6% males) with a mean age of 63 ± 11 years developed barotrauma in the form of either subcutaneous emphysema, pneumothorax, or pneumomediastinum. The incidence of barotrauma was 4.74% (11/232) and 17.35% (21/121) in non-invasive group and invasive group, respectively. The median length of hospital stay was 22 (15.7 −33.0) days with an overall mortality of 62.5% (n = 20). Conclusions: Patients with COVID-19 ARDS have a high incidence rate of barotrauma. Pulmonary barotrauma should be considered in patients with COVID-19 pneumonia who exhibit worsening of their respiratory disease as it is likely associated with a high mortality risk. Utilizing lung-protective ventilation strategies may reduce the risk of barotrauma.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Pulmonary Barotrauma in COVID-19 Patients With ARDS on Invasive and Non-Invasive Positive Pressure Ventilation

Rajdev

Spanel

McMillan

et al. 2021

J Intensive Care Med

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“…Due to the shortage of ICU beds during the pandemic, 35 a relatively high number of patients were treated with non-invasive respiratory support for many days even when their clinical status would have required intubation and invasive mechanical ventilation, which may have led to P-SILI. In COVID-19, four potential mechanisms of P-SILI may be suggested: 1) increased lung stress/strain, 36 , 37 , 38 , 39 2) inhomogeneous distribution of ventilation, 4 40 3 ) changes in lung perfusion, 16 23 and 4) patient-ventilator asynchronies during non-invasive positive pressure ventilation (NPPV). 41 42 Increased lung stress/strain …”

Section: Mechanisms Of P-silimentioning

confidence: 99%

Noninvasive respiratory support and patient self-inflicted lung injury in COVID-19: a narrative review

Battaglini

Robba

Ball

et al. 2021

British Journal of Anaesthesia

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Coronavirus disease 2019 (COVID-19) pneumonia is associated with hypoxemic respiratory failure, ranging from mild to severe. Due to the worldwide shortage of intensive care unit beds, a relatively high number of patients with respiratory failure are receiving prolonged non-invasive respiratory support, even when their clinical status would have required invasive mechanical ventilation. There are few experimental and clinical data reporting that vigorous breathing effort during spontaneous ventilation can worsen lung injury and cause a phenomenon that has been termed patient self-inflicted lung injury (P-SILI). The aim of this narrative review is to provide an overview of P-SILI pathophysiology and the role of non-invasive respiratory support in COVID-19 pneumonia. Respiratory mechanics, vascular compromise, viscoelastic properties, lung inhomogeneity, work of breathing, and oesophageal pressure swings are discussed. The concept of P-SILI has been widely investigated in recent years, but controversies persist regarding its mechanisms. To minimize the risk of P-SILI, intensivists should better understand its underlying pathophysiology to optimize the type of non-invasive respiratory support provided to patients with COVID-19 pneumonia, as well as decide on the optimal timing of intubation for these patients.

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“…Although Δ P as a risk factor for VILI has been exclusively studied in patients under controlled mechanical ventilation, the potentially harmful effects of high Δ P are probably present in any mode of ventilation. Recently, the concept of self-inflicted lung injury has been introduced, referring to patients in assisted ventilation [9–11]. As the beneficial effects of spontaneous breathing during mechanical ventilation are well established, it becomes increasingly important to identify patients at risk of self-inflicted lung injury during assisted ventilation [9–11].…”

Section: Introductionmentioning

confidence: 99%

“…Recently, the concept of self-inflicted lung injury has been introduced, referring to patients in assisted ventilation [9–11]. As the beneficial effects of spontaneous breathing during mechanical ventilation are well established, it becomes increasingly important to identify patients at risk of self-inflicted lung injury during assisted ventilation [9–11]. To identify patients at risk and prevent self-inflicted lung injury, monitoring of Δ P during assisted ventilation might be helpful.…”

Section: Introductionmentioning

confidence: 99%

Driving pressure during proportional assist ventilation: an observational study

Vaporidi

Psarologakis

Proklou

et al. 2019

Ann. Intensive Care

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BackgroundDuring passive mechanical ventilation, the driving pressure of the respiratory system is an important mediator of ventilator-induced lung injury. Monitoring of driving pressure during assisted ventilation, similar to controlled ventilation, could be a tool to identify patients at risk of ventilator-induced lung injury. The aim of this study was to describe driving pressure over time and to identify whether and when high driving pressure occurs in critically ill patients during assisted ventilation.MethodsSixty-two patients fulfilling criteria for assisted ventilation were prospectively studied. Patients were included when the treating physician selected proportional assist ventilation (PAV+), a mode that estimates respiratory system compliance. In these patients, continuous recordings of all ventilator parameters were obtained for up to 72 h. Driving pressure was calculated as tidal volume-to-respiratory system compliance ratio. The distribution of driving pressure and tidal volume values over time was examined, and periods of sustained high driving pressure (≥ 15 cmH2O) and of stable compliance were identified and analyzed.ResultsThe analysis included 3200 h of ventilation, consisting of 8.8 million samples. For most (95%) of the time, driving pressure was < 15 cmH2O and tidal volume < 11 mL/kg (of ideal body weight). In most patients, high driving pressure was observed for short periods of time (median 2.5 min). Prolonged periods of high driving pressure were observed in five patients (8%). During the 661 periods of stable compliance, high driving pressure combined with a tidal volume ≥ 8 mL/kg was observed only in 11 cases (1.6%) pertaining to four patients. High driving pressure occurred almost exclusively when respiratory system compliance was low, and compliance above 30 mL/cmH2O excluded the presence of high driving pressure with 90% sensitivity and specificity.ConclusionsIn critically ill patients fulfilling criteria for assisted ventilation, and ventilated in PAV+ mode, sustained high driving pressure occurred in a small, yet not negligible number of patients. The presence of sustained high driving pressure was not associated with high tidal volume, but occurred almost exclusively when compliance was below 30 mL/cmH2O.Electronic supplementary materialThe online version of this article (10.1186/s13613-018-0477-4) contains supplementary material, which is available to authorized users.

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Protecting lungs during spontaneous breathing: what can we do?

Abstract: door of optimizing ventilator settings and modes to reduce P-SILI remains open. Back to a physiology standpoint, seeking for a ventilatory strategy to minimize P-SILI with preserved spontaneous effort should not and will not stop.

Cited by 13 publications

References 24 publications

Pulmonary Barotrauma in COVID-19 Patients With ARDS on Invasive and Non-Invasive Positive Pressure Ventilation

Pulmonary Barotrauma in COVID-19 Patients With ARDS on Invasive and Non-Invasive Positive Pressure Ventilation

Noninvasive respiratory support and patient self-inflicted lung injury in COVID-19: a narrative review

Driving pressure during proportional assist ventilation: an observational study

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