Volume-controlled Ventilation Does Not Prevent Injurious Inflation during Spontaneous Effort

Yoshida, Toyohiko; Nakahashi, Susumu; Nakamura, Maria Aparecida Miyuki; Koyama, Yusuke; Roldán, Rollin; Torsani, Vinícius; Santis, Roberta R. De; Gomes, Susimeire; Uchiyama, Akinori; Amato, Marcelo B. P.; Kavanagh, Brian P.; Fujino, Yuji

doi:10.1164/rccm.201610-1972oc

Cited by 122 publications

(99 citation statements)

References 29 publications

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“…Growing evidence suggests that the presence of spontaneous breathing during mechanical ventilation is associated with several advantages, but may be harmful at the same time, particularly during the acute phase [1][2][3]. One of the possible mechanisms of injury Open Access *Correspondence: giacomo.bellani1@unimib.it 2 School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy Full list of author information is available at the end of the article associated with spontaneous breathing and assisted ventilation is the development of pendelluft [1].…”

Section: Introductionmentioning

confidence: 99%

Occurrence of pendelluft under pressure support ventilation in patients who failed a spontaneous breathing trial: an observational study

Coppadoro

Grassi

Giovannoni

et al. 2020

Ann. Intensive Care

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Background: Pendelluft, the movement of gas within different lung regions, is present in animal models of assisted mechanical ventilation and associated with lung overstretching. Due to rebreathing of CO 2 as compared to fresh gas, pendelluft might reduce ventilatory efficiency possibly exacerbating patient's respiratory workload during weaning. Our aim was to measure pendelluft by electrical impedance tomography (EIT) in patients who failed a spontaneous breathing trial (SBT).Methods: This is an observational study conducted in a general intensive care unit of a tertiary-level teaching hospital. EIT signal was recorded in 20 patients while pressure support (PS) ventilation was progressively reduced from clinical level (baseline) to 2 cmH 2 O, as in an SBT; four ventral-to-dorsal lung regions of interest were identified for pendelluft measurement. A regional gas movement (> 6 mL) occurring in a direction opposite to the global EIT signal was considered diagnostic for high pendelluft.Results: Eight patients out of 20 (40%) were classified as high-pendelluft; baseline clinical characteristics did not differ between high-and low-pendelluft patients. At PS reduction, pendelluft and EtCO 2 increased more in the highpendelluft group (p < .001 and .011, respectively). The volume of gas subject to pendelluft moved almost completely from the ventral towards the dorsal lung regions, while the opposite movement was minimal (16.3 [10:32.8] vs. 0 [0:1.8] mL, p = .001). In a subgroup of patients, increased pendelluft volumes positively correlated with markers of respiratory distress such as increased respiratory rate, p0.1, and EtCO 2 . Conclusions: Occult pendelluft can be measured by EIT, and is frequently present in patients failing an SBT. When present, pendelluft increases with the reduction of ventilator support and is associated with increased EtCO 2 , suggesting a reduction of the ability to eliminate CO 2 .

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Section: Introductionmentioning

confidence: 99%

Occurrence of pendelluft under pressure support ventilation in patients who failed a spontaneous breathing trial: an observational study

Coppadoro

Grassi

Giovannoni

et al. 2020

Ann. Intensive Care

View full text Add to dashboard Cite

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“…Most studies, however, were small (<50 patients/group), the intervention was not blinded and BPD not the primary outcome. This, combined with recent animal data suggesting that VTV might not eliminate lung injury during spontaneous breaths,24 raises questions whether the evidence that VTV is superior to other forms of respiratory support can already be regarded conclusive.…”

Section: Introductionmentioning

confidence: 99%

Prevention of bronchopulmonary dysplasia in extremely low gestational age neonates: current evidence

Poets

Lorenz

2018

Arch Dis Child Fetal Neonatal Ed

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Bronchopulmonary dysplasia (BPD) is one of the most frequent complications in extremely low gestational age neonates, but has remained largely unchanged in rate. We reviewed data on BPD prevention focusing on recent meta-analyses. Interventions with proven effectiveness in reducing BPD include the primary use of non-invasive respiratory support, the application of surfactant without endotracheal ventilation and the use of volume-targeted ventilation in infants requiring endotracheal intubation. Following extubation, synchronised nasal ventilation is more effective than continuous positive airway pressure in reducing BPD. Pharmacologically, commencing caffeine citrate on postnatal day 1 or 2 seems more effective than a later start. Applying intramuscular vitamin A for the first 4 weeks reduces BPD, but is expensive and painful and thus not widely used. Low-dose hydrocortisone for the first 10 days prevents BPD, but was associated with almost twice as many cases of late-onset sepsis in infants born at 24-25 weeks' gestation. Inhaled corticosteroids, despite reducing BPD, were associated with a higher mortality rate. Administering dexamethasone to infants still requiring mechanical ventilation around postnatal weeks 2-3 may represent the best trade-off between restricting steroids to infants at risk of BPD while still affording high efficacy. Finally, identifying infants colonised with ureaplasma and treating those requiring intubation and mechanical ventilation with azithromycin is another promising approach to BPD prevention. Further interventions yet only backed by cohort studies include exclusive breastmilk feeding and a better prevention of nosocomial infections.

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“…Yoshida's study (18), however, found this is not the case in injured lungs. During spontaneous breathing, the tidal change in pleural pressure at dependent lung is significantly greater than at the middle lung (esophageal pressure).…”

Section: New Messages From Yoshida's Studymentioning

confidence: 82%

“…Of note, both high regional lung stress and "pendelluft" have been linked with lung injury by the same group of researchers (24). Moreover, the excessive regional lung stress at dependent lung was eliminated only when strenuous inspiratory effort was suppressed by paralysis in Yoshida's study (18). This may well be one of the reasons why eliminating spontaneous effort by administration of neuromuscular blocking agents at the early stage of ARDS can improve survival in patients who already received volume controlled ventilation (12).…”

Section: New Messages From Yoshida's Studymentioning

confidence: 89%

“…The overall tidal volume and the tidal change in transpulmonary pressure estimated by esophageal manometry were controlled in both spontaneous breathing and passive ventilation, as expected. Surprisingly, volume controlled ventilation failed to limit the tidal change in transpulmonary pressure at dependent lung regions during spontaneous effort, which became comparable to pressure controlled ventilation (18).…”

Section: New Messages From Yoshida's Studymentioning

confidence: 90%

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Protecting lungs during spontaneous breathing: what can we do?

Chen

Brochard

2017

J. Thorac. Dis.

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Volume-controlled Ventilation Does Not Prevent Injurious Inflation during Spontaneous Effort

Abstract: Limitation of Vt and Pl(es) by volume-controlled ventilation could not eliminate harm caused by spontaneous breathing unless the level of spontaneous effort was lowered and local dependent lung stress was reduced.

Cited by 122 publications

References 29 publications

Occurrence of pendelluft under pressure support ventilation in patients who failed a spontaneous breathing trial: an observational study

Occurrence of pendelluft under pressure support ventilation in patients who failed a spontaneous breathing trial: an observational study

Prevention of bronchopulmonary dysplasia in extremely low gestational age neonates: current evidence

Protecting lungs during spontaneous breathing: what can we do?

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