Close down the lungs and keep them resting to minimize ventilator-induced lung injury

Pelosi, Paolo; Rocco, Patrícia Rieken Macêdo; Abreu, Marcelo Gama de

doi:10.1186/s13054-018-1991-3

Cited by 76 publications

(78 citation statements)

References 47 publications

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“…The fact that hypotension and hemodynamic impairment are common might suggest that limited levels of PEEP could be beneficial in this type of patients by having less negative impact on hemodynamic. These results are in accordance with recently published literature [24,29], suggesting that the use of high PEEP can negatively impact the hemodynamic system, thus challenging the traditional concept of "open lung approach", and avoiding repeated alveolar collapse and expansion and keeping the lung partially at rest [30].…”

Section: Intraoperative Complications and Outcomessupporting

confidence: 92%

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study

Robba¹,

Hemmes²,

Neto³

et al. 2020

BMC Anesthesiol

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Background: Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. Methods: Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. Results: Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (V T ) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH 2 0. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. Conclusions: Neurosurgical patients are ventilated with low V T and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs.

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Section: Intraoperative Complications and Outcomessupporting

confidence: 92%

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study

Robba¹,

Hemmes²,

Neto³

et al. 2020

BMC Anesthesiol

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“…We found that most of our respondents utilize lower PEEP levels in case of intracranial hypertension, thus suggesting that there is still concern regarding the cerebrovascular effects of PEEP on ICP. However, surprisingly, our results show that physicians are keen to use quite high PEEPs (up to 15 in patients with PaO 2 /FiO 2 > 300) in patients without intracranial hypertension, which is in contrast with growing evidence challenging the utility of "open lung approach" [20]. Probably, the availability of adequate neuro and cardiorespiratory monitoring tools could be useful in setting the right level of PEEP, but more prospective randomized studies are needed to identify the correct level of PEEP in head-injured patients.…”

Section: Ventilator Settings and Respiratory Targets In Tbicontrasting

confidence: 67%

VENTILatOry strategies in patients with severe traumatic brain injury: the VENTILO Survey of the European Society of Intensive Care Medicine (ESICM)

Picetti

Pelosi²,

Taccone

et al. 2020

Crit Care

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Background: Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure.Methods: An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO 2 )/inspired fraction of oxygen (FiO 2 ) > 300 (scenario 1), 150-300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. Results: There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6-8 ml/kg of predicted body weight (PBW) in scenarios 1-2 (72% PaO 2 /FIO 2 > 300 and 61% PaO 2 /FiO 2 150-300) and 4-6 ml/kg/ PBW in scenario 3 (53% PaO 2 /FiO 2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH 2 O in patients with a PaO 2 /FiO 2 ≤ 300 without intracranial hypertension (41% if PaO 2 /FiO 2 150-300 and 50% if PaO 2 /FiO 2 < 150) and 10 cmH 2 O in patients with intracranial hypertension (32% if PaO 2 /FiO 2 150-300 and 33% if PaO 2 /FiO 2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36-40 mmHg whereas the most common PaO 2 target was 81-100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. Conclusions: Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.

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“…Furthermore, an aggressive recruitment strategy used in one study resulted even in increased mortality [23]. Some authors started to suggest that lung pressures, including PEEP, should be minimized to reduce VILI in patients with injured and non-injured lungs [24][25][26]; these concepts seem to be promising also for fibrotic lungs where susceptibility to VILI is particularly high.…”

Section: Effects Of Peep In Ae-ildmentioning

confidence: 99%

“…This particular technique is one of the methods proposed to achieve an "open lung approach". However, despite decades of intense clinical research in ARDS, ventilatory strategies aimed at achieving an 'open lung' (open the lung and keep it open) with the use of PEEP failed to translate these findings in the clinical setting [32], and some author suggested the 'lung rest' (close the lung and keep it resting) strategy [24].…”

Section: Effects Of Peep In Ae-ildmentioning

confidence: 99%

Ventilatory support and mechanical properties of the fibrotic lung acting as a “squishy ball”

Marchioni

Tonelli

Rossi

et al. 2020

Ann. Intensive Care

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Protective ventilation is the cornerstone of treatment of patients with the acute respiratory distress syndrome (ARDS); however, no studies have yet established the best ventilatory strategy to adopt when patients with acute exacerbation of interstitial lung disease (AE-ILD) are admitted to the intensive care unit. Due to the severe impairment of the respiratory mechanics, the fibrotic lung is at high risk of developing ventilator-induced lung injury, regardless of the lung fibrosis etiology. The purpose of this review is to analyze the effects of mechanical ventilation in AE-ILD and to increase the knowledge on the characteristics of fibrotic lung during artificial ventilation, introducing the concept of "squishy ball lung". The role of positive end-expiratory pressure is discussed, proposing a "lung resting strategy" as opposed to the "open lung approach". The review also discusses the practical management of AE-ILD patients discussing illustrative clinical cases.

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Close down the lungs and keep them resting to minimize ventilator-induced lung injury

Cited by 76 publications

References 47 publications

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study

Intraoperative ventilator settings and their association with postoperative pulmonary complications in neurosurgical patients: post-hoc analysis of LAS VEGAS study

VENTILatOry strategies in patients with severe traumatic brain injury: the VENTILO Survey of the European Society of Intensive Care Medicine (ESICM)

Ventilatory support and mechanical properties of the fibrotic lung acting as a “squishy ball”

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