Extracorporeal CO&lt;sub&gt;2&lt;/sub&gt; Removal

Terragni, Pierpaolo; Birocco, Alberto; Faggiano, Chiara; Ranieri, V. Marco

doi:10.1159/000313758

Cited by 39 publications

(33 citation statements)

References 28 publications

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“…Irrespective of the CMV vs. SV strategy, achieving a P/F ≥ 150−200 swiftly should be the concern (~30 min [47] vs. a few hours [90,91] vs. a few days [28,30,48,71,92]). The take-home message remains: "avoid tracheal tubes, minimize sedation, prevent ventilator-induced lung injury and nosocomial infections" [69]. Thus, we [27,28,30,71,93] capitalize on previous approaches to move faster in the same direction.…”

Section: B Anything New Under the Sun? Yes: Analytical Management!mentioning

confidence: 99%

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: B Anything New Under the Sun? Yes: Analytical Management!mentioning

confidence: 99%

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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Section: Physiology-based Trialsmentioning

confidence: 99%

“…To achieve a low driving pressure and high PEEP, an ultra-low Vt can be achieved using CO 2 removal [37] or high frequency ventilation. As CO 2 is much more diffusible than O 2 , venovenous CO 2 removal using a low flow through extra-renal replacement (ERR) will allow [37] the use of an ultra-low Vt and increases in the PEEP with an acceptable Pplat (≤ 25−30 cm H 2 O) and PaCO 2 . Accordingly, arterio-venous CO 2 removal allowed earlier weaning in patients with mild + severe ARDS (P/F < 150), lowered the midazolam + sufentanil requirements and increased spontaneous ventilation [155].…”

Section: Physiology-based Trialsmentioning

confidence: 99%

“…The answer to this question would explain why ARDS was postulated to be partially generated by mechanical ventilation [33−36] irrespective of the progression of the disease (iatrogenic disease or ventilator-induced lung injury (VILI)). This hypothesis implies swift therapy ("avoid tracheal tubes, minimize sedation, prevent ventilator-induced lung injury and nosocomial infections" [37]) and led to the biases exposed above].…”

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confidence: 99%

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Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Petitjeans

Pichot²,

Ghignone

et al. 2016

Anaesthesiol Intensive Ther

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Severe acute respiratory distress syndrome (ARDS, PaO 2 /FiO 2 < 100 on PEEP ≥ 5 cm H 2 O) is treated using controlled mechanical ventilation (CMV), recently combined with muscle relaxation for 48 h and prone positioning. While the amplitude of tidal volume appears set £ 6 mL kg -1 , the level of positive end-expiratory pressure (PEEP) remains controversial. This overview summarizes several salient points, namely: a) ARDS is an oxygenation defect: consolidation/difuse alveolar damage is reversed by PEEP and/or prone positioning, at least during the early phase of ARDS b) ARDS is a dynamic disease and partially iatrogenic. This implies that the management of the ventilator may be a life-saver by reducing the duration of mechanical ventilation, or detrimental by extending this duration, leading into critical care-acquired diseases. Indeed, a high PEEP (10−24 cm H 2 O) appears to be a life-saver in the context of early severe diffuse ARDS; c) tidal volume and plateau pressure cannot be identical for all patients; d) the only remaining rationale for CMV and muscle relaxation is to suppress patient-ventilator asynchrony and to lower VO 2 , during the acute cardio-ventilatory distress. Therefore, in early severe diffuse ARDS, this review argues for a combination of a high PEEP (preferably titrated on transpulmonary pressure) with spontaneous ventilation + pressure support (or newer modes of ventilation). However, conditionalities are stringent: upfront circulatory optimization, upright positioning, lowered VO 2 , lowered acidotic and hypercapnic drives, sedation without ventilatory depression and without lowered muscular tone. As these propositions require evidence-based demonstration, the accepted practice remains, in 2016, controlled mechanical ventilation, muscle relaxation, and prone position.

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“…Indeed, one referee complimented our non-invasive management: "avoid tracheal tubes, minimize sedation, prevent ventilator-induced lung injury and nosocomial infections" [21]. Conversely, another referee considered this [3] management as malpractice (P 140, l 7).…”

Section: Referencesmentioning

confidence: 99%

Cut-off point for switching from non- -invasive ventilation to intubation in severe ARDS. Fifty shades of grey?

Quintin

2016

Anaesthesiol Intensive Ther

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Extracorporeal CO<sub>2</sub> Removal

Abstract: Abstract

Cited by 39 publications

References 28 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?

Early severe acute respiratory distress syndrome: What’s going on? Part I: pathophysiology

Cut-off point for switching from non- -invasive ventilation to intubation in severe ARDS. Fifty shades of grey?

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