Intrinsic positive end-expiratory pressure during ventilation through small endotracheal tubes during general anesthesia: incidence, mechanism, and predictive factors

Gemma, Marco; Nicelli, Elisa; Corti, D; Vitis, Assunta De; Patroniti, Nicolò; Calvi, Maria Rosa; Beretta, Luigi

doi:10.1016/j.jclinane.2016.01.029

Cited by 3 publications

(2 citation statements)

References 21 publications

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“…In paper III we found that by applying respiratory resistance the time constant increased but so did the intrinsic PEEP. This is in coherence with previous studies that have shown that increased resistance in healthy lungs increases time constant, induces hyperinflation [149][150][151], increases carbon dioxide and decreases cardiac output [149,152]. Increasing PEEP irrespective of resistance increases the time constant too.…”

Section: Discussionsupporting

confidence: 92%

Transpulmonary driving pressure during mechanical ventilation–validation of a non‐invasive measurement method

Gudmundsson

Persson

Perchiazzi

et al. 2019

Acta Anaesthesiol Scand

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Background: One of the most common diagnoses in the intensive care unit is acute respiratory failure. In its most severe form it is called acute respiratory distress syndrome and often requires mechanical ventilation. The main challenge for physicians is to provide mechanical ventilation that treats the patient´s hypoxia, which can be due to a variety of causes, without damaging the lung. Method:In paper I computed tomography scans were acquired in ten anesthetized surfactant depleted pigs. The volume of gas and atelectasis were correlated with transpulmonary pressure as the pressure support and PEEP were lowered. In paper II a non-invasive method for measuring transpulmonary driving pressure was validated in 31 mechanically ventilated intensive care patients. In paper III external expiratory resistors were added to the expiratory limb of the ventilator while calculating expiratory time constant, respiratory compliance, driving pressure and intrinsic PEEP in 12 anesthetized pigs. In paper IV transpulmonary pressure was calculated from esophageal pressure in supine and prone position in 10 anesthetized lung healthy patients.Results: Gradual decrease in transpulmonary pressure causes a proportional increase in atelectasis and decrease in gas content while the work of breathing increases. There is a good statistical agreement between the conventional and the non-invasive method for measuring transpulmonary driving pressure. Increasing the expiratory resistance increases the expiratory time constant and increases intrinsic PEEP in healthy lungs. There is a great variability in esophageal pressure in the part of the esophagus 22 -44cm from the nostrils in both supine and prone position. Depending on method the transpulmonary pressure either increases or decreases when patients are turned in prone position. Conclusion:There is no transpulmonary pressure threshold, where atelectasis with desaturation or cyclic collapse suddenly occurs during gradual decrease in the ventilator support. The PEEP-step method is comparable to the traditional esophageal balloon method for measuring transpulmonary driving pressure. The application of expiratory resistors could be useful during weaning from mechanical ventilation. The mean end-expiratory esophageal pressure changes which affect the calculation of transpulmonary pressure but uncertainties about the use of absolute esophageal pressure remains.

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Section: Discussionsupporting

confidence: 92%

Transpulmonary driving pressure during mechanical ventilation–validation of a non‐invasive measurement method

Gudmundsson

Persson

Perchiazzi

et al. 2019

Acta Anaesthesiol Scand

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“…4 Due to incomplete exhalation, dynamic hyperinflation (commonly referred to as 'gas trapping' or 'stacking') can occur. 5,6 This results in accumulation of intrathoracic gas volume, with increasing intrathoracic pressure, leading to cardiovascular depression and pulmonary injury. Due to known complications associated with over-distension and excessive ventilatory pressures, 1,7 concerns have been raised regarding the safety of ventilation through small airway devices, when upper airway obstruction impedes the escape of excess gas from the lungs.…”

Section: Introductionmentioning

confidence: 99%

Ventilation strategies for front of neck airway rescue: an in silico study

Laviola

Niklas

Das

et al. 2021

British Journal of Anaesthesia

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A new perspective during laryngo-tracheal surgery: the use of an ultra-thin endotracheal tube (Tritube®) and flow-controlled ventilation—a retrospective case series and a review of the literature

Grassetto

Pettenuzzo

Badii

et al. 2022

J Anesth Analg Crit Care

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Background Upper airway surgery often poses a challenge to both anesthesiologists and surgeons, as airway access, mechanical ventilation, and surgical difficulties may occur in a tricky combination. To fulfill the need for a tubeless surgery, techniques such as apneic oxygenation or jet ventilation may be used, which carry the risk of several complications. The ultrathin cuffed endotracheal tube Tritube can be used with flow-controlled ventilation (FCV) to provide adequate surgical field and ventilation. To assess the feasibility, safety, and effectiveness of this technique, we describe a series of 21 patients, with various lung conditions, undergoing laryngo-tracheal surgery with FCV delivered via Tritube. Moreover, we perform a narrative systematic review to summarize clinical data on the use of Tritube during upper airway surgery. Results All patients were successfully intubated in one attempt with Tritube. The median (interquartile range [IQR]) tidal volume was 6.7 (6.2–7.1) mL/kg of ideal body weight, the median end-expiratory pressure was 5.3 (5.0–6.4) cmH2O, and the median peak tracheal pressure was 16 (15–18) cmH2O. The median minute volume was 5.3 (5.0–6.4) L/min. Median global alveolar driving pressure was 8 (7–9) cmH2O. The median maximum level of end-tidal CO2 was 39 (35–41) mmHg. During procedures involving laser, the maximum fraction of inspired oxygen was 0.3, with the median lowest peripheral oxygen saturation of 96% (94–96%). No complications associated with intubation or extubation occurred. In one patient, the ventilator needed to be rebooted for a software issue. In two (10%) patients, Tritube needed to be flushed with saline to remove secretions. In all patients, optimal visualization and accessibility of the surgical site were obtained, according to the surgeon in charge. Thirteen studies (seven case reports, two case series, three prospective observational studies, and one randomized controlled trial) were included in the narrative systematic review and described. Conclusions Tritube in combination with FCV provided adequate surgical exposure and ventilation in patients undergoing laryngo-tracheal surgery. While training and experience with this new method is needed, FCV delivered with Tritube may represent an ideal approach that benefits surgeons, anesthesiologists, and patients with difficult airways and compromised lung mechanics.

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Intrinsic positive end-expiratory pressure during ventilation through small endotracheal tubes during general anesthesia: incidence, mechanism, and predictive factors

Cited by 3 publications

References 21 publications

Transpulmonary driving pressure during mechanical ventilation–validation of a non‐invasive measurement method

Transpulmonary driving pressure during mechanical ventilation–validation of a non‐invasive measurement method

Ventilation strategies for front of neck airway rescue: an in silico study

A new perspective during laryngo-tracheal surgery: the use of an ultra-thin endotracheal tube (Tritube®) and flow-controlled ventilation—a retrospective case series and a review of the literature

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