Monitoring Patient Respiratory Effort During Mechanical Ventilation: Lung and Diaphragm-Protective Ventilation

Bertoni, Michele; Spadaro, Savino; Goligher, Ewan C.

doi:10.1186/s13054-020-2777-y

Cited by 81 publications

(76 citation statements)

References 55 publications

(64 reference statements)

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“…In the current investigation we showed how the inspiratory swing of CVP, a near-ubiquitous monitoring in the ICU, can be used to track inspiratory effort with an acceptable accuracy. Since monitoring of inspiratory effort was suggested for patients at higher risk of complications from injurious breathing [10], such as those with more severe lung injury or systemic inflammation, and patients with COVID-19-associated acute respiratory failure have a form of injury that was found similar to patients with ARDS unrelated to COVID-19 [51], we speculate that using ΔCVP to assess inspiratory effort may be a useful tool in other patients with acute hypoxemic respiratory failure.…”

Section: Clinical Impactmentioning

confidence: 99%

“…The association between variables was expressed as the coefficient of determination (R 2 ). The diagnostic performance of the CVP swing and diaphragm TR for detecting either a low or a high inspiratory effort (arbitrarily defined as an esophageal pressure swing < 5 and > 8 cmH 2 O, respectively) [10,11] was assessed by calculating the area under the Receiver Operating Characteristic (ROC) curve, sensitivity, specificity, positive and negative predictive value. To calculate positive and negative predictive values, the prevalence of the condition in the population was assumed to be equal to the prevalence in the sample.…”

Section: Statisticsmentioning

confidence: 99%

“…We investigated the diagnostic characteristics of central venous pressure swing and diaphragm thickening ratio in detecting a low or a high inspiratory effort, as defined by widely accepted threshold values of esophageal pressure swing [10,11]. Concerning a low level of inspiratory effort, both indices had a similar diagnostic performance, as assessed by the area under the ROC curve.…”

Section: Diagnostic Performancementioning

confidence: 99%

“…Pressure Support Ventilation is the assisted ventilation modality most widely used during the weaning phase [7,8], in which the work of breathing ventilation is shared between the ventilator and the patient [9]. Since an excessive unloading of the diaphragm may lead to the development of disuse atrophy, while an insufficient ventilator assistance may be associated vigorous spontaneous efforts and the consequent co-development of under assistance diaphragm myotrauma and self-inflicted lung injury [10,11], an acceptable level of muscle unloading while preserving spontaneous breathing is generally suggested as the most reasonable strategy to avoid complications and achieve a successful weaning from mechanical ventilation [12].…”

Section: Introductionmentioning

confidence: 99%

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Central venous pressure swing outperforms diaphragm ultrasound as a measure of inspiratory effort during pressure support ventilation in COVID-19 patients

Lassola

Miori

Sanna

et al. 2021

J Clin Monit Comput

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Purpose The COVID-19-related shortage of ICU beds magnified the need of tools to properly titrate the ventilator assistance. We investigated whether bedside-available indices such as the ultrasonographic changes in diaphragm thickening ratio (TR) and the tidal swing in central venous pressure (ΔCVP) are reliable estimates of inspiratory effort, assessed as the tidal swing in esophageal pressure (ΔPes). Methods Prospective, observational clinical investigation in the intensive care unit of a tertiary care Hospital. Fourteen critically-ill patients were enrolled (age 64 ± 7 years, BMI 29 ± 4 kg/m2), after 6 [3; 9] days from onset of assisted ventilation. A three-level pressure support trial was performed, at 10 (PS10), 5 (PS5) and 0 cmH2O (PS0). In each step, the esophageal and central venous pressure tidal swing were recorded, as well as diaphragm ultrasound. Results The reduction of pressure support was associated with an increased respiratory rate and a reduced tidal volume, while minute ventilation was unchanged. ΔPes significantly increased with reducing support (5 [3; 8] vs. 8 [14; 13] vs. 12 [6; 16] cmH2O, p < 0.0001), as did the diaphragm TR (9.2 ± 6.1 vs. 17.6 ± 7.2 vs. 28.0 ± 10.0%, p < 0.0001) and the ΔCVP (4 [3; 7] vs. 8 [5; 9] vs. 10 [7; 11] cmH2O, p < 0.0001). ΔCVP was significantly associated with ΔPes (R2 = 0.810, p < 0.001), as was diaphragm TR, albeit with a lower coefficient of determination (R2 = 0.399, p < 0.001). Conclusions In patients with COVID-19-associated respiratory failure undergoing assisted mechanical ventilation, ΔCVP is a better estimate of inspiratory effort than diaphragm ultrasound.

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Section: Clinical Impactmentioning

confidence: 99%

Section: Statisticsmentioning

confidence: 99%

Section: Diagnostic Performancementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Central venous pressure swing outperforms diaphragm ultrasound as a measure of inspiratory effort during pressure support ventilation in COVID-19 patients

Lassola

Miori

Sanna

et al. 2021

J Clin Monit Comput

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“…Airway occlusion pressure ( P 0.1 ) is a simple, non-invasive measure for estimating respiratory drive during mechanical ventilation, which can be used automatically in almost all mechanical ventilators [ 8 , 9 ]. P 0.1 is defined as the negative airway pressure occurring during the first 0.1 s of an occluded inspiration (Fig.…”

Section: Respiratory Drive and Effortmentioning

confidence: 99%

Oxygen administration for patients with ARDS

Ohshimo

2021

j intensive care

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Acute respiratory distress syndrome (ARDS) is a fatal condition with insufficiently clarified etiology. Supportive care for severe hypoxemia remains the mainstay of essential interventions for ARDS. In recent years, adequate ventilation to prevent ventilator-induced lung injury (VILI) and patient self-inflicted lung injury (P-SILI) as well as lung-protective mechanical ventilation has an increasing attention in ARDS.Ventilation-perfusion mismatch may augment severe hypoxemia and inspiratory drive and consequently induce P-SILI. Respiratory drive and effort must also be carefully monitored to prevent P-SILI. Airway occlusion pressure (P0.1) and airway pressure deflection during an end-expiratory airway occlusion (Pocc) could be easy indicators to evaluate the respiratory drive and effort. Patient-ventilator dyssynchrony is a time mismatching between patient’s effort and ventilator drive. Although it is frequently unrecognized, dyssynchrony can be associated with poor clinical outcomes. Dyssynchrony includes trigger asynchrony, cycling asynchrony, and flow delivery mismatch. Ventilator-induced diaphragm dysfunction (VIDD) is a form of iatrogenic injury from inadequate use of mechanical ventilation. Excessive spontaneous breathing can lead to P-SILI, while excessive rest can lead to VIDD. Optimal balance between these two manifestations is probably associated with the etiology and severity of the underlying pulmonary disease.High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NPPV) are non-invasive techniques for supporting hypoxemia. While they are beneficial as respiratory supports in mild ARDS, there can be a risk of delaying needed intubation. Mechanical ventilation and ECMO are applied for more severe ARDS. However, as with HFNC/NPPV, inappropriate assessment of breathing workload potentially has a risk of delaying the timing of shifting from ventilator to ECMO. Various methods of oxygen administration in ARDS are important. However, it is also important to evaluate whether they adequately reduce the breathing workload and help to improve ARDS.

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The difference in clinical features and prognosis of severe adenoviral pneumonia in children of different ages

Wang

Tan

2022

Journal of Medical Virology

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This study aims to analyze the difference in clinical features and prognosis of severe adenovirus pneumonia (SAP) in children of different ages and analyze the risk factors for poor prognosis in children with SAP. A retrospective observational study was performed to describe the clinical features and analyze the risk factors for death and postinfectious bronchiolitis obliterans (PIBO) in 303 children hospitalized with SAP from January 2015 through to January 2020. The participants were divided into four age groups: <6 months (n = 25, 8.3%); 6-12 months (n = 98, 32.3%); 12-36 months(n = 118, 38.9%); and >36 months (n = 62, 20.5%). Fever rate, peak, and duration were the lowest in the <6 months group, while no significant difference was found among other age groups. Serum levels of lactate dehydrogenase and a load of adenovirus were the lowest in the <6 months group, and the highest in the 6-12 and 12-36 months groups, respectively. A total of 80.9% of patients recovered, 3.3% of patients died, and 15.8% of patients were diagnosed with PIBO. The mortality rate showed no significance between age groups. The >36 months group had the highest recovery rate and the lowest incidence of PIBO, while the 6-12 months group had the lowest recovery rate and the highest incidence of PIBO. Independent risk factors for PIBO among all participants from the four groups were invasive mechanical ventilation, administration of intravenous steroids, duration of fever, and male gender. Independent risk factors for death among all participants from the four groups were hypercapnia, low albumin levels, and invasive mechanical ventilation.Risk factor analysis of different ages was not possible due to the limited sample size.The morbidity, clinical features, and prognosis of SAP are affected by children's ages.Pediatric patients with a longer duration of fever, hypercapnia, low serum albumin levels, invasive mechanical ventilation, and intravenous steroids use are more likely to develop a poor prognosis in SAP, especially if the patient is male.

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Monitoring Patient Respiratory Effort During Mechanical Ventilation: Lung and Diaphragm-Protective Ventilation

Cited by 81 publications

References 55 publications

Central venous pressure swing outperforms diaphragm ultrasound as a measure of inspiratory effort during pressure support ventilation in COVID-19 patients

Central venous pressure swing outperforms diaphragm ultrasound as a measure of inspiratory effort during pressure support ventilation in COVID-19 patients

Oxygen administration for patients with ARDS

The difference in clinical features and prognosis of severe adenoviral pneumonia in children of different ages

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