Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI)

Nieman, Gary F.; Satalin, Joshua; Andrews, Penny; Aiash, Hani; Habashi, Nader M.; Gatto, Louis A.

doi:10.1186/s40635-017-0121-x

Cited by 107 publications

(100 citation statements)

References 120 publications

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“…There is no consensus on how best to set PEEP to effectively stabilize lung tissue (Coruh and Luks, 2014;Gattinoni et al, 2017;Nieman et al, 2017a;Bergez et al, 2019). The current ARDSnet method for setting PEEP uses a sliding scale of oxygenation (Acute Respiratory Distress Syndrome Network, 2000), but increased oxygenation does not correlate well with an increase in alveolar stability (Andrews et al, 2015), a key VILI mechanism (Wellman et al, 2014(Wellman et al, , 2016Cereda et al, 2016bCereda et al, , 2017.…”

Section: Problems With Stabilizing the Lungmentioning

confidence: 99%

“…Many methods have been used in an attempt to titrate the PEEP to stabilize lung tissue. These methods include using dead space, lung stress and strain, lung compliance, CT, pressure-volume curve inflection points, and electrical impedance tomography, but there is no current bedside technique to determine whether the set PEEP has actually stabilized the lung (Nieman et al, 2017a). The above problems with the ARDSnet protect, rest, and stabilize method may partially explain the lack of improved outcome in ARDS mortality over the last 20 years (Figure 1) (Brun-Buisson et al, 2004;Phua et al, 2009;Villar et al, 2011;Caser et al, 2014;Bellani et al, 2016;Laffey et al, 2016;Villar et al, 2016;Maca et al, 2017;Raymondos et al, 2017;Rezoagli et al, 2017;Fan et al, 2018;McNicholas et al, 2018;Pham et al, 2019).…”

Section: Problems With Stabilizing the Lungmentioning

confidence: 99%

“…Indeed, our work in translational animal models and a meta-analysis of data on surgical intensive care unit (SICU) patients has shown that our time-controlled adaptive ventilation (TCAV) method, using airway pressure release ventilation (APRV) mode, is highly effective at keeping the lung open and stable, significantly reducing morbidity in translational animal models and reducing the ARDS incidence and mortality rates of SICU patients at high risk of developing ARDS (Roy et al, 2012;Andrews et al, 2013;Emr et al, 2013;Roy S.K. et al, 2013;Kollisch-Singule et al, 2014a,b, 2015aNieman et al, Nieman et al, 2015, 2017aSmith et al, 2015;Jain et al, 2016Jain et al, , 2017Satalin et al, 2018;Silva et al, 2018;Mahajan et al, 2019).…”

Section: A Physiologically Informed Strategy To Effectively Open and mentioning

confidence: 99%

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A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

et al. 2020

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Acute respiratory distress syndrome (ARDS) causes a heterogeneous lung injury and remains a serious medical problem, with one of the only treatments being supportive care in the form of mechanical ventilation. It is very difficult, however, to mechanically ventilate the heterogeneously damaged lung without causing secondary ventilatorinduced lung injury (VILI). The acutely injured lung becomes time and pressure dependent, meaning that it takes more time and pressure to open the lung, and it recollapses more quickly and at higher pressure. Current protective ventilation strategies, ARDSnet low tidal volume (LVt) and the open lung approach (OLA), have been unsuccessful at further reducing ARDS mortality. We postulate that this is because the LVt strategy is constrained to ventilating a lung with a heterogeneous mix of normal and focalized injured tissue, and the OLA, although designed to fully open and stabilize the lung, is often unsuccessful at doing so. In this review we analyzed the pathophysiology of ARDS that renders the lung susceptible to VILI. We also analyzed the alterations in alveolar and alveolar duct mechanics that occur in the acutely injured lung and discussed how these alterations are a key mechanism driving VILI. Our analysis suggests that the time component of each mechanical breath, at both inspiration and expiration, is critical to normalize alveolar mechanics and protect the lung from VILI. Animal studies and a meta-analysis have suggested that the time-controlled adaptive ventilation (TCAV) method, using the airway pressure release ventilation mode, eliminates the constraints of ventilating a lung with heterogeneous injury, since it is highly effective at opening and stabilizing the time-and pressure-dependent lung. In animal studies it has been shown that by "casting open" the acutely injured lung with TCAV we can (1) reestablish normal expiratory lung volume as assessed by direct observation of subpleural alveoli; (2) return normal parenchymal microanatomical structural support, known as alveolar interdependence and parenchymal tethering, as assessed by morphometric analysis of lung histology; (3) facilitate regeneration of normal surfactant function measured as increases in surfactant proteins A and B; and (4) significantly increase lung compliance, which reduces the pathologic impact of driving pressure and mechanical power at any given tidal volume.

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Section: Problems With Stabilizing the Lungmentioning

confidence: 99%

Section: Problems With Stabilizing the Lungmentioning

confidence: 99%

Section: A Physiologically Informed Strategy To Effectively Open and mentioning

confidence: 99%

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A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

et al. 2020

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“…In current literature, APRV is recommended as a protective mode of PPV, favored above a majority of traditional modes for ARDS management [36]. A recent review by Niemen, et al suggests that APRV allows for personalization in generating intrinsic PEEP to stabilize the lung and avoid VILI [37].…”

Section: Aprv Current Considerationsmentioning

confidence: 99%

An Investigation of Various Inspiratory Times and Inflation Pressures during Airway Pressure Release Ventilation

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E²,

C³

et al. 2019

Int J Respir Pulm Med

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An Evaluation of Various Inspiratory Times and Inflation Pressures During Airway Pressure Release Ventilation. Introduction: There are few recommendations how best to apply certain modes of mechanical ventilation, and the application of Airway Pressure Release Ventilation (APRV) requires strategic implementation of specific inspiratory (I-time) and expiratory times (E-time) and particular mean airway pressures (MAWP), neither of which is standardized. We sought to identify whether an ideal I-time or MAWP could be identified to favor more positive clinical outcomes. Methods: A retrospective analysis of archived electronic health record data to evaluate the clinical outcomes of adult patients that had been placed on APRV for a target of at least 8 hours. 68 adult subjects were evaluated from a convenient sample. Results: All outcomes of interest (surrogates) for shortterm clinical outcomes to include the PaO 2 /FiO 2 (P/F) ratio, Oxygen Index (OI), Oxygen Saturation Index (OSI), and Modified Sequential Organ Failure Assessment (MSOFA) scores showed improvement after at least approximately 8 hours on APRV. Most notably, there was significant improvement in P/F ratio (p = 0.012) and OSI (p = 0.000). Results of regression analysis showed MAWP as a significant positive predictor of post-APRV OSI and P high as a significant positive predictor of post-APRV MSOFA score. Conclusion: In summary, it was found that settings for P high, Plow, and T low in addition to overall MAWP and Body Mass Index (BMI) had significant correlation to impact at least one of the short-term clinical outcomes measured with a lower setting for both P high and MAWP predictive of a better post-APRV OSI and MSOFA score.

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“…To summarize, the TCAV method is an extended Continuous Positive Airway Pressure (CPAP) Phase combined with a very brief Release Phase that is set and adjusted by changes in lung physiology. [21][22][23][24][25][26][27] The TCAV method has been shown effective at treating unilateral ALI (pulmonary contusion and pneumonia) where the patient's lungs have significantly different compliance. [28-32] Unilateral lung injury would therefore be a similar to ventilating two patients, each with a different lung compliance, on one ventilator and suggest that TCAV can simultaneously ventilate two lungs with different compliances.…”

Section: Introductionmentioning

confidence: 99%

Ventilating Two Subjects with One Ventilator: Achievable but not Advisable

Satalin

Blair

Kollisch-Singule

et al. 2020

Preprint

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Background: The world is in the midst of the COVID-19 viral pandemic and the number of patients requiring mechanical ventilation may exceed the number of ventilators available. New information is being sought on the feasibility of using one ventilator on multiple patients should the need arise. In this study, we hypothesized that two rabbits could be simultaneously mechanically ventilated using a simple, readily available, dual circuit. Methods: Two pairs of New Zealand White rabbits (n=4) were anesthetized and hooked up to a simple dual circuit and ventilated in the Airway Pressure Release Ventilation mode. Arterial and venous lines were placed for arterial blood gases, hemodynamic monitoring and fluid administration. Following one hour of ventilation, a surfactant washout was performed and mechanical ventilation resumed. Animals were euthanized after an additional one hour of ventilation. Results: Both Pairs of rabbits had a similar pre-injury PaO2/FiO2 ratio. Following injury, all rabbits had a decline in PaO2/FiO2 with 2 maintaining a PaO2/FiO2 ratio consistent with moderate ARDS, 1 consistent with mild and 1 return to normal. Both Pairs of rabbits had a similar pre-injury PaCO2. Rabbits in Pair 1 maintained similar arterial carbon dioxide (PaCO2) levels following ARDS. Pair 2 showed an increase in PaCO2 with ARDS due to the much higher PaCO2 in the rabbit with the more severe lung injury.Conclusion: A dual ventilator circuit can be constructed from materials in any respiratory therapy department. Using this dual circuit, two animals with ARDS can be oxygenated and ventilation sufficiently to meet current standards.

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Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI)

Cited by 107 publications

References 120 publications

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

An Investigation of Various Inspiratory Times and Inflation Pressures during Airway Pressure Release Ventilation

Ventilating Two Subjects with One Ventilator: Achievable but not Advisable

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