Transpulmonary Pressure and Gas Exchange During Decremental PEEP Titration in Pulmonary ARDS Patients

Rodríguez, Pablo; Bonelli, Ignacio; Setten, Mariano; Attie, Shiry; Madorno, Matías; Maskin, Luis Patricio; Valentini, Ricardo

doi:10.4187/respcare.01977

Cited by 36 publications

(12 citation statements)

References 34 publications

(41 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The inspiratory and expiratory transpulmonary pressures were calculated by subtracting the inspiratory and expiratory esophageal pressures from the plateau pressure and PEEP, respectively. ( 24 ) Hemodynamic stability was assured in all patients by monitoring of clinical parameters (heart rate, mucous membrane color, capillary refill time and temperature), systolic blood pressure using the noninvasive Doppler technique (Parks Electronical Doppler Model 811B, Perimed UK, Bury St Edmunds, UK) and pulse oximetry (measured in the tongue) (Oximax NPB-40; Nellcor TM Puritan Bennett Inc. 710 Medtronic Parkway, Minneapolis, EUA)…”

Section: Methodsmentioning

confidence: 99%

Sizing the lung in dogs: the inspiratory capacity defines the tidal volume

Donati¹,

Gogniat²,

Madorno³

et al. 2018

Revista Brasileira De Terapia Intensiva

View full text Add to dashboard Cite

ObjectiveTo evaluate a novel physiological approach for setting the tidal volume in mechanical ventilation according to inspiratory capacity, and to determine if it results in an appropriate mechanical and gas exchange measurements in healthy and critically ill dogs.MethodsTwenty healthy animals were included in the study to assess the tidal volume expressed as a percentage of inspiratory capacity. For inspiratory capacity measurement, the mechanical ventilator was set as follows: pressure control mode with 35cmH2O of inspired pressure and zero end-expiratory pressure for 5 seconds. Subsequently, the animals were randomized into four groups and ventilated with a tidal volume corresponding to the different percentages of inspiratory capacity. Subsequently, ten critically ill dogs were studied.ResultsHealthy dogs ventilated with a tidal volume of 17% of the inspiratory capacity showed normal respiratory mechanics and presented expected PaCO2 values more frequently than the other groups. The respiratory system and transpulmonary driving pressure were significantly higher among the critically ill dogs but below 15 cmH2O in all cases.ConclusionsThe tidal volume based on the inspiratory capacity of each animal has proven to be a useful and simple tool when setting ventilator parameters. A similar approach should also be evaluated in other species, including human beings, if we consider the potential limitations of tidal volume titration based on the calculated ideal body weight.

show abstract

Section: Methodsmentioning

confidence: 99%

Sizing the lung in dogs: the inspiratory capacity defines the tidal volume

Donati¹,

Gogniat²,

Madorno³

et al. 2018

Revista Brasileira De Terapia Intensiva

View full text Add to dashboard Cite

show abstract

“…The presence of less than 10% non-aerated areas in the CT at end-expiration and the slightly positive P TPEE values confirm the adequate PEEP level used in this experimental model [ 10 , 26 ]. Moreover, it has been suggested that the optimal PEEP level in ARDS and IAH patients is the level reached after adjustment to the best Crs after lung recruitment [ 42 ] and interchangeable with a PEEP titration to best Ptp [ 43 ].…”

Section: Discussionmentioning

confidence: 99%

Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance

et al. 2015

View full text Add to dashboard Cite

IntroductionThe stress index (SI), a parameter derived from the shape of the pressure-time curve, can identify injurious mechanical ventilation. We tested the hypothesis that adjusting tidal volume (VT) to a non-injurious SI in an open lung condition avoids hypoventilation while preventing overdistension in an experimental model of combined lung injury and low chest-wall compliance (Ccw).MethodsLung injury was induced by repeated lung lavages using warm saline solution, and Ccw was reduced by controlled intra-abdominal air-insufflation in 22 anesthetized, paralyzed and mechanically ventilated pigs. After injury animals were recruited and submitted to a positive end-expiratory pressure (PEEP) titration trial to find the PEEP level resulting in maximum compliance. During a subsequent four hours of mechanical ventilation, VT was adjusted to keep a plateau pressure (Pplat) of 30 cmH2O (Pplat-group, n = 11) or to a SI between 0.95 and 1.05 (SI-group, n = 11). Respiratory rate was adjusted to maintain a ‘normal’ PaCO2 (35 to 65 mmHg). SI, lung mechanics, arterial-blood gases haemodynamics pro-inflammatory cytokines and histopathology were analyzed. In addition Computed Tomography (CT) data were acquired at end expiration and end inspiration in six animals.ResultsPaCO2 was significantly higher in the Pplat-group (82 versus 53 mmHg, P = 0.01), with a resulting lower pH (7.19 versus 7.34, P = 0.01). We observed significant differences in VT (7.3 versus 5.4 mlKg−1, P = 0.002) and Pplat values (30 versus 35 cmH2O, P = 0.001) between the Pplat-group and SI-group respectively. SI (1.03 versus 0.99, P = 0.42) and end-inspiratory transpulmonary pressure (PTP) (17 versus 18 cmH2O, P = 0.42) were similar in the Pplat- and SI-groups respectively, without differences in overinflated lung areas at end- inspiration in both groups. Cytokines and histopathology showed no differences.ConclusionsSetting tidal volume to a non-injurious stress index in an open lung condition improves alveolar ventilation and prevents overdistension without increasing lung injury. This is in comparison with limited Pplat protective ventilation in a model of lung injury with low chest-wall compliance.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0726-3) contains supplementary material, which is available to authorized users.

show abstract

“…(37) Another study suggested that calculation of the stress index was better than either plateau pressure or P TP for preventing overdistention injury. (38) Stress index is a characteristic of the airway pressure-time relationship during tidal ventilation that reflects the balance between alveolar overdistention and cyclic recruitment-derecruitment.…”

Section: Other Methods For Avoiding Vilimentioning

confidence: 99%

The promises and problems of transpulmonary pressure measurements in acute respiratory distress syndrome

Sahetya

Brower

2016

Current Opinion in Critical Care

View full text Add to dashboard Cite

Purpose of Review The optimal strategy for assessing and preventing ventilator induced lung injury in the acute respiratory distress syndrome (ARDS) is controversial. Recent investigative efforts have focused on personalizing ventilator settings to individual respiratory mechanics. This review examines the strengths and weaknesses of using transpulmonary pressure measurements to guide ventilator management in ARDS. Recent findings Recent clinical studies suggest that adjusting ventilator settings based on transpulmonary pressure measurements is feasible, may improve oxygenation, and reduce ventilator induced lung injury Summary The measurement of transpulmonary pressure relies upon esophageal manometry, which requires the acceptance of several assumptions and potential errors. Notably, this includes the ability of localized esophageal pressures to represent global pleural pressure. Recent investigations demonstrated improved oxygenation in ARDS patients when PEEP was adjusted to target a specific end-inspiratory or end-expiratory transpulmonary pressures. However, there are different methods for estimating transpulmonary pressure and different goals for PEEP titration among recent studies. More research is needed to refine techniques for the estimation and utilization of transpulmonary pressure to guide ventilator settings in ARDS patients.

show abstract

Transpulmonary Pressure and Gas Exchange During Decremental PEEP Titration in Pulmonary ARDS Patients

Cited by 36 publications

References 34 publications

Sizing the lung in dogs: the inspiratory capacity defines the tidal volume

Sizing the lung in dogs: the inspiratory capacity defines the tidal volume

Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance

The promises and problems of transpulmonary pressure measurements in acute respiratory distress syndrome

Contact Info

Product

Resources

About