Use of intrathoracic pressure regulation therapy in breathing patients for the treatment of hypotension secondary to trauma

Abstract

BackgroundIntrathoracic pressure regulation (IPR) therapy has been shown to increase blood pressure in hypotensive patients. The potential value of this therapy in patients with hypotension secondary to trauma with bleeding is not well understood. We hypothesized that IPR would non-invasively and safely enhance blood pressure in spontaneously breathing patients with trauma-induced hypotension.MethodsThis prospective observational cohort study assessed vital signs from hypotensive patients with a systolic blood pressure (SBP) ≤90 mmHg secondary to trauma treated with IPR (ResQGARD™, ZOLL Medical) by pre-hospital emergency medical personnel in three large US metropolitan areas. Upon determination of hypotension, facemask-based IPR was initiated as long as bleeding was controlled. Vital signs were recorded before, during, and after IPR. An increased SBP with IPR use was the primary study endpoint. Device tolerance and ease of use were also reported.ResultsA total of 54 patients with hypotension secondary to trauma were treated from 2009 to 2016. The mean ± SD SBP increased from 80.9 ± 12.2 mmHg to 106.6 ± 19.2 mmHg with IPR (p < 0.001) and mean arterial pressures (MAP) increased from 62.2 ± 10.5 mmHg to 81.9 ± 16.6 mmHg (p < 0.001). There were no significant changes in mean heart rate or oxygen saturation. Approximately 75% of patients reported moderate to easy tolerance of the device. There were no safety concerns or reported adverse events.ConclusionsThese findings support the use of IPR to treat trauma-induced hypotension as long as bleeding has been controlled.

Mechanisms of inspiration that modulate cardiovascular control: the other side of breathing

“…These studies demonstrated that spontaneous breathing against inspiratory resistance increased during progressive central hypovolemia (22,63,66), an outcome that was associated with increased stroke volume (66), cardiac output (66), arterial blood pressure (22,66), and improved cerebral blood flow dynamics with delayed symptoms (63). When translated to the treatment of more than 250 hypotensive patients in studies conducted at independent sites during prehospital transport, average blood pressure increased from 80/50 mmHg to~100/65 mmHg with a 47% increase in pulse pressure and improved feelings of well-being reported in Ͼ85% of the patients (10,11,44,70,78,79). When applied to 20 normovolemic anesthetized patients who underwent coronary artery bypass graft before sternotomy, inspiratory resistance caused cardiac output to increase by Ͼ12% while maintaining arterial blood pressure (34).…”

Anesthetic management of thoracoscopic procedures in neonates: a retrospective analysis of 45 cases

“…Intraoperative hypercarbia was largely due to CO 2 insufflation and was treated by hyperventilation. Some studies have reported that infants who undergo thoracoscopic surgery are more likely to develop hypercapnia (19). Sevoflurane (0.5-1.0 MAC) and an intravenous infusion of remifentanil (0.2-0.3 mg /kg/min) were used to maintain general anesthesia.…”

Saving the brain after mild-to-moderate traumatic injury: A report on new insights of the physiology underlying adequate maintenance of cerebral perfusion

“…Although human experimental evidence for enhancing cerebral perfusion with IPR therapy is compelling, translation to clinical use is essential. In this regard, IPR therapy application for the treatment of all-cause hypotension in a civilian prehospital setting resulted in elevation of ABP from approximately 80/45 mm Hg to approximately 100/60 mm Hg with amelioration of symptoms 22,36 . It is important to note that elevated ABP elicited by IPR therapy in spontaneously breathing trauma patients with hemorrhage remained in a hypotensive level with no evidence of increased bleeding 36 …”

“…In this regard, IPR therapy application for the treatment of all-cause hypotension in a civilian prehospital setting resulted in elevation of ABP from approximately 80/45 mm Hg to approximately 100/60 mm Hg with amelioration of symptoms. 22,36 It is important to note that elevated ABP elicited by IPR therapy in spontaneously breathing trauma patients with hemorrhage remained in a hypotensive level with no evidence of increased bleeding. 36 Although elevated ABP reported in hypotensive patients using IPR therapy is encouraging for treatment of TBI, measurements of cerebral hemodynamics are rare.…”

“…22,36 It is important to note that elevated ABP elicited by IPR therapy in spontaneously breathing trauma patients with hemorrhage remained in a hypotensive level with no evidence of increased bleeding. 36 Although elevated ABP reported in hypotensive patients using IPR therapy is encouraging for treatment of TBI, measurements of cerebral hemodynamics are rare. Because of the potential effect of reducing ICP, IPR therapy has been proposed as a noninvasive method to enhance cerebral perfusion in brain-injured patients.…”