Personalizing mechanical ventilation for acute respiratory distress syndrome.
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ABSTRACT:
SUBMITTER: Berngard SC
PROVIDER: S-EPMC4805818 | biostudies-other | 2016 Mar
REPOSITORIES: biostudies-other
Publications
Personalizing mechanical ventilation for acute respiratory distress syndrome.
Berngard S Clark SC Beitler Jeremy R JR Malhotra Atul A
Journal of thoracic disease 20160301 3
Lung-protective ventilation with low tidal volumes remains the cornerstone for treating patient with acute respiratory distress syndrome (ARDS). Personalizing such an approach to each patient's unique physiology may improve outcomes further. Many factors should be considered when mechanically ventilating a critically ill patient with ARDS. Estimations of transpulmonary pressures as well as individual's hemodynamics and respiratory mechanics should influence PEEP decisions as well as response to ...[more]
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Project description:The current ventilatory care goal for acute respiratory distress syndrome (ARDS) and the only evidence-based approach for managing ARDS is to ventilate with a tidal volume (VT) of 6 mL/kg predicted body weight (PBW). However, it is not uncommon for some caregivers to feel inclined to deviate from this strategy for one reason or another. To accommodate this inclination in a rationalized manner, we previously developed an algorithm that allows for VT to depart from 6 mL/kg PBW based on physiological criteria. The goal of the present study was to test the feasibility of this algorithm in a small retrospective study.Current values of peak airway pressure, positive end-expiratory pressure (PEEP), and arterial oxygen saturation are used in a fuzzy logic algorithm to decide how much VT should differ from 6 mL/kg PBW and how much PEEP should change from its current setting. We retrospectively tested the predictions of the algorithm against 26 cases of decision making in 17 patients with ARDS.Differences between algorithm and physician VT decisions were within 2.5 mL/kg PBW, except in 1 of 26 cases, and differences between PEEP decisions were within 2.5 cm H2O, except in 3 of 26 cases. The algorithm was consistently more conservative than physicians in changing VT but was slightly less conservative when changing PEEP.Within the limits imposed by a small retrospective study, we conclude that our fuzzy logic algorithm makes sensible decisions while at the same time keeping practice close to the current ventilatory care goal.
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Project description:Acute respiratory distress syndrome (ARDS) is characterised by different degrees of severity and different stages. Understanding these differences can help to better adapt the ventilatory settings to protect the lung from ventilator-induced lung injury by reducing hyperinflation or keeping the lung open when it is possible. The same therapies may be useful and beneficial in certain forms of ARDS, and risky or harmful at other stages: this includes high positive end-expiratory pressure, allowance of spontaneous breathing activity or use of noninvasive ventilation. The severity of the disease is the primary indicator to individualise treatment. Monitoring tools such as oesophageal pressure or lung volume measurements may also help to set the ventilator. At an earlier stage, an adequate lung protective strategy may also help to prevent the development of ARDS.
| S-EPMC9487769 | biostudies-literature
Project description:Purpose of reviewTo review clinical evidence on whether or not to allow mechanically ventilated patients with acute respiratory distress syndrome (ARDS) to breathe spontaneously.Recent findingsObservational data (LUNG SAFE study) indicate that mechanical ventilation allowing for spontaneous breathing (SB) is associated with more ventilator-free days and a shorter stay in the intensive care unit without any effect on hospital mortality. A paediatric trial, comparing airway pressure release ventilation (APRV) and low-tidal volume ventilation, showed an increase in mortality in the APRV group. Conversely, in an unpublished trial comparing SB and controlled ventilation (NCT01862016), the authors concluded that SB is feasible but did not improve outcomes in ARDS patients.SummaryA paucity of clinical trial data continues to prevent firm guidance on if or when to allow SB during mechanical ventilation in patients with ARDS. No published large randomised controlled trial exists to inform practice about the benefits and harms of either mode.
| S-EPMC7925253 | biostudies-literature
Project description:BackgroundRecruitment manoeuvres involve transient elevations in airway pressure applied during mechanical ventilation to open ('recruit') collapsed lung units and increase the number of alveoli participating in tidal ventilation. Recruitment manoeuvres are often used to treat patients in intensive care who have acute respiratory distress syndrome (ARDS), but the effect of this treatment on clinical outcomes has not been well established. This systematic review is an update of a Cochrane review originally published in 2009.ObjectivesOur primary objective was to determine the effects of recruitment manoeuvres on mortality in adults with acute respiratory distress syndrome.Our secondary objective was to determine, in the same population, the effects of recruitment manoeuvres on oxygenation and adverse events (e.g. rate of barotrauma).Search methodsFor this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), the Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO), Latin American and Caribbean Health Sciences (LILACS) and the International Standard Randomized Controlled Trial Number (ISRCTN) registry from inception to August 2016.Selection criteriaWe included randomized controlled trials (RCTs) of adults who were mechanically ventilated that compared recruitment manoeuvres versus standard care for patients given a diagnosis of ARDS.Data collection and analysisTwo review authors independently assessed trial quality and extracted data. We contacted study authors for additional information.Main resultsTen trials met the inclusion criteria for this review (n = 1658 participants). We found five trials to be at low risk of bias and five to be at moderate risk of bias. Six of the trials included recruitment manoeuvres as part of an open lung ventilation strategy that was different from control ventilation in aspects other than the recruitment manoeuvre (such as mode of ventilation, higher positive end-expiratory pressure (PEEP) titration and lower tidal volume or plateau pressure). Six studies reported mortality outcomes. Pooled data from five trials (1370 participants) showed a reduction in intensive care unit (ICU) mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.72 to 0.97, P = 0.02, low-quality evidence), pooled data from five trials (1450 participants) showed no difference in 28-day mortality (RR 0.86, 95% CI 0.74 to 1.01, P = 0.06, low-quality evidence) and pooled data from four trials (1313 participants) showed no difference in in-hospital mortality (RR 0.88, 95% CI 0.77 to 1.01, P = 0.07, low-quality evidence). Data revealed no differences in risk of barotrauma (RR 1.09, 95% CI 0.78 to 1.53, P = 0.60, seven studies, 1508 participants, moderate-quality evidence).Authors' conclusionsWe identified significant clinical heterogeneity in the 10 included trials. Results are based upon the findings of several (five) trials that included an "open lung ventilation strategy", whereby the intervention group differed from the control group in aspects other than the recruitment manoeuvre (including co-interventions such as higher PEEP, different modes of ventilation and higher plateau pressure), making interpretation of the results difficult. A ventilation strategy that included recruitment manoeuvres in participants with ARDS reduced intensive care unit mortality without increasing the risk of barotrauma but had no effect on 28-day and hospital mortality. We downgraded the quality of the evidence to low, as most of the included trials provided co-interventions as part of an open lung ventilation strategy, and this might have influenced results of the outcome.
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Project description:To determine the frequency of low-tidal volume ventilation in pediatric acute respiratory distress syndrome and assess if any demographic or clinical factors improve low-tidal volume ventilation adherence.Descriptive post hoc analysis of four multicenter pediatric acute respiratory distress syndrome studies.Twenty-six academic PICU.Three hundred fifteen pediatric acute respiratory distress syndrome patients.All patients who received conventional mechanical ventilation at hours 0 and 24 of pediatric acute respiratory distress syndrome who had data to calculate ideal body weight were included. Two cutoff points for low-tidal volume ventilation were assessed: less than or equal to 6.5?mL/kg of ideal body weight and less than or equal to 8?mL/kg of ideal body weight. Of 555 patients, we excluded 240 for other respiratory support modes or missing data. The remaining 315 patients had a median PaO2-to-FIO2 ratio of 140 (interquartile range, 90-201), and there were no differences in demographics between those who did and did not receive low-tidal volume ventilation. With tidal volume cutoff of less than or equal to 6.5?mL/kg of ideal body weight, the adherence rate was 32% at hour 0 and 33% at hour 24. A low-tidal volume ventilation cutoff of tidal volume less than or equal to 8?mL/kg of ideal body weight resulted in an adherence rate of 58% at hour 0 and 60% at hour 24. Low-tidal volume ventilation use was no different by severity of pediatric acute respiratory distress syndrome nor did adherence improve over time. At hour 0, overweight children were less likely to receive low-tidal volume ventilation less than or equal to 6.5?mL/kg ideal body weight (11% overweight vs 38% nonoverweight; p = 0.02); no difference was noted by hour 24. Furthermore, in the overweight group, using admission weight instead of ideal body weight resulted in misclassification of up to 14% of patients as receiving low-tidal volume ventilation when they actually were not.Low-tidal volume ventilation is underused in the first 24 hours of pediatric acute respiratory distress syndrome. Age, Pediatric Risk of Mortality-III, and pediatric acute respiratory distress syndrome severity were not associated with improved low-tidal volume ventilation adherence nor did adherence improve over time. Overweight children were less likely to receive low-tidal volume ventilation strategies in the first day of illness.
| S-EPMC5199719 | biostudies-other
Project description:ObjectivesBlood products are often transfused in critically ill children, although recent studies have recognized their potential for harm. Translatability to pediatric acute respiratory distress syndrome is unknown given that hypoxemia has excluded pediatric acute respiratory distress syndrome patients from clinical trials. We aimed to determine whether an association exists between blood product transfusion and survival or duration of ventilation in pediatric acute respiratory distress syndrome.DesignRetrospective analysis of prospectively enrolled cohort.SettingLarge, academic PICU.PatientsInvasively ventilated children meeting Berlin Acute Respiratory Distress Syndrome and Pediatric Acute Lung Injury Consensus Conference Pediatric Acute Respiratory Distress Syndrome criteria from 2011 to 2015.InterventionsWe recorded transfusion of RBC, fresh frozen plasma, and platelets within the first 3 days of pediatric acute respiratory distress syndrome onset. Each product was tested for independent association with survival (Cox) and duration of mechanical ventilation (competing risk regression with extubation as primary outcome and death as competing risk). A sensitivity analysis using 1:1 propensity matching was also performed.Measurements and main resultsOf 357 pediatric acute respiratory distress syndrome patients, 155 (43%) received RBC, 82 (23%) received fresh frozen plasma, and 92 (26%) received platelets. Patients who received RBC, fresh frozen plasma, or platelets had higher severity of illness score, lower PaO2/FIO2, and were more often immunocompromised (all p < 0.05). Patients who received RBC, fresh frozen plasma, or platelets had worse survival and longer duration of ventilation by univariate analysis (all p < 0.05). After multivariate adjustment for above confounders, no blood product was associated with survival. After adjustment for the same confounders, RBC were associated with decreased probability of extubation (subdistribution hazard ratio, 0.65; 95% CI, 0.51-0.83). The association between RBC and prolonged ventilation was confirmed in propensity-matched subgroup analysis.ConclusionsRBC transfusion was independently associated with longer duration of mechanical ventilation in pediatric acute respiratory distress syndrome. Hemoglobin transfusion thresholds should be tested specifically within pediatric acute respiratory distress syndrome to establish whether a more restrictive transfusion strategy would improve outcomes.
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Project description:Acute respiratory distress syndrome (ARDS) is a life-threatening condition involving acute hypoxemic respiratory failure. Mechanical ventilation remains the cornerstone of management for ARDS; however, potentially injurious mechanical forces introduce the risk of ventilator-induced lung injury, multiple organ failure, and death. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy aimed at ensuring adequate gas exchange for patients suffering from severe ARDS with profound hypoxemia where conventional mechanical ventilation has failed. ECMO allows for lower tidal volumes and airway pressures, which can reduce the risk of further lung injury, and allow the lungs to rest. However, the collateral effect of ECMO should be considered. Recent studies have reported correlations between mechanical ventilator settings during ECMO and mortality. In many cases, mechanical ventilation settings should be tailored to the individual; however, researchers have yet to establish optimal ventilator settings or determine the degree to which ventilation load can be decreased. This paper presents an overview of previous studies and clinical trials pertaining to the management of mechanical ventilation during ECMO for patients with severe ARDS, with a focus on clinical findings, suggestions, protocols, guidelines, and expert opinions. We also identified a number of issues that have yet to be adequately addressed.
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Project description:BackgroundFoxp3+ regulatory T cells (Tregs) play essential roles in immune homeostasis and repair of damaged lung tissue. We hypothesized that patients whose lung injury resolves quickly, as measured by time to liberation from mechanical ventilation, have a higher percentage of Tregs amongst CD4+ T cells in either airway, bronchoalveolar lavage (BAL) or peripheral blood samples.MethodsWe prospectively enrolled patients with ARDS requiring mechanical ventilation and collected serial samples, the first within 72 h of ARDS diagnosis (day 0) and the second 48-96 h later (day 3). We analyzed immune cell populations and cytokines in BAL, tracheal aspirates and peripheral blood, as well as cytokines in plasma, obtained at the time of bronchoscopy. The study cohort was divided into fast resolvers (FR; n = 8) and slow resolvers (SR; n = 5), based on the median number of days until first extubation for all participants (n = 13). The primary measure was the percentage of CD4+ T cells that were Tregs.ResultsThe BAL of FR contained more Tregs than SR. This finding did not extend to Tregs in tracheal aspirates or blood. BAL Tregs expressed more of the full-length FOXP3 than a splice variant missing exon 2 compared to Tregs in simultaneously obtained peripheral blood.ConclusionTregs are present in the bronchoalveolar space during ARDS. A greater percentage of CD4+ cells were Tregs in the BAL of FR than SR. Tregs may play a role in the resolution of ARDS, and enhancing their numbers or functions may be a therapeutic target.
| S-EPMC7656499 | biostudies-literature
Project description:Background:Tidal hyperinflation can still occur with mechanical ventilation using low tidal volume (LVT) (6?mL/kg predicted body weight (PBW)) in acute respiratory distress syndrome (ARDS), despite a well-demonstrated reduction in mortality. Methods:Retrospective chart review from August 2012 to October 2014. Inclusion: Age >18years, PaO2/FiO2<200 with bilateral pulmonary infiltrates, absent heart failure, and ultra-protective mechanical ventilation (UPMV) defined as tidal volume (VT) <6?mL/kg PBW. Exclusion: UPMV use for <24?h. Demographics, admission Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, arterial blood gas, serum bicarbonate, ventilator parameters for pre-, during, and post-UPMV periods including modes, VT, peak inspiratory pressure (PIP), plateau pressure (Pplat), driving pressure, etc. were gathered. We compared lab and ventilator data for pre-, during, and post-UPMV periods. Results:Fifteen patients (male:female?=?7:8, age 42.13?±?11.29 years) satisfied criteria, APACHEII 20.6?±?7.1, mean days in intensive care unit and hospitalization were 18.5?±?8.85 and 20.81?±?9.78 days, 9 (60%) received paralysis and 7 (46.67%) required inotropes. Eleven patients had echocardiogram, 7 (63.64%) demonstrated right ventricular volume or pressure overload. Eleven patients (73.33%) survived. During-UPMV, VT ranged 2-5?mL/kg PBW(3.99?±?0.73), the arterial partial pressure of carbon dioxide (PaCO2) was higher than pre-UPMV values (84.81?±?18.95 cmH2O vs. 69.16?±?33.09 cmH2O), but pH was comparable and none received extracorporeal carbon dioxide removal (ECCO2-R). The positive end-expiratory pressure (14.18?±?7.56 vs. 12.31?±?6.84 cmH2O), PIP (38.21?±?12.89 vs. 32.59?±?9.88), and mean airway pressures (19.98?±?7.61 vs. 17.48?±?6.7?cm H2O) were higher during UPMV, but Pplat and PaO2/FiO2 were comparable during- and pre-UPMV. Driving pressure was observed to be higher in those who died than who survived (24.18?±?12.36 vs. 13.42?±?3.25). Conclusion:UPMV alone may be a safe alternative option for ARDS patients in centers without ECCO2-R.
| S-EPMC6376584 | biostudies-literature
Project description:While effective treatments for acute respiratory distress syndrome (ARDS) are lacking, mechanical lung ventilation can sustain adequate gas exchange in critically ill patients with respiratory failure due to ARDS. However, as a result of the phenomenon of ventilator-induced lung injury (VILI), there is an increasing need to seek beneficial pharmacological therapies for ARDS. Recent studies have suggested the renin-angiotensin system (RAS), which consists of the ACE/Ang-II/AT1R axis and ACE2/Ang-(1-7)/MasR axis, plays a dual role in the pathogenesis of ARDS and VILI. This review highlights the deleterious action of ACE/Ang-II/AT1R axis and the beneficial role of ACE2/Ang-(1-7)/MasR axis, as well as AT2R, in VILI and ARDS, and also discusses the possibility of targeting RAS components with pharmacological interventions to improve outcomes in ARDS.
| S-EPMC7110665 | biostudies-literature