Aurio Fajardo-Campoverd, Luis Mamami-Cruz, Miguel Ibarra-Estrada, Ismael Maldonado-Beltrán, Angelo Roncalli, Ehab Daoud
Introduction The calculation of energy transfer in patients with acute respiratory distress syndrome (ARDS), has multiple interpretations and proposals. The parameters described as safe to minimize mechanical ventilator-associated lung injury (VALI) include only static values in their conception, and dynamic variables have been relegated to a secondary role. Subjects and Methods Analytical, observational, retrospective study of patients hospitalized in a respiratory intensive care unit, with a diagnosis of severe ARDS due to SARS-CoV-2 in whom mechanical ventilator management was guided by the use of esophageal catheter for the calculation of ventilatory variables. Thirty-four patients were included in this study, 23.5 % were women and the mean body mass index was 34.9 kg/m2. The primary objective was to quantify the amount of energy (Mechanical Power MP) transmitted by using multiple known equations and the secondary objective was to find the variables best associated with such energy transfer and with the severity of ARDS using Bayesian analysis. Results A mean of 22.2 days on invasive mechanical ventilation was recorded. Baseline MPGattinoni averaged 21.4 J/min, which did not change significantly at 30 minutes (7.5%) or 24 hours (- 0.4%) from baseline, despite esophageal catheter-guided management. The Bayesian analyses used to calculate the a posteriori inclusion probability showed that respiratory rate was the only variable consistently related to energy transfer, regardless of the equation used for its calculation and the chronological time at which these equations were measured [baseline MPGattinoni: (mean, 0.89; 95% Cred Interval: 0.75 to 1.02), at 30 minutes: (mean, 1.09; 95% Cred Interval: 0.68 to 1.49), at 24 hours: (mean, 0.65; 95% Cred Interval: 0.01 to 1.03)] or [baseline MPModesto: (mean, 0.1; 95% Cred Interval: 0.09 to 0.1), at 30 minutes: (mean, 0.1; 95% Cred Interval: 0.09 to 0.1), at 24 hours: (mean, 0.1; 95% Cred Interval: 0.09 to 0.1)]. Conclusions In severe ARDS, it is essential to minimize VALI. The calculation of energy transfer, regardless of the equation used, should always be a dynamic objective to be measured. Respiratory rate is probably the most relevant dynamic variable in the genesis of VALI. Keywords: mechanical power, elastic power, respiratory rate, ARDS, COVID-19
{"title":"Cyclic energy: the transcendental relevance of respiratory rate. A retrospective observational study with Bayesian analysis","authors":"Aurio Fajardo-Campoverd, Luis Mamami-Cruz, Miguel Ibarra-Estrada, Ismael Maldonado-Beltrán, Angelo Roncalli, Ehab Daoud","doi":"10.53097/jmv.10093","DOIUrl":"https://doi.org/10.53097/jmv.10093","url":null,"abstract":"Introduction The calculation of energy transfer in patients with acute respiratory distress syndrome (ARDS), has multiple interpretations and proposals. The parameters described as safe to minimize mechanical ventilator-associated lung injury (VALI) include only static values in their conception, and dynamic variables have been relegated to a secondary role. Subjects and Methods Analytical, observational, retrospective study of patients hospitalized in a respiratory intensive care unit, with a diagnosis of severe ARDS due to SARS-CoV-2 in whom mechanical ventilator management was guided by the use of esophageal catheter for the calculation of ventilatory variables. Thirty-four patients were included in this study, 23.5 % were women and the mean body mass index was 34.9 kg/m2. The primary objective was to quantify the amount of energy (Mechanical Power MP) transmitted by using multiple known equations and the secondary objective was to find the variables best associated with such energy transfer and with the severity of ARDS using Bayesian analysis. Results A mean of 22.2 days on invasive mechanical ventilation was recorded. Baseline MPGattinoni averaged 21.4 J/min, which did not change significantly at 30 minutes (7.5%) or 24 hours (- 0.4%) from baseline, despite esophageal catheter-guided management. The Bayesian analyses used to calculate the a posteriori inclusion probability showed that respiratory rate was the only variable consistently related to energy transfer, regardless of the equation used for its calculation and the chronological time at which these equations were measured [baseline MPGattinoni: (mean, 0.89; 95% Cred Interval: 0.75 to 1.02), at 30 minutes: (mean, 1.09; 95% Cred Interval: 0.68 to 1.49), at 24 hours: (mean, 0.65; 95% Cred Interval: 0.01 to 1.03)] or [baseline MPModesto: (mean, 0.1; 95% Cred Interval: 0.09 to 0.1), at 30 minutes: (mean, 0.1; 95% Cred Interval: 0.09 to 0.1), at 24 hours: (mean, 0.1; 95% Cred Interval: 0.09 to 0.1)]. Conclusions In severe ARDS, it is essential to minimize VALI. The calculation of energy transfer, regardless of the equation used, should always be a dynamic objective to be measured. Respiratory rate is probably the most relevant dynamic variable in the genesis of VALI. Keywords: mechanical power, elastic power, respiratory rate, ARDS, COVID-19","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140239238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background Prone position has many documented benefits on severe ARDS patients especially on mortality. The benefits in ARDS secondary to severe burns have not been fully documented. Aim To quantify the effects of prone positioning on gas exchange, ventilatory mechanics and their correlations with mechanical power in burn subjects with ARDS. Methods Cross-sectional observational analytical study that took place between January 2023 and October 2023 in Burns ICU in Brazil on subjects with moderate to severe ARDS ventilated with the volume controlled mode. Data were collected in the first prone positioning lasting 24 hours in the first 30 minutes after changing position and 30 minutes before returning to the supine position. The parameters of the components of mechanical ventilation and mechanical power calculated by the Gatinoni’s formula (respiratory rate, tidal volume, driving pressure, PEEP, peak and plateau pressures) were collected to evaluate ventilatory mechanics, and the values of the FiO2, PaO2, PaO2/FiO2 ratio, SpO2, EtCO2, PaCO2, PaCO2 - EtCO2 gradient to assess gas exchange. Mean, minimum and maximum values, 1st and 3rd quartiles, median and standard deviation are calculated. To compare the results obtained at the two evaluation moments, the student’s t-test for dependent samples and non-parametric Wilcoxon tests were considered. To evaluate the association between the variation between the two moments of each variable, and the variation in mechanical power, the Pearson correlation coefficient was calculated. The normality of the variables was assessed using the Jarque-Béra test. P values <0.05 indicated statistical significance. Results Except for EtCO2 (P 0.939) and PaCO2 (P 0.391) all other variables presented statistical significance in relation to their variations with reduction in FiO2 (P <0.001), reduction in PaCO2 - EtCO2 gradient (P 0.011), and increases in PaO2 (P 0.008), PaO2/FiO2 (P <0.001), SpO2 (P 0.004). In the analysis of variables, reduction in respiratory rate (P 0.142), VT (P 0.385), peak pressure (P 0.085), plateau pressure (P 0.009), PEEP (P 0.032), driving pressure (P 0.083), elastance (P 0.180), mechanical power (P < 0.001) with increase static compliance (P 0.414) and resistance pressure (P 0.443). Among the ventilatory mechanics variables, only the reductions in plateau pressure, PEEP, and mechanical power showed statistical significance. Conclusion The prone position in burns induced ARDS improved oxygenation and reduced arterial partial pressure to end tidal CO2 gradient, furthermore, reducing plateau pressures and PEEP, which in turn reduced mechanical power. Keywords: mechanical power, burns, ARDS, prone position
{"title":"Effects of the prone position on gas exchange and ventilatory mechanics and their correlations with mechanical power in burn patients with ARDS","authors":"C. Franck, Ehab Daoud","doi":"10.53097/jmv.10095","DOIUrl":"https://doi.org/10.53097/jmv.10095","url":null,"abstract":"Background Prone position has many documented benefits on severe ARDS patients especially on mortality. The benefits in ARDS secondary to severe burns have not been fully documented. Aim To quantify the effects of prone positioning on gas exchange, ventilatory mechanics and their correlations with mechanical power in burn subjects with ARDS. Methods Cross-sectional observational analytical study that took place between January 2023 and October 2023 in Burns ICU in Brazil on subjects with moderate to severe ARDS ventilated with the volume controlled mode. Data were collected in the first prone positioning lasting 24 hours in the first 30 minutes after changing position and 30 minutes before returning to the supine position. The parameters of the components of mechanical ventilation and mechanical power calculated by the Gatinoni’s formula (respiratory rate, tidal volume, driving pressure, PEEP, peak and plateau pressures) were collected to evaluate ventilatory mechanics, and the values of the FiO2, PaO2, PaO2/FiO2 ratio, SpO2, EtCO2, PaCO2, PaCO2 - EtCO2 gradient to assess gas exchange. Mean, minimum and maximum values, 1st and 3rd quartiles, median and standard deviation are calculated. To compare the results obtained at the two evaluation moments, the student’s t-test for dependent samples and non-parametric Wilcoxon tests were considered. To evaluate the association between the variation between the two moments of each variable, and the variation in mechanical power, the Pearson correlation coefficient was calculated. The normality of the variables was assessed using the Jarque-Béra test. P values <0.05 indicated statistical significance. Results Except for EtCO2 (P 0.939) and PaCO2 (P 0.391) all other variables presented statistical significance in relation to their variations with reduction in FiO2 (P <0.001), reduction in PaCO2 - EtCO2 gradient (P 0.011), and increases in PaO2 (P 0.008), PaO2/FiO2 (P <0.001), SpO2 (P 0.004). In the analysis of variables, reduction in respiratory rate (P 0.142), VT (P 0.385), peak pressure (P 0.085), plateau pressure (P 0.009), PEEP (P 0.032), driving pressure (P 0.083), elastance (P 0.180), mechanical power (P < 0.001) with increase static compliance (P 0.414) and resistance pressure (P 0.443). Among the ventilatory mechanics variables, only the reductions in plateau pressure, PEEP, and mechanical power showed statistical significance. Conclusion The prone position in burns induced ARDS improved oxygenation and reduced arterial partial pressure to end tidal CO2 gradient, furthermore, reducing plateau pressures and PEEP, which in turn reduced mechanical power. Keywords: mechanical power, burns, ARDS, prone position","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140240997","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kimberly A Weil, V. Baumann, Brittany Brown, R. Nadeau, H. Hrdlicka, Brett Gerstenhaber, David Rosenblum, Edward Manning
Objective Guillain-Barre Syndrome (GBS) is a rare acute inflammatory demyelinating polyneuropathy, resulting in loss of muscle function and potentially respiratory failure requiring prolonged mechanical ventilation. Data describing the demographics and outcomes of patients with severe GBS requiring prolonged ventilation in the long-term acute care hospital (LTACH) setting is limited. We hypothesized that patients with GBS requiring prolonged mechanical ventilation require longer lengths of stay in an LTACH and are discharged with poorer functional status than GBS patients who do not require mechanical ventilation. Design, Setting, and Participants We conducted a retrospective study of GBS patients admitted over a 9-year period at an independent, large LTACH and compared ventilated versus non-ventilated GBS patients’ lengths of stay and functional ability at the time of admission and discharge. Interventions Not Applicable Main Outcome Measures and Results We found no significant difference in mean (standard error of means) lengths of stay between ventilated and non-ventilated GBS patients admitted to an LTACH (48.4 (± 8.0) vs. 38.8 (± 5.7) days, P 0.37). We also found that ventilated patients with GBS were discharged from an LTACH with similar functional ability than non-ventilated GBS patients (4.5 vs. 4.0, P 0.43 on 10 ft walk; 4.7 vs. 4.5 on P 0.70; 5.0 vs. 4.2, P 0.21 on 150 ft walk). Conclusion These findings suggest that GBS patients suffering from prolonged mechanical ventilation may expect similar lengths of stay in an LTACH as non-ventilated GBS patients and a similar or greater rate of functional improvement during their stay. These data support admission of chronically ventilated GBS patients to an LTACH for ongoing care after their acute care without the anticipation of greater length of stay or less rehabilitation outcomes with respect to non-ventilated GBS patients. Keywords: Guillain-Barre Syndrome, Assisted Ventilation, Pulmonary Rehabilitation, LTACH, Critical Care
{"title":"Guillain-Barre in the long-term acute care hospital setting: Ventilation does not prolong stay","authors":"Kimberly A Weil, V. Baumann, Brittany Brown, R. Nadeau, H. Hrdlicka, Brett Gerstenhaber, David Rosenblum, Edward Manning","doi":"10.53097/jmv.10094","DOIUrl":"https://doi.org/10.53097/jmv.10094","url":null,"abstract":"Objective Guillain-Barre Syndrome (GBS) is a rare acute inflammatory demyelinating polyneuropathy, resulting in loss of muscle function and potentially respiratory failure requiring prolonged mechanical ventilation. Data describing the demographics and outcomes of patients with severe GBS requiring prolonged ventilation in the long-term acute care hospital (LTACH) setting is limited. We hypothesized that patients with GBS requiring prolonged mechanical ventilation require longer lengths of stay in an LTACH and are discharged with poorer functional status than GBS patients who do not require mechanical ventilation. Design, Setting, and Participants We conducted a retrospective study of GBS patients admitted over a 9-year period at an independent, large LTACH and compared ventilated versus non-ventilated GBS patients’ lengths of stay and functional ability at the time of admission and discharge. Interventions Not Applicable Main Outcome Measures and Results We found no significant difference in mean (standard error of means) lengths of stay between ventilated and non-ventilated GBS patients admitted to an LTACH (48.4 (± 8.0) vs. 38.8 (± 5.7) days, P 0.37). We also found that ventilated patients with GBS were discharged from an LTACH with similar functional ability than non-ventilated GBS patients (4.5 vs. 4.0, P 0.43 on 10 ft walk; 4.7 vs. 4.5 on P 0.70; 5.0 vs. 4.2, P 0.21 on 150 ft walk). Conclusion These findings suggest that GBS patients suffering from prolonged mechanical ventilation may expect similar lengths of stay in an LTACH as non-ventilated GBS patients and a similar or greater rate of functional improvement during their stay. These data support admission of chronically ventilated GBS patients to an LTACH for ongoing care after their acute care without the anticipation of greater length of stay or less rehabilitation outcomes with respect to non-ventilated GBS patients. Keywords: Guillain-Barre Syndrome, Assisted Ventilation, Pulmonary Rehabilitation, LTACH, Critical Care","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140241031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mechanical power has recently emerged as an important indicator of ventilator lung injury, and mortality. Most studies have focused on the whole respiratory system mechanical power, and few have studied the trans-pulmonary mechanical power. A newer calculation highlighted the concept of alveolar mechanics and mechanical power. In this brief review, we illustrate the various types and different calculations of the respiratory system, lung, and alveolar mechanical power. Keywords: Mechanical power, trans-pulmonary mechanical power, alveolar mechanical power
{"title":"Alveolar mechanics at the bedside","authors":"Joshua Hu, Yusuke Hirao","doi":"10.53097/jmv.10096","DOIUrl":"https://doi.org/10.53097/jmv.10096","url":null,"abstract":"Mechanical power has recently emerged as an important indicator of ventilator lung injury, and mortality. Most studies have focused on the whole respiratory system mechanical power, and few have studied the trans-pulmonary mechanical power. A newer calculation highlighted the concept of alveolar mechanics and mechanical power. In this brief review, we illustrate the various types and different calculations of the respiratory system, lung, and alveolar mechanical power. Keywords: Mechanical power, trans-pulmonary mechanical power, alveolar mechanical power","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140240782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objectives Spontaneous pneumothorax among patients with obstructive sleep apnea treated by nocturnal continuous positive airway pressure (CPAP) has not been well documented. Methods We present three cases of patients on chronic CPAP who experienced spontaneous pneumothorax without clear predisposing factors. Their personal and family medical histories, imaging characteristics, and CPAP settings are reviewed. Results In all three cases, the patients had bullae ipsilateral to the pneumothoraces that either formed (n = 1) or grew significantly (n = 2) after CPAP initiation. No other risk factors for pneumothorax or bullae were identified. Conclusions This case series demonstrates a need for further investigation into a possible connection between spontaneous pneumothorax, bullae development, and CPAP use. Keywords: obstructive sleep apnea, continuous positive airway pressure, bullae, complications of noninvasive mechanical ventilation, spontaneous pneumothorax
{"title":"Enlarging bullae and spontaneous pneumothorax associated with CPAP use: A case series of three patients","authors":"Allison Navarrete-Welton, Kamran Manzoor, Taro Minami, Naomi Kramer","doi":"10.53097/jmv.10097","DOIUrl":"https://doi.org/10.53097/jmv.10097","url":null,"abstract":"Objectives Spontaneous pneumothorax among patients with obstructive sleep apnea treated by nocturnal continuous positive airway pressure (CPAP) has not been well documented. Methods We present three cases of patients on chronic CPAP who experienced spontaneous pneumothorax without clear predisposing factors. Their personal and family medical histories, imaging characteristics, and CPAP settings are reviewed. Results In all three cases, the patients had bullae ipsilateral to the pneumothoraces that either formed (n = 1) or grew significantly (n = 2) after CPAP initiation. No other risk factors for pneumothorax or bullae were identified. Conclusions This case series demonstrates a need for further investigation into a possible connection between spontaneous pneumothorax, bullae development, and CPAP use. Keywords: obstructive sleep apnea, continuous positive airway pressure, bullae, complications of noninvasive mechanical ventilation, spontaneous pneumothorax","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140237639","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We present the case of a 60-year-old male patient admitted to our intensive care unit after a high-velocity car accident. On-site clinical examination revealed normal consciousness with no focal deficits. Chest X–Ray was suggestive of right pneumothorax with pneumomediastinum and extensive subcutaneous emphysema. CT scan revealed right pneumothorax, pneumomediastinum, extensive subcutaneous emphysema and extradural pneumorachis. A right tube thoracostomy was done and the patient was placed on High flow nasal cannula at 40 lpm and 100% FiO2. There was a gradual resolution of pneumothorax and all the extra-alveolar air including pneumorachis by the 7th day. The patient was discharged in a clinically stable condition. Keywords: Pneumothorax, Pneumomediastinum, Pneumorachis
我们介绍了一例因高速车祸而被送入重症监护室的 60 岁男性患者的病例。现场临床检查显示患者意识正常，无局灶性障碍。胸部 X 光检查提示右侧气胸，伴有气胸和广泛的皮下气肿。CT 扫描显示右侧气胸、气胸、广泛的皮下气肿和硬膜外气胸。医生为患者做了右侧管状胸腔造口术，并使用高流量鼻插管，流量为 40 升/分钟，FiO2 为 100%。到第七天，气胸和所有肺泡外空气（包括气噎膈）逐渐消退。患者出院时临床情况稳定。关键词气胸、气腹、气噎
{"title":"Traumatic air myelogram","authors":"M. Krishna, KS Phaneendra, V. Kola","doi":"10.53097/jmv.10091","DOIUrl":"https://doi.org/10.53097/jmv.10091","url":null,"abstract":"We present the case of a 60-year-old male patient admitted to our intensive care unit after a high-velocity car accident. On-site clinical examination revealed normal consciousness with no focal deficits. Chest X–Ray was suggestive of right pneumothorax with pneumomediastinum and extensive subcutaneous emphysema. CT scan revealed right pneumothorax, pneumomediastinum, extensive subcutaneous emphysema and extradural pneumorachis. A right tube thoracostomy was done and the patient was placed on High flow nasal cannula at 40 lpm and 100% FiO2. There was a gradual resolution of pneumothorax and all the extra-alveolar air including pneumorachis by the 7th day. The patient was discharged in a clinically stable condition. Keywords: Pneumothorax, Pneumomediastinum, Pneumorachis","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138997382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract This case shows the use of ultrasound guidance to optimize non-invasive mechanical ventilation for a 62-year-old patient with a complex medical history. Point-of-care ultrasound (POCUS) was used to assess diaphragmatic function and hemodynamics, leading to adjustments in ventilator setting. The approach improved gas exchange, resolved respiratory acidosis, and enhanced hemodynamics, providing a promising strategy for ventilator management in complex clinical cases. Keywords: Non-Invasive Mechanical Ventilation, Point-of-Care Ultrasound, Diaphragmatic Ultrasound, Focused Echocardiography, Ventilator-Induced Diaphragmatic Dysfunction, Hemodynamics.
{"title":"The role of Point of Care Ultrasound (POCUS) and focused echocardiography in optimization of non-invasive mechanical ventilation: from diaphragmatic functionality to hemodynamic monitoring","authors":"Mauro Pavone, Giuseppina Biondi, Claudio Matruzzo, Federico Rapisarda, Leda D’Amico, Raimondo Gullo, Maira Circo, S. Torrisi, SIlvia Puglisi, Daniele Lombardo, Maria Bellanti, Domenico Compagnone, Rosario Oliveri","doi":"10.53097/jmv.10090","DOIUrl":"https://doi.org/10.53097/jmv.10090","url":null,"abstract":"Abstract This case shows the use of ultrasound guidance to optimize non-invasive mechanical ventilation for a 62-year-old patient with a complex medical history. Point-of-care ultrasound (POCUS) was used to assess diaphragmatic function and hemodynamics, leading to adjustments in ventilator setting. The approach improved gas exchange, resolved respiratory acidosis, and enhanced hemodynamics, providing a promising strategy for ventilator management in complex clinical cases. Keywords: Non-Invasive Mechanical Ventilation, Point-of-Care Ultrasound, Diaphragmatic Ultrasound, Focused Echocardiography, Ventilator-Induced Diaphragmatic Dysfunction, Hemodynamics.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138997710","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background Patients receiving mechanical ventilation for more than 48 hours are at risk for developing ventilator-associated pneumonia (VAP). Methods We investigated aerosol flow in a ventilator circuit attached to test lungs to better understand how airflow dynamics in ventilator tubing can contribute to the pathogenesis of VAP. The ventilator was operated so that the lungs cyclically inflated and deflated. Aerosolized saline was used as a surrogate for bioaerosols and was generated in the circuit with an aerosol generator attached to the tubing below an endotracheal cuff that sealed an endotracheal tube at the opening of the lungs. We used a particle collector and analyzer attached to the circuit approximately two feet from the opening of the lungs to determine whether aerosols flowed into the tubing. Results We detected significant levels of aerosolized particles (P <0.05) that traveled retrogradely into the ventilator circuit. The highest nozzle pressure tested, 13 hPa, produced mean 0.5, 0.7 and 1.0 m aerosol levels of 24 ±5, 10±4 and 8±3 particles/ft 3, respectively. The lowest nozzle pressure tested, 10 hPa, produced mean 0.5, 0.7 and 1.0 m aerosol levels of 14 ±5, 4 ±2, and 3 ±2 particles/ft3. Conclusions Aerosolized material that enters the circuit near the endotracheal cuff travels into the ventilator tubing during mechanical ventilation. Our results suggest that infectious material could travel a similar route and contaminate the air in the ventilator circuit which then enters the patient. Keywords: ventilator-associated pneumonia, bioaerosol, aerosol, contamination, ventilator circuit
{"title":"Aerosol dispersion in a ventilator circuit: towards a model for enhancing our understanding of ventilator-associated pneumonia","authors":"Gregory Carroll, David Kirschman","doi":"10.53097/jmv.10089","DOIUrl":"https://doi.org/10.53097/jmv.10089","url":null,"abstract":"Background Patients receiving mechanical ventilation for more than 48 hours are at risk for developing ventilator-associated pneumonia (VAP). Methods We investigated aerosol flow in a ventilator circuit attached to test lungs to better understand how airflow dynamics in ventilator tubing can contribute to the pathogenesis of VAP. The ventilator was operated so that the lungs cyclically inflated and deflated. Aerosolized saline was used as a surrogate for bioaerosols and was generated in the circuit with an aerosol generator attached to the tubing below an endotracheal cuff that sealed an endotracheal tube at the opening of the lungs. We used a particle collector and analyzer attached to the circuit approximately two feet from the opening of the lungs to determine whether aerosols flowed into the tubing. Results We detected significant levels of aerosolized particles (P <0.05) that traveled retrogradely into the ventilator circuit. The highest nozzle pressure tested, 13 hPa, produced mean 0.5, 0.7 and 1.0 m aerosol levels of 24 ±5, 10±4 and 8±3 particles/ft 3, respectively. The lowest nozzle pressure tested, 10 hPa, produced mean 0.5, 0.7 and 1.0 m aerosol levels of 14 ±5, 4 ±2, and 3 ±2 particles/ft3. Conclusions Aerosolized material that enters the circuit near the endotracheal cuff travels into the ventilator tubing during mechanical ventilation. Our results suggest that infectious material could travel a similar route and contaminate the air in the ventilator circuit which then enters the patient. Keywords: ventilator-associated pneumonia, bioaerosol, aerosol, contamination, ventilator circuit","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138996293","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Clinicians might have opportunities to recognize different types of mechanical ventilators circuits and compare them in critical care situations. As a clinician it is important to know the features of those configurations and take them into consideration when choosing modes and settings for patients because it affects the outcome of monitoring and ventilators’ performance. There are three types of ventilators circuits: double limb, single limb with exhalation valve, and single limb with exhalation port. Keywords: Ventilator circuits, exhalation valve, exhalation port
{"title":"Mechanical ventilators circuit types","authors":"Kimiyo Yamasaki","doi":"10.53097/jmv.10092","DOIUrl":"https://doi.org/10.53097/jmv.10092","url":null,"abstract":"Clinicians might have opportunities to recognize different types of mechanical ventilators circuits and compare them in critical care situations. As a clinician it is important to know the features of those configurations and take them into consideration when choosing modes and settings for patients because it affects the outcome of monitoring and ventilators’ performance. There are three types of ventilators circuits: double limb, single limb with exhalation valve, and single limb with exhalation port. Keywords: Ventilator circuits, exhalation valve, exhalation port","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138999465","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kensuke Takaoka, Shane Toma, Philip Lee, Ehab Daoud
Background Mechanical ventilation is a critical therapeutic intervention in the management of patients with respiratory failure. Understanding the implications of different ventilation modes is essential in preventing ventilator-induced lung injuries (VILI). Recently, mechanical power has emerged as a critical element in the development of VILI and mortality. Previous bench work studies have suggested that new optimal (adaptive) modes, such as Adaptive Ventilation Mode 2 (AVM-2), can reduce the mechanical power in turn might reduce the rates of VILI. This study aims to compare the conventional Pressure-Controlled Ventilation (PCV) mode with an emerging design of Adaptive Ventilation Mode-2 (AVM-2), to measure the differences in mechanical power, alongside it’s components of PEEP, Tidal, Elastic, Resistive, Inspiratory, Total work, tidal volume, driving pressure and Power Compliance Index. Methods Between January 2023 and June of 2023, we conducted a prospective crossover study on twenty-two subjects admitted to our ICU within the first day after initiation of mechanical ventilation. Subjects were initially started on PCV settings chosen by the primary treatment team, then switched to AVM-2 with comparable minute ventilation. Mechanical power and its work components (tidal, resistive, PEEP, elastic, inspiratory, total), tidal volume, driving pressure, respiratory rate, and positive end-expiratory pressure, were recorded for each patient every 15 min for the duration of 2 consecutive hours on each mode. Statistical analysis, including paired t-tests were performed to assess the significance of differences between the two ventilation modes. The data is provided in means and 土 SD. Results There were significant differences between PCV and AVM-2 in mechanical power (J/min): 21.62 土 7.61 vs 14.21 土 6.41 (P < 0.001), PEEP work (J): 4.83 土 2.71 vs 4.11 土 2.51 (P < 0.001), Tidal work (J): 3.83 土 1.51 vs 2.21 土 0.89 (P < 0.001), Elastic work (J): 8.62 土 3.13 vs 6.32 土 3.21 (P < 0.001), Resistive work (J): 3.23 土 1.61 vs 1.81 土 1.31 (P 0.013), Inspiratory work (J): 6.95 土 2.58 vs 4.05 土 2.01 (P < 0.001), Total work (J): 11.81 土 3.81 vs 8.11 土 4.23 (P < 0.001). There were significant differences between PCV and AVM-2 in tidal volume (ml): 511 土 8.22 vs 413 土 10.21 (P < 0.001), tidal volume / IBW 7.38 土 1.74 vs 6.49 土 1.72 (P 0.004), driving pressure (cmH2O): 24.45 土 6.29 vs 20.11 土 6.59 (P 0.012), minute ventilation (L/min): 8.96 土 1.34 vs 7.42 土 1.41 (P < 0.001). The respiratory rate (bpm) was not significantly different between PCV and AVM-2 19.61 土 4.32 vs 18.32 土 1.43 (P 0.176). There were no significant differences between PCV and AVM-2 in static compliance (ml/cmH2O) 20.24 土 5.16 vs 22.72 土 6.79 (P 0.346), PaCO2 (mmHg) 44.94 土 9.62 vs 44.13 土 10.11 (P 0.825), and PaO2:FiO2 243.54 土 109.85 vs 274.21 土 125.13 (P 0.343), but significantly higher power compliance index in PCV vs AVM-2: 1.11 土 0.41 vs 0.71 土 0.33 (P < 0.001). Conclusion This study demonstra
{"title":"A comparative analysis of mechanical power and Its components in pressure-controlled ventilation mode and AVM-2 mode","authors":"Kensuke Takaoka, Shane Toma, Philip Lee, Ehab Daoud","doi":"10.53097/jmv.10088","DOIUrl":"https://doi.org/10.53097/jmv.10088","url":null,"abstract":"Background Mechanical ventilation is a critical therapeutic intervention in the management of patients with respiratory failure. Understanding the implications of different ventilation modes is essential in preventing ventilator-induced lung injuries (VILI). Recently, mechanical power has emerged as a critical element in the development of VILI and mortality. Previous bench work studies have suggested that new optimal (adaptive) modes, such as Adaptive Ventilation Mode 2 (AVM-2), can reduce the mechanical power in turn might reduce the rates of VILI. This study aims to compare the conventional Pressure-Controlled Ventilation (PCV) mode with an emerging design of Adaptive Ventilation Mode-2 (AVM-2), to measure the differences in mechanical power, alongside it’s components of PEEP, Tidal, Elastic, Resistive, Inspiratory, Total work, tidal volume, driving pressure and Power Compliance Index. Methods Between January 2023 and June of 2023, we conducted a prospective crossover study on twenty-two subjects admitted to our ICU within the first day after initiation of mechanical ventilation. Subjects were initially started on PCV settings chosen by the primary treatment team, then switched to AVM-2 with comparable minute ventilation. Mechanical power and its work components (tidal, resistive, PEEP, elastic, inspiratory, total), tidal volume, driving pressure, respiratory rate, and positive end-expiratory pressure, were recorded for each patient every 15 min for the duration of 2 consecutive hours on each mode. Statistical analysis, including paired t-tests were performed to assess the significance of differences between the two ventilation modes. The data is provided in means and 土 SD. Results There were significant differences between PCV and AVM-2 in mechanical power (J/min): 21.62 土 7.61 vs 14.21 土 6.41 (P < 0.001), PEEP work (J): 4.83 土 2.71 vs 4.11 土 2.51 (P < 0.001), Tidal work (J): 3.83 土 1.51 vs 2.21 土 0.89 (P < 0.001), Elastic work (J): 8.62 土 3.13 vs 6.32 土 3.21 (P < 0.001), Resistive work (J): 3.23 土 1.61 vs 1.81 土 1.31 (P 0.013), Inspiratory work (J): 6.95 土 2.58 vs 4.05 土 2.01 (P < 0.001), Total work (J): 11.81 土 3.81 vs 8.11 土 4.23 (P < 0.001). There were significant differences between PCV and AVM-2 in tidal volume (ml): 511 土 8.22 vs 413 土 10.21 (P < 0.001), tidal volume / IBW 7.38 土 1.74 vs 6.49 土 1.72 (P 0.004), driving pressure (cmH2O): 24.45 土 6.29 vs 20.11 土 6.59 (P 0.012), minute ventilation (L/min): 8.96 土 1.34 vs 7.42 土 1.41 (P < 0.001). The respiratory rate (bpm) was not significantly different between PCV and AVM-2 19.61 土 4.32 vs 18.32 土 1.43 (P 0.176). There were no significant differences between PCV and AVM-2 in static compliance (ml/cmH2O) 20.24 土 5.16 vs 22.72 土 6.79 (P 0.346), PaCO2 (mmHg) 44.94 土 9.62 vs 44.13 土 10.11 (P 0.825), and PaO2:FiO2 243.54 土 109.85 vs 274.21 土 125.13 (P 0.343), but significantly higher power compliance index in PCV vs AVM-2: 1.11 土 0.41 vs 0.71 土 0.33 (P < 0.001). Conclusion This study demonstra","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138999471","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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