Abstract Background Mortality in ARDS was reduced significantly after the introduction of the low tidal volume ventilation strategy. It has been recently shown that lung-protective ventilation strategies should primarily target driving pressure rather than Vt and that ventilator induced lung injury is not just dependent on tidal volume but also other factors like respiratory rate and driving pressure. Ventilator induced lung injury is also thought to be dependent on the amount of energy transferred by the ventilator to the patient which in turn is dependent on tidal volume size (VT), plateau pressure (Pplat), respiratory rate (RR). Mechanical power can be calculated accurately through power equations which can increase their applicability in clinical practice. One simple composite equation (driving pressure multiplied by four plus respiratory rate [4DPRR]) has been recently suggested as a simple surrogate for the power equation. This equation also doesn’t include PEEP as it has been theorized that it is the only elastic dynamic component of driving energy which affects the outcome and not the elastic static component (i.e., PEEP) and the resistive power (related to flow and airway resistance). Objectives To assess the mechanical power as measured by 4DPRR in mechanically ventilated patients who have moderate to severe COVID-19 ARDS. Methods: We obtained data on ventilatory variables and mechanical power from the patients who were admitted with moderate to severe COVID ARDS in our hospital from March 2021 to June 2021. Results We included 34 patients (28% women; mean age, 57 ± 17 yrs.). The average ΔP was 21.44 ± 3.98 cmH2O, the RR was 23.8 ± 3.84 breaths/min, and the mean driving pressure was 21.4 cmH2O. 28% (n = 10) of patients expired. There was no significant association of 4DPRR (P 0.72), Pplat (P 0.79).and RR (P 0.21) with mortality as predicted by area under ROC curves. Conclusions Driving power and plateau pressure were associated with mortality during controlled mechanical ventilation in COVID ARDS, but a simpler model of mechanical power using only the driving pressure and respiratory rate was found to be a poor predictor of mortality. Keywords: COVID-19, ARDS, Mechanical power, Driving pressure, Plateau pressure
{"title":"4DPRR- Index for predicting mortality in COVID-19 ARDS","authors":"G. Paul, M. R. Krishna, Pl Gautam","doi":"10.53097/jmv.10048","DOIUrl":"https://doi.org/10.53097/jmv.10048","url":null,"abstract":"Abstract Background Mortality in ARDS was reduced significantly after the introduction of the low tidal volume ventilation strategy. It has been recently shown that lung-protective ventilation strategies should primarily target driving pressure rather than Vt and that ventilator induced lung injury is not just dependent on tidal volume but also other factors like respiratory rate and driving pressure. Ventilator induced lung injury is also thought to be dependent on the amount of energy transferred by the ventilator to the patient which in turn is dependent on tidal volume size (VT), plateau pressure (Pplat), respiratory rate (RR). Mechanical power can be calculated accurately through power equations which can increase their applicability in clinical practice. One simple composite equation (driving pressure multiplied by four plus respiratory rate [4DPRR]) has been recently suggested as a simple surrogate for the power equation. This equation also doesn’t include PEEP as it has been theorized that it is the only elastic dynamic component of driving energy which affects the outcome and not the elastic static component (i.e., PEEP) and the resistive power (related to flow and airway resistance). Objectives To assess the mechanical power as measured by 4DPRR in mechanically ventilated patients who have moderate to severe COVID-19 ARDS. Methods: We obtained data on ventilatory variables and mechanical power from the patients who were admitted with moderate to severe COVID ARDS in our hospital from March 2021 to June 2021. Results We included 34 patients (28% women; mean age, 57 ± 17 yrs.). The average ΔP was 21.44 ± 3.98 cmH2O, the RR was 23.8 ± 3.84 breaths/min, and the mean driving pressure was 21.4 cmH2O. 28% (n = 10) of patients expired. There was no significant association of 4DPRR (P 0.72), Pplat (P 0.79).and RR (P 0.21) with mortality as predicted by area under ROC curves. Conclusions Driving power and plateau pressure were associated with mortality during controlled mechanical ventilation in COVID ARDS, but a simpler model of mechanical power using only the driving pressure and respiratory rate was found to be a poor predictor of mortality. Keywords: COVID-19, ARDS, Mechanical power, Driving pressure, Plateau pressure","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44676528","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}
Parthav Shah, J. Yeo, W. Techasatian, Franck Claudio, Ehab Daoud
Introduction Recent studies suggested that the energy delivered by the mechanical ventilator to the lungs termed the mechanical power can induce and increase the risks of ventilator induced lung injury. The components of the mechanical power include the variables delivered by the ventilator: tidal volume, respiratory rate, inspiratory flow, airway pressure. Adaptive Ventilator Mode-2 (AVM-2) is a pressure-controlled mode with an optimal targeting scheme based on the inspiratory power equation that adjusts the respiratory rate and tidal volume to achieve a target minute ventilation. This mode conceptually should reduce the mechanical power delivered to the patients and thus reduce the incidence of ventilator induced lung injury. Methodology A bench study using a lung simulator (TTL, Michigan Instruments, Michigan, USA) was conducted. We constructed a passive single compartment normal respiratory mechanics model with compliance of 50 ml/cmH2O, and resistance of 10 cmH2O/L/s, with IBW 70 kg. We compared three different ventilator modes: Adaptive Ventilation Mode-2 (AVM-2), Pressure Regulated Volume Control (PRVC), and Volume Controlled Ventilation (VCV) in four different scenarios: 2 levels of minute ventilation 7 and 10.5 Lit/min (Experiment 1 and 2 respectively), each with 2 different PEEP levels 5 and 10 cmH2O (Experiment A and B respectively) termed Experiments 1A, 1B, 2A, and 2B respectively. The AVM-2 mode automatically selects the optimal tidal volume, and respiratory rate per the dialed percent minute ventilation with an I:E ratio of 1:1. In the PRVC, VCV we selected target tidal volume 6ml/kg/IBW (420 ml), and respiratory rate adjusted to match the minute ventilation for the AVM-2 mode. I:E ratio was kept 1:2 to avoid intrinsic PEEP. The study was conducted using a bellavista™ 1000 e Ventilator (Vyaire Medical, Illinois, USA). The mechanical power delivered by the ventilator for each mode was computed and compared between the three modes in each experiment. Statistical analysis was done using Kruskal-Wallis test to analyze the difference between the three modes, post HOC Tukey test was used to analyze the difference between each mode with the confidence intervals, P < 0.05 was considered statistically significant. Results There were statistically significant differences between all the three modes regarding the ventilator delivered mechanical power. The AVM-2 mode delivered significantly less mechanical power than VCV which in turn was less than PRVC. Experiment 1A: AVM-2 8.76 土 0.05, VCV 9.78 土 0.04, PRVC 10.82 土 0.08, P < 0.001 Experiment 1B: AVM-2 11.27 ± 0.09 VCV 12.81 ± 0.05, PRVC 13.88 ± 0.06, P < 0.001. Experiment 2A: AVM-2 14.76 ± 0.05, VCV 15.79 ± 0.05, PRVC 18.29 ± 0.07, P < 0.001, Experiment 2B: AVM-2 18.76 ± 0.04, VCV 20.56 ± 0.04, PRVC 21.17 土 0.03, P < 0.001. Discussion AVM2 mode delivered less mechanical power compared to two conventional modes using low tidal volume in a normal lung model. This might reduce the incidence of
{"title":"Mechanical power in AVM-2 versus conventional ventilation modes in a normal lung model: A bench study","authors":"Parthav Shah, J. Yeo, W. Techasatian, Franck Claudio, Ehab Daoud","doi":"10.53097/jmv.10047","DOIUrl":"https://doi.org/10.53097/jmv.10047","url":null,"abstract":"Introduction Recent studies suggested that the energy delivered by the mechanical ventilator to the lungs termed the mechanical power can induce and increase the risks of ventilator induced lung injury. The components of the mechanical power include the variables delivered by the ventilator: tidal volume, respiratory rate, inspiratory flow, airway pressure. Adaptive Ventilator Mode-2 (AVM-2) is a pressure-controlled mode with an optimal targeting scheme based on the inspiratory power equation that adjusts the respiratory rate and tidal volume to achieve a target minute ventilation. This mode conceptually should reduce the mechanical power delivered to the patients and thus reduce the incidence of ventilator induced lung injury. Methodology A bench study using a lung simulator (TTL, Michigan Instruments, Michigan, USA) was conducted. We constructed a passive single compartment normal respiratory mechanics model with compliance of 50 ml/cmH2O, and resistance of 10 cmH2O/L/s, with IBW 70 kg. We compared three different ventilator modes: Adaptive Ventilation Mode-2 (AVM-2), Pressure Regulated Volume Control (PRVC), and Volume Controlled Ventilation (VCV) in four different scenarios: 2 levels of minute ventilation 7 and 10.5 Lit/min (Experiment 1 and 2 respectively), each with 2 different PEEP levels 5 and 10 cmH2O (Experiment A and B respectively) termed Experiments 1A, 1B, 2A, and 2B respectively. The AVM-2 mode automatically selects the optimal tidal volume, and respiratory rate per the dialed percent minute ventilation with an I:E ratio of 1:1. In the PRVC, VCV we selected target tidal volume 6ml/kg/IBW (420 ml), and respiratory rate adjusted to match the minute ventilation for the AVM-2 mode. I:E ratio was kept 1:2 to avoid intrinsic PEEP. The study was conducted using a bellavista™ 1000 e Ventilator (Vyaire Medical, Illinois, USA). The mechanical power delivered by the ventilator for each mode was computed and compared between the three modes in each experiment. Statistical analysis was done using Kruskal-Wallis test to analyze the difference between the three modes, post HOC Tukey test was used to analyze the difference between each mode with the confidence intervals, P < 0.05 was considered statistically significant. Results There were statistically significant differences between all the three modes regarding the ventilator delivered mechanical power. The AVM-2 mode delivered significantly less mechanical power than VCV which in turn was less than PRVC. Experiment 1A: AVM-2 8.76 土 0.05, VCV 9.78 土 0.04, PRVC 10.82 土 0.08, P < 0.001 Experiment 1B: AVM-2 11.27 ± 0.09 VCV 12.81 ± 0.05, PRVC 13.88 ± 0.06, P < 0.001. Experiment 2A: AVM-2 14.76 ± 0.05, VCV 15.79 ± 0.05, PRVC 18.29 ± 0.07, P < 0.001, Experiment 2B: AVM-2 18.76 ± 0.04, VCV 20.56 ± 0.04, PRVC 21.17 土 0.03, P < 0.001. Discussion AVM2 mode delivered less mechanical power compared to two conventional modes using low tidal volume in a normal lung model. This might reduce the incidence of ","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45212277","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}
In this article, we highlight one of the pioneers of mechanical ventilation. Dr Björn Jonson is a physiologist, physician and currently a Professor Emeritus at Lund University in Sweden. He has spent the last sixty years of his life dedicated to research and inventions in the fields of respiratory failure and mechanical ventilation. With several devices invented, more than fifteen patents, more than 200 published articles and concepts, Dr. Jonson’s work has changed and revolutionized the way we understand the science of respiratory failure, and the way we practice and monitor mechanical ventilation today. More importantly, are the countless lives of patients saved all over the world because of his contribution. Keywords: Flow regulators, Servo Ventilator, Capnography
{"title":"Pioneers in Mechanical Ventilation: Björn Jonson","authors":"Ehab Daoud","doi":"10.53097/jmv.10050","DOIUrl":"https://doi.org/10.53097/jmv.10050","url":null,"abstract":"In this article, we highlight one of the pioneers of mechanical ventilation. Dr Björn Jonson is a physiologist, physician and currently a Professor Emeritus at Lund University in Sweden. He has spent the last sixty years of his life dedicated to research and inventions in the fields of respiratory failure and mechanical ventilation. With several devices invented, more than fifteen patents, more than 200 published articles and concepts, Dr. Jonson’s work has changed and revolutionized the way we understand the science of respiratory failure, and the way we practice and monitor mechanical ventilation today. More importantly, are the countless lives of patients saved all over the world because of his contribution. Keywords: Flow regulators, Servo Ventilator, Capnography","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45764447","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}
Parthav Shah, K. Benavente, T. Czech, W. Techasatian
Spinal Cord injury is a disabling condition which affects the respiratory system. The most affected neurological level is the cervical spine. Many patients with cervical spinal cord injury are unable to sustain independent ventilation and require mechanical ventilation. Long term use of mechanical ventilation is associated with poor quality of life, increased morbidity, and mortality. In patients with intact phrenic nerve, diaphragmatic pacing can be used to help wean the patients off mechanical ventilation. In this review, we summarize the indications, contraindications, benefits, safety, and effectiveness of diaphragmatic pacing. We also report a brief case of a 62-year-old male with quadriplegia secondary to C2-C3 fracture who was intubated after drowning but was extubated with the help of diaphragmatic pacing. Keywords: Cervical spinal injury, Diaphragmatic pacemaker, Mechanical Ventilation
{"title":"Diaphragmatic Pacing in Spinal Cord Injury","authors":"Parthav Shah, K. Benavente, T. Czech, W. Techasatian","doi":"10.53097/jmv.10049","DOIUrl":"https://doi.org/10.53097/jmv.10049","url":null,"abstract":"Spinal Cord injury is a disabling condition which affects the respiratory system. The most affected neurological level is the cervical spine. Many patients with cervical spinal cord injury are unable to sustain independent ventilation and require mechanical ventilation. Long term use of mechanical ventilation is associated with poor quality of life, increased morbidity, and mortality. In patients with intact phrenic nerve, diaphragmatic pacing can be used to help wean the patients off mechanical ventilation. In this review, we summarize the indications, contraindications, benefits, safety, and effectiveness of diaphragmatic pacing. We also report a brief case of a 62-year-old male with quadriplegia secondary to C2-C3 fracture who was intubated after drowning but was extubated with the help of diaphragmatic pacing. Keywords: Cervical spinal injury, Diaphragmatic pacemaker, Mechanical Ventilation","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48771787","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}
C. Franck, Samuel da Rossa Sousa, Guilherme Voltolini, R. Melo, I. Moraes
The Reinforced Orotracheal Tube (ROT) is an airway device for intubation that allows invasive ventilation during general anesthesia. The ROT differs from a Conventional Endotracheal Tube (CET) by the presence of a stainless-steel spiral, which strengthens the wall and hinders collapse. The ROT can be used when there is a risk of obstructing the flow of gases through compression or elbowing of the endotracheal tube, during orofacial surgical procedures, neurosurgery or in non-supine surgical positions under deep general anesthesia. The metallic spiral, which reinforces the lumen of this endotracheal tube, is subject to damage and deformities that can compromise the permeability of its lumen. The ROT should be used only during the surgical procedure under deep general anesthesia. If there is a need for the permanence of orotracheal intubation in the postoperative period of patients referred to the intensive care unit, the ROT should be replaced by the polyvinyl chloride CET, given the risk of damage to the ROT due to bites with fracture of the metal rod and obstruction by folding, as in this case, which will be reported below. The rarity of similar reports in the literature and the severity of obstruction of an endotracheal tube causing severe hypoxemic disorders, guided the objective of this case report, which aims to guide preventive and resolving measures, in addition to including to the list of diagnoses of causes of acute obstructions of an endotracheal tube. Keywords: Airway obstruction; Armoured tube; intubation: mechanical ventilation.
{"title":"Airway obstruction by a folding metal rod within a Reinforced Oral tracheal Tube: Case Report","authors":"C. Franck, Samuel da Rossa Sousa, Guilherme Voltolini, R. Melo, I. Moraes","doi":"10.53097/jmv.10051","DOIUrl":"https://doi.org/10.53097/jmv.10051","url":null,"abstract":"The Reinforced Orotracheal Tube (ROT) is an airway device for intubation that allows invasive ventilation during general anesthesia. The ROT differs from a Conventional Endotracheal Tube (CET) by the presence of a stainless-steel spiral, which strengthens the wall and hinders collapse. The ROT can be used when there is a risk of obstructing the flow of gases through compression or elbowing of the endotracheal tube, during orofacial surgical procedures, neurosurgery or in non-supine surgical positions under deep general anesthesia. The metallic spiral, which reinforces the lumen of this endotracheal tube, is subject to damage and deformities that can compromise the permeability of its lumen. The ROT should be used only during the surgical procedure under deep general anesthesia. If there is a need for the permanence of orotracheal intubation in the postoperative period of patients referred to the intensive care unit, the ROT should be replaced by the polyvinyl chloride CET, given the risk of damage to the ROT due to bites with fracture of the metal rod and obstruction by folding, as in this case, which will be reported below. The rarity of similar reports in the literature and the severity of obstruction of an endotracheal tube causing severe hypoxemic disorders, guided the objective of this case report, which aims to guide preventive and resolving measures, in addition to including to the list of diagnoses of causes of acute obstructions of an endotracheal tube. Keywords: Airway obstruction; Armoured tube; intubation: mechanical ventilation.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48907813","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}
C. Franck, Gustavo Maysonnave Franck, Raquel Galvão Feronato
Introduction The Acute Respiratory Distress Syndrome caused by the Coronavirus 2019 (SARS-CoV-2) may be associated with the Acute Respiratory Distress Syndrome (ARDS) and Ventilation Induced Lung Injury (VILI). However, there are still doubts about the potential damage generators and their influences on patient outcome. Objective To analyze the mechanical ventilation factors that influence the mortality in SARS-CoV-2. Assess the outcomes based on age, on parameters of the mechanical ventilator, on Mechanical Power and on its fragments through univariate and multivariate analysis of age, PEEP, Driving Pressure, elastance. Method Observational, longitudinal, prospective, analytical, and quantitative study of age and of the parameters of the mechanical ventilator, alongside the calculous of the Mechanical Power and its components of patients with SARS-CoV-2. Results We identified significant impact on the outcome in the univariate analysis of age (p<0.001), respiratory rate (p=0.047), elastance (p<0.001), compliance (p<0.001), driving pressure (p<0.001), inspiratory pressure variation (p<0.001), peak airway pressure (p=0.009), plateau pressure (p<0.013), PEEP (p<0.001), dynamic elastic power (p<0.001) and static elastic power (p=0.005). In the multivariate analysis the increase in age (p<0.001), in elastance (p=0.0029) and in Mechanical Power (p=0.023), and the reduction in PEEP (p=0.044) showed significant impact on the death risk. Conclusion The increase in age and in mechanical power with increased dynamic elastic power and decreased static elastic power influenced the mortality rate of patients with SARS-CoV-2 undergoing mechanical ventilation, i.e. it is related to the increase in driving pressure to overcome a high elastance and low capacity to recruit for PEEP.
{"title":"Influence of age, mechanical power, its fragments and components on the mortality rate in SARS-CoV-2 patients undergoing mechanical ventilation","authors":"C. Franck, Gustavo Maysonnave Franck, Raquel Galvão Feronato","doi":"10.53097/jmv.10041","DOIUrl":"https://doi.org/10.53097/jmv.10041","url":null,"abstract":"Introduction The Acute Respiratory Distress Syndrome caused by the Coronavirus 2019 (SARS-CoV-2) may be associated with the Acute Respiratory Distress Syndrome (ARDS) and Ventilation Induced Lung Injury (VILI). However, there are still doubts about the potential damage generators and their influences on patient outcome. Objective To analyze the mechanical ventilation factors that influence the mortality in SARS-CoV-2. Assess the outcomes based on age, on parameters of the mechanical ventilator, on Mechanical Power and on its fragments through univariate and multivariate analysis of age, PEEP, Driving Pressure, elastance. Method Observational, longitudinal, prospective, analytical, and quantitative study of age and of the parameters of the mechanical ventilator, alongside the calculous of the Mechanical Power and its components of patients with SARS-CoV-2. Results We identified significant impact on the outcome in the univariate analysis of age (p<0.001), respiratory rate (p=0.047), elastance (p<0.001), compliance (p<0.001), driving pressure (p<0.001), inspiratory pressure variation (p<0.001), peak airway pressure (p=0.009), plateau pressure (p<0.013), PEEP (p<0.001), dynamic elastic power (p<0.001) and static elastic power (p=0.005). In the multivariate analysis the increase in age (p<0.001), in elastance (p=0.0029) and in Mechanical Power (p=0.023), and the reduction in PEEP (p=0.044) showed significant impact on the death risk. Conclusion The increase in age and in mechanical power with increased dynamic elastic power and decreased static elastic power influenced the mortality rate of patients with SARS-CoV-2 undergoing mechanical ventilation, i.e. it is related to the increase in driving pressure to overcome a high elastance and low capacity to recruit for PEEP.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42991863","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}
Medical history is often overlooked as advances keep moving forward. Seldom is it that advances in medicine are truly new, unique ideas, but rather built on ideas that have been considered before. Even our latest developments will become history or forgotten as science and medicine advance. This history of intermittent mandatory ventilation (IMV) is a two-part article in which the first part attempts to show that the concepts and apparatus that involve the now common mode of ventilation have been considered and described for nearly 200 years, if not earlier. This older history is not brought forward to diminish what has been done in the last 50 years, but to enhance awareness of how ideas and even mechanical ventilators change over time. This second part will describe how those ideas and mechanics changed into what we now call IMV in its many forms.
{"title":"History of Intermittent Mandatory Ventilation 1971 to present. Part two","authors":"Ronald Sanderson, C. Rogers","doi":"10.53097/jmv.10043","DOIUrl":"https://doi.org/10.53097/jmv.10043","url":null,"abstract":"Medical history is often overlooked as advances keep moving forward. Seldom is it that advances in medicine are truly new, unique ideas, but rather built on ideas that have been considered before. Even our latest developments will become history or forgotten as science and medicine advance. This history of intermittent mandatory ventilation (IMV) is a two-part article in which the first part attempts to show that the concepts and apparatus that involve the now common mode of ventilation have been considered and described for nearly 200 years, if not earlier. This older history is not brought forward to diminish what has been done in the last 50 years, but to enhance awareness of how ideas and even mechanical ventilators change over time. This second part will describe how those ideas and mechanics changed into what we now call IMV in its many forms.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47968091","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}
Patient-ventilator asynchrony/dysynchrony is a mismatch between the patient and the ventilator's delivered breaths and the ability of the ventilator to meet the patient demands. Any factor that alters the harmony between these two components produces asynchrony, which can cause discomfort and an increase in the patient's work of breathing. Delayed cycling occurs when the neural time is less than the mechanical time of the ventilator. Keywords: asynchrony, ventilator, delayed cycling, work of breathing, neural time, mechanical time.
{"title":"Identifying asynchronies: Delayed cycling","authors":"Victor Perez, Jamille Pasco","doi":"10.53097/jmv.10045","DOIUrl":"https://doi.org/10.53097/jmv.10045","url":null,"abstract":"Patient-ventilator asynchrony/dysynchrony is a mismatch between the patient and the ventilator's delivered breaths and the ability of the ventilator to meet the patient demands. Any factor that alters the harmony between these two components produces asynchrony, which can cause discomfort and an increase in the patient's work of breathing. Delayed cycling occurs when the neural time is less than the mechanical time of the ventilator. Keywords: asynchrony, ventilator, delayed cycling, work of breathing, neural time, mechanical time.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"70769223","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}
K. Benavente, S. Yoshimura, James Davis, A. Dhupa, Ehab Daoud
Background Benefits of the prone position in ARDS are well established, and the evidence of its benefits for the COVID-19 patients are growing. However, the clinical utilization of such a maneuver is less established. We attempted to analyze the clinician’s utilization and attitude of the prone position and what is the main drive for its usage. Methods An international survey of eight questions. The questionnaire was anonymous and included the country of practice, percentage of patients with COVID-19 they have placed in the prone position while undergoing mechanical ventilation, most important factor that determined the need for the prone position (SpO2, PaO2:FiO2, FIO2, PEEP), duration of prone position in hours/day, use of neuro-muscular blocking agents, body position (flat, trendelenburg, reverse trendelenburg), the use of a specific protocol for the prone position, if they believe that prone position is beneficial, and if their practice will change or not. The survey was active for five months. Statistical analysis included frequencies of each response, as well as subgroup analyses designed to identify potential correlates of longer or shorter proning durations. The questionnaire assessed clinicians optimism regarding the continuing use of proning in the future, and how different cutoffs for proning initiation may be associated with attitudes towards proning. Associations between categorical variables were analyzed using Fisher’s exact test. A P-value of < 0.05 was considered statistically significant. Results are expressed in Means ± Standard Deviation (SD) Results 294 questionnaires were collected from 35 countries with 78% of responders from the USA. Median duration of proning was 14.8 ± 2.8 hours per day. 74% of clinicians utilized an established protocol for proning their patients. The decision to initiate proning was non-significant and split between the use of oxygen saturation SpO2 (30%) mean 92.44 ± 5.61, PaO2:FiO2 ratio (28%) mean 188.44 ± 57.36, FiO2 mean 78.6 ± 15.65, PEEP mean 12.96 ± 4.66, or immediate prone positioning following intubation (22%). 41.2% of surveyed utilize the prone position in 25-50%, average percent patients proned calculated at 7.1%. Estimated 77% of respondents reported prone positioning to be helpful in 50% or less of cases. 91% of responders used NMB either always or frequently, and there was statistical significance between the use of NMB and perceived benefits of proning (P < 0.001). 74% of those surveyed use a protocol for proning, the use of protocol and the perceived benefits of proning was statistically significant (P <0.001). Conclusion There are few agreements between clinicians on the duration of the proning sessions and use of NMB and using a protocol for proning. There was no agreement on the trigger of the prone position or the belief of its usefulness. This ambiguity should trigger an evidence-based ARDS management using the prone position in COVID-19 patients.
{"title":"Application of the prone position during COVID-19 pandemic. (PROCOV). An international survey of clinicians","authors":"K. Benavente, S. Yoshimura, James Davis, A. Dhupa, Ehab Daoud","doi":"10.53097/jmv.10042","DOIUrl":"https://doi.org/10.53097/jmv.10042","url":null,"abstract":"Background Benefits of the prone position in ARDS are well established, and the evidence of its benefits for the COVID-19 patients are growing. However, the clinical utilization of such a maneuver is less established. We attempted to analyze the clinician’s utilization and attitude of the prone position and what is the main drive for its usage. Methods An international survey of eight questions. The questionnaire was anonymous and included the country of practice, percentage of patients with COVID-19 they have placed in the prone position while undergoing mechanical ventilation, most important factor that determined the need for the prone position (SpO2, PaO2:FiO2, FIO2, PEEP), duration of prone position in hours/day, use of neuro-muscular blocking agents, body position (flat, trendelenburg, reverse trendelenburg), the use of a specific protocol for the prone position, if they believe that prone position is beneficial, and if their practice will change or not. The survey was active for five months. Statistical analysis included frequencies of each response, as well as subgroup analyses designed to identify potential correlates of longer or shorter proning durations. The questionnaire assessed clinicians optimism regarding the continuing use of proning in the future, and how different cutoffs for proning initiation may be associated with attitudes towards proning. Associations between categorical variables were analyzed using Fisher’s exact test. A P-value of < 0.05 was considered statistically significant. Results are expressed in Means ± Standard Deviation (SD) Results 294 questionnaires were collected from 35 countries with 78% of responders from the USA. Median duration of proning was 14.8 ± 2.8 hours per day. 74% of clinicians utilized an established protocol for proning their patients. The decision to initiate proning was non-significant and split between the use of oxygen saturation SpO2 (30%) mean 92.44 ± 5.61, PaO2:FiO2 ratio (28%) mean 188.44 ± 57.36, FiO2 mean 78.6 ± 15.65, PEEP mean 12.96 ± 4.66, or immediate prone positioning following intubation (22%). 41.2% of surveyed utilize the prone position in 25-50%, average percent patients proned calculated at 7.1%. Estimated 77% of respondents reported prone positioning to be helpful in 50% or less of cases. 91% of responders used NMB either always or frequently, and there was statistical significance between the use of NMB and perceived benefits of proning (P < 0.001). 74% of those surveyed use a protocol for proning, the use of protocol and the perceived benefits of proning was statistically significant (P <0.001). Conclusion There are few agreements between clinicians on the duration of the proning sessions and use of NMB and using a protocol for proning. There was no agreement on the trigger of the prone position or the belief of its usefulness. This ambiguity should trigger an evidence-based ARDS management using the prone position in COVID-19 patients.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46507429","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}
Flexible bronchoscopy has been utilized in the intensive care units and in mechanically ventilated patients for many decades. The procedure is reasonably safe and has wide range of diagnostic and therapeutic benefits in patients undergoing mechanical ventilation. Though guidelines exist for bronchoscopy in adults in general and for those in the intensive care units (ICU), there are no guidelines specifically established for bronchoscopy during mechanical ventilation. In this review, we try to summarize the indications (Why), physiologic effects of bronchoscopy, complications, and the contraindications (Why not) to the use of this procedure and the evidence behind it. Special section on the single use disposable bronchoscopes and the use of bronchoscopy during the COVID-19 era are discussed.
{"title":"Flexible bronchoscopy during mechanical ventilation. Why and why not","authors":"K. Benavente, Kimiyo H. Yamasaki, Ehab Daoud","doi":"10.53097/jmv.10044","DOIUrl":"https://doi.org/10.53097/jmv.10044","url":null,"abstract":"Flexible bronchoscopy has been utilized in the intensive care units and in mechanically ventilated patients for many decades. The procedure is reasonably safe and has wide range of diagnostic and therapeutic benefits in patients undergoing mechanical ventilation. Though guidelines exist for bronchoscopy in adults in general and for those in the intensive care units (ICU), there are no guidelines specifically established for bronchoscopy during mechanical ventilation. In this review, we try to summarize the indications (Why), physiologic effects of bronchoscopy, complications, and the contraindications (Why not) to the use of this procedure and the evidence behind it. Special section on the single use disposable bronchoscopes and the use of bronchoscopy during the COVID-19 era are discussed.","PeriodicalId":73813,"journal":{"name":"Journal of mechanical ventilation","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49596936","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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