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Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial

BACKGROUND: Insufficient or excessive respiratory effort during acute hypoxemic respiratory failure (AHRF) increases the risk of lung and diaphragm injury. We sought to establish whether respiratory effort can be optimized to achieve lung- and diaphragm-protective (LDP) targets (esophageal pressure...

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Autores principales: Dianti, Jose, Fard, Samira, Wong, Jenna, Chan, Timothy C. Y., Del Sorbo, Lorenzo, Fan, Eddy, Amato, Marcelo B. Passos, Granton, John, Burry, Lisa, Reid, W. Darlene, Zhang, Binghao, Ratano, Damian, Keshavjee, Shaf, Slutsky, Arthur S., Brochard, Laurent J., Ferguson, Niall D., Goligher, Ewan C.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9422941/
https://www.ncbi.nlm.nih.gov/pubmed/36038890
http://dx.doi.org/10.1186/s13054-022-04123-9
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author Dianti, Jose
Fard, Samira
Wong, Jenna
Chan, Timothy C. Y.
Del Sorbo, Lorenzo
Fan, Eddy
Amato, Marcelo B. Passos
Granton, John
Burry, Lisa
Reid, W. Darlene
Zhang, Binghao
Ratano, Damian
Keshavjee, Shaf
Slutsky, Arthur S.
Brochard, Laurent J.
Ferguson, Niall D.
Goligher, Ewan C.
author_facet Dianti, Jose
Fard, Samira
Wong, Jenna
Chan, Timothy C. Y.
Del Sorbo, Lorenzo
Fan, Eddy
Amato, Marcelo B. Passos
Granton, John
Burry, Lisa
Reid, W. Darlene
Zhang, Binghao
Ratano, Damian
Keshavjee, Shaf
Slutsky, Arthur S.
Brochard, Laurent J.
Ferguson, Niall D.
Goligher, Ewan C.
author_sort Dianti, Jose
collection PubMed
description BACKGROUND: Insufficient or excessive respiratory effort during acute hypoxemic respiratory failure (AHRF) increases the risk of lung and diaphragm injury. We sought to establish whether respiratory effort can be optimized to achieve lung- and diaphragm-protective (LDP) targets (esophageal pressure swing − 3 to − 8 cm H(2)O; dynamic transpulmonary driving pressure ≤ 15 cm H(2)O) during AHRF. METHODS: In patients with early AHRF, spontaneous breathing was initiated as soon as passive ventilation was not deemed mandatory. Inspiratory pressure, sedation, positive end-expiratory pressure (PEEP), and sweep gas flow (in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO)) were systematically titrated to achieve LDP targets. Additionally, partial neuromuscular blockade (pNMBA) was administered in patients with refractory excessive respiratory effort. RESULTS: Of 30 patients enrolled, most had severe AHRF; 16 required VV-ECMO. Respiratory effort was absent in all at enrolment. After initiating spontaneous breathing, most exhibited high respiratory effort and only 6/30 met LDP targets. After titrating ventilation, sedation, and sweep gas flow, LDP targets were achieved in 20/30. LDP targets were more likely to be achieved in patients on VV-ECMO (median OR 10, 95% CrI 2, 81) and at the PEEP level associated with improved dynamic compliance (median OR 33, 95% CrI 5, 898). Administration of pNMBA to patients with refractory excessive effort was well-tolerated and effectively achieved LDP targets. CONCLUSION: Respiratory effort is frequently absent  under deep sedation but becomes excessive when spontaneous breathing is permitted in patients with moderate or severe AHRF. Systematically titrating ventilation and sedation can optimize respiratory effort for lung and diaphragm protection in most patients. VV-ECMO can greatly facilitate the delivery of a LDP strategy. Trial registration: This trial was registered in Clinicaltrials.gov in August 2018 (NCT03612583). SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-022-04123-9.
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spelling pubmed-94229412022-08-30 Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial Dianti, Jose Fard, Samira Wong, Jenna Chan, Timothy C. Y. Del Sorbo, Lorenzo Fan, Eddy Amato, Marcelo B. Passos Granton, John Burry, Lisa Reid, W. Darlene Zhang, Binghao Ratano, Damian Keshavjee, Shaf Slutsky, Arthur S. Brochard, Laurent J. Ferguson, Niall D. Goligher, Ewan C. Crit Care Research BACKGROUND: Insufficient or excessive respiratory effort during acute hypoxemic respiratory failure (AHRF) increases the risk of lung and diaphragm injury. We sought to establish whether respiratory effort can be optimized to achieve lung- and diaphragm-protective (LDP) targets (esophageal pressure swing − 3 to − 8 cm H(2)O; dynamic transpulmonary driving pressure ≤ 15 cm H(2)O) during AHRF. METHODS: In patients with early AHRF, spontaneous breathing was initiated as soon as passive ventilation was not deemed mandatory. Inspiratory pressure, sedation, positive end-expiratory pressure (PEEP), and sweep gas flow (in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO)) were systematically titrated to achieve LDP targets. Additionally, partial neuromuscular blockade (pNMBA) was administered in patients with refractory excessive respiratory effort. RESULTS: Of 30 patients enrolled, most had severe AHRF; 16 required VV-ECMO. Respiratory effort was absent in all at enrolment. After initiating spontaneous breathing, most exhibited high respiratory effort and only 6/30 met LDP targets. After titrating ventilation, sedation, and sweep gas flow, LDP targets were achieved in 20/30. LDP targets were more likely to be achieved in patients on VV-ECMO (median OR 10, 95% CrI 2, 81) and at the PEEP level associated with improved dynamic compliance (median OR 33, 95% CrI 5, 898). Administration of pNMBA to patients with refractory excessive effort was well-tolerated and effectively achieved LDP targets. CONCLUSION: Respiratory effort is frequently absent  under deep sedation but becomes excessive when spontaneous breathing is permitted in patients with moderate or severe AHRF. Systematically titrating ventilation and sedation can optimize respiratory effort for lung and diaphragm protection in most patients. VV-ECMO can greatly facilitate the delivery of a LDP strategy. Trial registration: This trial was registered in Clinicaltrials.gov in August 2018 (NCT03612583). SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13054-022-04123-9. BioMed Central 2022-08-29 /pmc/articles/PMC9422941/ /pubmed/36038890 http://dx.doi.org/10.1186/s13054-022-04123-9 Text en © The Author(s) 2022 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research
Dianti, Jose
Fard, Samira
Wong, Jenna
Chan, Timothy C. Y.
Del Sorbo, Lorenzo
Fan, Eddy
Amato, Marcelo B. Passos
Granton, John
Burry, Lisa
Reid, W. Darlene
Zhang, Binghao
Ratano, Damian
Keshavjee, Shaf
Slutsky, Arthur S.
Brochard, Laurent J.
Ferguson, Niall D.
Goligher, Ewan C.
Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial
title Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial
title_full Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial
title_fullStr Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial
title_full_unstemmed Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial
title_short Strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial
title_sort strategies for lung- and diaphragm-protective ventilation in acute hypoxemic respiratory failure: a physiological trial
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9422941/
https://www.ncbi.nlm.nih.gov/pubmed/36038890
http://dx.doi.org/10.1186/s13054-022-04123-9
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