scholarly journals Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate acute respiratory distress syndrome

Critical Care ◽  
2016 ◽  
Vol 20 (1) ◽  
Author(s):  
Vito Fanelli ◽  
Marco V. Ranieri ◽  
Jordi Mancebo ◽  
Onnen Moerer ◽  
Michael Quintel ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Protective Ventilation ◽  
Carbon Dioxide Removal ◽  
Low Flow ◽  
Extracorporeal Carbon Dioxide Removal

Effects of Ultraprotective Ventilation, Extracorporeal Carbon Dioxide Removal, and Spontaneous Breathing on Lung Morphofunction and Inflammation in Experimental Severe Acute Respiratory Distress Syndrome

2015 ◽  
Vol 122 (3) ◽  
pp. 631-646 ◽  
Author(s):  
Andreas Güldner ◽  
Thomas Kiss ◽  
Thomas Bluth ◽  
Christopher Uhlig ◽  
Anja Braune ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Spontaneous Breathing ◽  
Distress Syndrome ◽  
Carbon Dioxide Removal ◽  
Intrapulmonary Shunt ◽  
Extracorporeal Carbon Dioxide Removal

Abstract Background: To investigate the role of ultraprotective mechanical ventilation (UP-MV) and extracorporeal carbon dioxide removal with and without spontaneous breathing (SB) to improve respiratory function and lung protection in experimental severe acute respiratory distress syndrome. Methods: Severe acute respiratory distress syndrome was induced by saline lung lavage and mechanical ventilation (MV) with higher tidal volume (VT) in 28 anesthetized pigs (32.8 to 52.5 kg). Animals (n = 7 per group) were randomly assigned to 6 h of MV (airway pressure release ventilation) with: (1) conventional P-MV with VT ≈6 ml/kg (P-MVcontr); (2) UP-MV with VT ≈3 ml/kg (UP-MVcontr); (3) UP-MV with VT ≈3 ml/kg and SB (UP-MVspont); and (4) UP-MV with VT ≈3 ml/kg and pressure supported SB (UP-MVPS). In UP-MV groups, extracorporeal carbon dioxide removal was used. Results: The authors found that: (1) UP-MVcontr reduced diffuse alveolar damage score in dorsal lung zones (median[interquartile]) (12.0 [7.0 to 16.8] vs. 22.5 [13.8 to 40.8]), but worsened oxygenation and intrapulmonary shunt, compared to P-MVcontr; (2) UP-MVspont and UP-MVPS improved oxygenation and intrapulmonary shunt, and redistributed ventilation towards dorsal areas, as compared to UP-MVcontr; (3) compared to P-MVcontr, UP-MVcontr and UP-MVspont, UP-MVPS yielded higher levels of tumor necrosis factor-α (6.9 [6.5 to 10.1] vs. 2.8 [2.2 to 3.0], 3.6 [3.0 to 4.7] and 4.0 [2.8 to 4.4] pg/mg, respectively) and interleukin-8 (216.8 [113.5 to 343.5] vs. 59.8 [45.3 to 66.7], 37.6 [18.8 to 52.0], and 59.5 [36.1 to 79.7] pg/mg, respectively) in dorsal lung zones. Conclusions: In this model of severe acute respiratory distress syndrome, MV with VT ≈3 ml/kg and extracorporeal carbon dioxide removal without SB slightly reduced lung histologic damage, but not inflammation, as compared to MV with VT = 4 to 6 ml/kg. During UP-MV, pressure supported SB increased lung inflammation.

scholarly journals Control of Respiratory Drive and Effort in Extracorporeal Membrane Oxygenation Patients Recovering from Severe Acute Respiratory Distress Syndrome

2016 ◽  
Vol 125 (1) ◽  
pp. 159-167 ◽  
Author(s):  
Tommaso Mauri ◽  
Giacomo Grasselli ◽  
Grazia Suriano ◽  
Nilde Eronia ◽  
Savino Spadaro ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Acute Respiratory Distress Syndrome ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Airway Pressure ◽  
Distress Syndrome ◽  
Carbon Dioxide Removal ◽  
Respiratory Drive ◽  
Extracorporeal Carbon Dioxide Removal ◽  
Carbon Dioxide Extraction

Abstract Background The amount of extracorporeal carbon dioxide removal may influence respiratory drive in acute respiratory distress syndrome (ARDS) patients undergoing extracorporeal membrane oxygenation (ECMO). The authors evaluated the effects of different levels of extracorporeal carbon dioxide removal in patients recovering from severe ARDS undergoing pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA). Methods The authors conducted a prospective, randomized, crossover study on eight spontaneously breathing ARDS patients undergoing venovenous ECMO since 28 ± 20 days. To modulate carbon dioxide extraction, ECMO gas flow (GF) was decreased from baseline resting protective conditions (i.e., GF100%, set to obtain pressure generated in the first 100 ms of inspiration against an occluded airway less than 2 cm H2O, respiratory rate less than or equal to 25 bpm, tidal volume less than 6 ml/kg, and peak airway pressure less than 25 cm H2O) to GF50%-GF25%-GF0% during both PSV and NAVA (random order for ventilation mode). Continuous recordings of airway pressure and flow and esophageal pressure were obtained and analyzed during all study phases. Results At higher levels of extracorporeal carbon dioxide extraction, pressure generated in the first 100 ms of inspiration against an occluded airway decreased from 2.8 ± 2.7 cm H2O (PSV, GF0%) and 3.0 ± 2.1 cm H2O (NAVA, GF0%) to 0.9 ± 0.5 cm H2O (PSV, GF100%) and 1.0 ± 0.8 cm H2O (NAVA, GF100%; P < 0.001) and patients’ inspiratory muscle pressure passed from 8.5 ± 6.3 and 6.5 ± 5.5 cm H2O to 4.5 ± 3.1 and 4.2 ± 3.7 cm H2O (P < 0.001). In time, decreased inspiratory drive and effort determined by higher carbon dioxide extraction led to reduction of tidal volume from 6.6 ± 0.9 and 7.5 ± 1.2 ml/kg to 4.9 ± 0.8 and 5.3 ± 1.3 ml/kg (P < 0.001) and of peak airway pressure from 21 ± 3 and 25 ± 4 cm H2O to 21 ± 3 and 21 ± 5 cm H2O (P < 0.001). Finally, transpulmonary pressure linearly decreased when the amount of carbon dioxide extracted by ECMO increased (R2 = 0.823, P < 0.001). Conclusions In patients recovering from ARDS undergoing ECMO, the amount of carbon dioxide removed by the artificial lung may influence spontaneous breathing. The effects of carbon dioxide removal on spontaneous breathing during the earlier acute phases of ARDS remain to be elucidated.

scholarly journals Ultra-protective mechanical ventilation without extra-corporeal carbon dioxide removal for acute respiratory distress syndrome

2018 ◽  
Vol 20 (1) ◽  
pp. 40-45 ◽  
Author(s):  
Hariharan Regunath ◽  
Nathanial Moulton ◽  
Daniel Woolery ◽  
Mohammed Alnijoumi ◽  
Troy Whitacre ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Tidal Volume ◽  
Distress Syndrome ◽  
Carbon Dioxide Removal ◽  
Driving Pressure ◽  
Protective Mechanical Ventilation

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.

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