Variations du volume pulmonaire au cours de la ventilation mécanique (modes ventilatoires et manœuvres positionnelles)

Le Syndrome de détresse respiratoire aiguë (SDRA) est une pathologie fréquente et grave. Son traitement fait appel à la ventilation mécanique qui est indispensable pour maintenir une oxygénation suffisante mais elle peut induire des lésions pulmonaires responsables d'une morbidité importante. Le volume pulmonaire est diminué au cours du SDRA ; sa mesure a longtemps été du domaine de la recherche clinique mais une technique de mesure au lit du patient a récemment été proposée : le lavage de l'azote. Ce travail avait pour but de tester la mesure du volume pulmonaire par la technique du lavage de l'azote dans des conditions d'utilisation comparables à celles du SDRA c'est à dire avec des niveaux de pression expiratoire positive (PEP) et de FiO2 élevés. Une fois cette étape préliminaire validée, nous avons utilisé la mesure du volume pulmonaire pour évaluer le recrutement induit par des réglages de PEP différents et lors de changements de position.Nous avons montré dans l'étude n1 que les mesures étaient suffisamment précises et reproductibles pour une utilisation clinique. La PEP et le niveau d'oxygénation influençaient peu les mesures. Dans l'étude n2, le recrutement induit par une PEP de type recrutement maximal réglée pour obtenir une pression de plateau (Pplat) entre 28 et 32 cmH2O, a été estimé à partir des mesures de volume pulmonaire comparées à l'augmentation minimale prédite du volume pulmonaire. Une bonne corrélation avec le recrutement mesuré par la technique des courbes pression - volume était trouvée sous réserve d'une élimination des mesures incohérentes.Parallèlement, la mesure du volume pulmonaire et l'oxygénation de patients en SDRA et Acute Lung Injury (ALI) ont été analysées lors de changements de position (Position demi-assise puis assise). Cette étude montre que le volume pulmonaire est augmenté lors de la verticalisation et particulièrement chez les patients augmentant leur oxygénation > 20%. Les patients ne répondant pas au positionnement avaient des volumes pulmonaires plus élevés et qui variaient peu.Les différents travaux réalisés ont permis de montrer la simplicité d'utilisation de la technique. Ceci offre des perspectives de recherche au lit du patient plus accessibles qu'avec les techniques de référence (scanner et dilution de l'hélium), et également des perspectives cliniques. Une approche de la déformation pulmonaire induite par la ventilation (strain) et potentiellement des lésions induites par la ventilation mécanique est rendue possible par la mise à disposition en clinique de cette technique.The acute respiratory distress syndrome (ARDS) is a frequent and severe form of acute respiratory failure. Mechanical ventilation is the cornerstone of treatment but it may induce a specific form of lung injury (Ventilator induced Lung Injury) responsible for superimposed morbidity and mortality. Lung volume is dramatically decreased during ARDS. Lung volume measurements remained limited to clinical research until recently when the nitrogen washout/washin technique has been adapted for bedside use and implemented in an intensive care ventilator. The aim of this work was to test the nitrogen washout/washin method in clinical conditions of ARDS treatment with high Positive End Expiratory Pressure (PEEP) and high oxygen fraction (FiO2). Once this preliminary validation study was realised, we used the technique to assess the amount of lung recruitment induced by PEEP and positioning.We showed in the first study that accuracy and reproducibility of the technique were acceptable. PEEP and FiO2 had a minor influence on measurements. In the second study, the recruitment induced by a maximal recruitment PEEP set to obtain a plateau pressure between 28-32 cmH2O has been estimated using end-expiratory lung volume (EELV) measurements. A significant correlation was found between the recruitment measured on Pressure/Volume curves and the recruitment estimated comparing the predicted minimal increase in lung volume and the true increase in EELV.In a third study, we have evaluated the concomitant effects of verticalization on EELV and oxygenation following a change from supine to semi recumbent, seated and back to supine position. In this third study, verticalization (seated position) resulted in a significant concomitant increase in lung volume and oxygenation. Interestingly, patients responding to verticalization had lower EELV at baseline than non-responders. Only the group of patients increasing their PaO2/FiO2>20% during verticalization had a significant increase in their EELV compared to non-responders.These three studies confirmed the feasibility of the technique, easier than the gold standard techniques (helium dilution or CT scan), and offering both research and clinical perspectives. This technique should also allow an easier approach of the strain induced by ventilation and assess the risk of ventilation induced lung injury.PARIS-EST-Université (770839901) / SudocPARIS12-Bib. électronique (940280011) / SudocSudocFranceF

Intrapulmonary percussive ventilation superimposed on spontaneous breathing: a physiological study in patients at risk for extubation failure

Purpose: Intrapulmonary percussive ventilation (IPV) is a high-frequency ventilation modality that can be superimposed on spontaneous breathing. IPV may diminish respiratory muscle loading and help to mobilize secretions. The aim of this prospective study was to assess the short-term effects of IPV in patients at high risk for extubation failure who were receiving preventive non-invasive ventilation (NIV) after extubation. Methods: Respiratory rate, work of breathing, and gas exchange were evaluated in 17 extubated patients during 20min of IPV and 20min of NIV delivered via a facial mask, separated by periods of spontaneous breathing. The pressure-support level during NIV was adjusted until tidal volume reached 6-8ml/kg and positive end-expiratory pressure (PEEP) 4-5cmH2O. For IPV, the pressurisation frequency was set at 250cycles/min and driving pressure at 1.2bar. The pressure-time product of the diaphragm (PTPdi/min) was measured using an oesophageal and gastric double-balloon catheter. Results: Transdiaphragmatic pressure and PTPdi/min improved significantly (p<0.01), from a median [25th-75th percentiles] of 264 [190-300] to 192 [152-221]cmH2Os/min with IPV and from 273 [212-397] to 176 [120-216]cmH2Os/min with NIV. Respiratory rate decreased significantly from 23 [19-27] to 22 [17-24] breaths/min for IPV and from 25 [19-28] to 20 [18-22] breaths/min for NIV (p<0.01). Mean PaCO2 decreased after NIV (from 46 [42-48] to 41 [36-42]mmHg, p<0.01) but not after IPV. There was no noticeable effect on oxygenation. Conclusions: IPV is an interesting alternative to NIV in patients at risk for post-extubation respiratory failure. Both NIV and IPV diminished the respiratory rate and work of breathing, but IPV was less effective in improving alveolar ventilatio

Accuracy and precision of end-expiratory lung-volume measurements by automated nitrogen washout/washin technique in patients with acute respiratory distress syndrome

Introduction End-expiratory lung volume (EELV) is decreased in acute respiratory distress syndrome (ARDS), and bedside EELV measurement may help to set positive end-expiratory pressure (PEEP). Nitrogen washout/washin for EELV measurement is available at the bedside, but assessments of accuracy and precision in real-life conditions are scant. Our purpose was to (a) assess EELV measurement precision in ARDS patients at two PEEP levels (three pairs of measurements), and (b) compare the changes (Δ) induced by PEEP for total EELV with the PEEP-induced changes in lung volume above functional residual capacity measured with passive spirometry (ΔPEEP-volume). The minimal predicted increase in lung volume was calculated from compliance at low PEEP and ΔPEEP to ensure the validity of lung-volume changes. Methods Thirty-four patients with ARDS were prospectively included in five university-hospital intensive care units. ΔEELV and ΔPEEP volumes were compared between 6 and 15 cm H2O of PEEP. Results After exclusion of three patients, variability of the nitrogen technique was less than 4%, and the largest difference between measurements was 81 ± 64 ml. ΔEELV and ΔPEEP-volume were only weakly correlated (r 2 = 0.47); 95% confidence interval limits, -414 to 608 ml). In four patients with the highest PEEP (≥ 16 cm H2O), ΔEELV was lower than the minimal predicted increase in lung volume, suggesting flawed measurements, possibly due to leaks. Excluding those from the analysis markedly strengthened the correlation between ΔEELV and ΔPEEP volume (r 2 = 0.80). Conclusions In most patients, the EELV technique has good reproducibility and accuracy, even at high PEEP. At high pressures, its accuracy may be limited in case of leaks. The minimal predicted increase in lung volume may help to check for accuracy

Diagnostic performance of fractional excretion of urea in the evaluation of critically ill patients with acute kidney injury: a multicenter cohort study

International audienceINTRODUCTION: Several factors, including diuretic use and sepsis, interfere with the fractional excretion of sodium, which is used to distinguish transient from persistent acute kidney injury (AKI). These factors do not affect the fractional excretion of urea (FeUrea). However, there are conflicting data on the diagnostic accuracy of FeUrea. METHODS: We conducted an observational, prospective, multicenter study at three ICUs in university hospitals. Unselected patients, except those with obstructive AKI, were admitted to the participating ICUs during a six-month period. Transient AKI was defined as AKI caused by renal hypoperfusion and reversal within three days. The results are reported as medians (interquartile ranges). RESULTS: A total of 203 patients were included. According to our definitions, 67 had no AKI, 54 had transient AKI and 82 had persistent AKI. FeUrea was 39% (28 to 40) in the no-AKI group, 41% (29 to 54) in the transient AKI group and 32% (22 to 51) in the persistent AKI group (P = 0.12). FeUrea was of little help in distinguishing transient AKI from persistent AKI, with the area under the receiver operating characteristic curve being 0.59 (95% confidence interval, 0.49 to 0.70; P = 0.06). Sensitivity was 63% and specificity was 54% with a cutoff of 35%. In the subgroup of patients receiving diuretics, the results were similar. CONCLUSIONS: FeUrea may be of little help in distinguishing transient AKI from persistent AKI in critically ill patients, including those receiving diuretic therapy. Additional studies are needed to evaluate alternative markers or strategies to differentiate transient from persistent AKI

Year in review in Intensive Care Medicine 2011: III. ARDS and ECMO, weaning, mechanical ventilation, noninvasive ventilation, pediatrics and miscellanea

SCOPUS: re.jinfo:eu-repo/semantics/publishe

Year in review in Intensive Care Medicine, 2008: II. Experimental, acute respiratory failure and ARDS, mechanical ventilation and endotracheal intubation

SCOPUS: re.jinfo:eu-repo/semantics/publishe

Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Variation of lung volume during artificial ventilation : effect of position and ventilatory modes

Le Syndrome de détresse respiratoire aiguë (SDRA) est une pathologie fréquente et grave. Son traitement fait appel à la ventilation mécanique qui est indispensable pour maintenir une oxygénation suffisante mais elle peut induire des lésions pulmonaires responsables d'une morbidité importante. Le volume pulmonaire est diminué au cours du SDRA ; sa mesure a longtemps été du domaine de la recherche clinique mais une technique de mesure au lit du patient a récemment été proposée : le lavage de l'azote. Ce travail avait pour but de tester la mesure du volume pulmonaire par la technique du lavage de l'azote dans des conditions d'utilisation comparables à celles du SDRA c'est à dire avec des niveaux de pression expiratoire positive (PEP) et de FiO2 élevés. Une fois cette étape préliminaire validée, nous avons utilisé la mesure du volume pulmonaire pour évaluer le recrutement induit par des réglages de PEP différents et lors de changements de position.Nous avons montré dans l'étude n°1 que les mesures étaient suffisamment précises et reproductibles pour une utilisation clinique. La PEP et le niveau d'oxygénation influençaient peu les mesures. Dans l'étude n°2, le recrutement induit par une PEP de type « recrutement maximal » réglée pour obtenir une pression de plateau (Pplat) entre 28 et 32 cmH2O, a été estimé à partir des mesures de volume pulmonaire comparées à l'augmentation minimale prédite du volume pulmonaire. Une bonne corrélation avec le recrutement mesuré par la technique des courbes pression - volume était trouvée sous réserve d'une élimination des mesures incohérentes.Parallèlement, la mesure du volume pulmonaire et l'oxygénation de patients en SDRA et Acute Lung Injury (ALI) ont été analysées lors de changements de position (Position demi-assise puis assise). Cette étude montre que le volume pulmonaire est augmenté lors de la verticalisation et particulièrement chez les patients augmentant leur oxygénation > 20%. Les patients ne répondant pas au positionnement avaient des volumes pulmonaires plus élevés et qui variaient peu.Les différents travaux réalisés ont permis de montrer la simplicité d'utilisation de la technique. Ceci offre des perspectives de recherche au lit du patient plus accessibles qu'avec les techniques de référence (scanner et dilution de l'hélium), et également des perspectives cliniques. Une approche de la déformation pulmonaire induite par la ventilation (strain) et potentiellement des lésions induites par la ventilation mécanique est rendue possible par la mise à disposition en clinique de cette technique.The acute respiratory distress syndrome (ARDS) is a frequent and severe form of acute respiratory failure. Mechanical ventilation is the cornerstone of treatment but it may induce a specific form of lung injury (Ventilator induced Lung Injury) responsible for superimposed morbidity and mortality. Lung volume is dramatically decreased during ARDS. Lung volume measurements remained limited to clinical research until recently when the nitrogen washout/washin technique has been adapted for bedside use and implemented in an intensive care ventilator. The aim of this work was to test the nitrogen washout/washin method in clinical conditions of ARDS treatment with high Positive End Expiratory Pressure (PEEP) and high oxygen fraction (FiO2). Once this preliminary validation study was realised, we used the technique to assess the amount of lung recruitment induced by PEEP and positioning.We showed in the first study that accuracy and reproducibility of the technique were acceptable. PEEP and FiO2 had a minor influence on measurements. In the second study, the recruitment induced by a “maximal recruitment” PEEP set to obtain a plateau pressure between 28-32 cmH2O has been estimated using end-expiratory lung volume (EELV) measurements. A significant correlation was found between the recruitment measured on Pressure/Volume curves and the recruitment estimated comparing the predicted minimal increase in lung volume and the true increase in EELV.In a third study, we have evaluated the concomitant effects of verticalization on EELV and oxygenation following a change from supine to semi recumbent, seated and back to supine position. In this third study, verticalization (seated position) resulted in a significant concomitant increase in lung volume and oxygenation. Interestingly, patients responding to verticalization had lower EELV at baseline than non-responders. Only the group of patients increasing their PaO2/FiO2>20% during verticalization had a significant increase in their EELV compared to non-responders.These three studies confirmed the feasibility of the technique, easier than the gold standard techniques (helium dilution or CT scan), and offering both research and clinical perspectives. This technique should also allow an easier approach of the strain induced by ventilation and assess the risk of ventilation induced lung injury

Variations du volume pulmonaire au cours de la ventilation mécanique : modes ventilatoires et manœuvres positionnelles

The acute respiratory distress syndrome (ARDS) is a frequent and severe form of acute respiratory failure. Mechanical ventilation is the cornerstone of treatment but it may induce a specific form of lung injury (Ventilator induced Lung Injury) responsible for superimposed morbidity and mortality. Lung volume is dramatically decreased during ARDS. Lung volume measurements remained limited to clinical research until recently when the nitrogen washout/washin technique has been adapted for bedside use and implemented in an intensive care ventilator. The aim of this work was to test the nitrogen washout/washin method in clinical conditions of ARDS treatment with high Positive End Expiratory Pressure (PEEP) and high oxygen fraction (FiO2). Once this preliminary validation study was realised, we used the technique to assess the amount of lung recruitment induced by PEEP and positioning.We showed in the first study that accuracy and reproducibility of the technique were acceptable. PEEP and FiO2 had a minor influence on measurements. In the second study, the recruitment induced by a “maximal recruitment” PEEP set to obtain a plateau pressure between 28-32 cmH2O has been estimated using end-expiratory lung volume (EELV) measurements. A significant correlation was found between the recruitment measured on Pressure/Volume curves and the recruitment estimated comparing the predicted minimal increase in lung volume and the true increase in EELV.In a third study, we have evaluated the concomitant effects of verticalization on EELV and oxygenation following a change from supine to semi recumbent, seated and back to supine position. In this third study, verticalization (seated position) resulted in a significant concomitant increase in lung volume and oxygenation. Interestingly, patients responding to verticalization had lower EELV at baseline than non-responders. Only the group of patients increasing their PaO2/FiO2>20% during verticalization had a significant increase in their EELV compared to non-responders.These three studies confirmed the feasibility of the technique, easier than the gold standard techniques (helium dilution or CT scan), and offering both research and clinical perspectives. This technique should also allow an easier approach of the strain induced by ventilation and assess the risk of ventilation induced lung injury.Le Syndrome de détresse respiratoire aiguë (SDRA) est une pathologie fréquente et grave. Son traitement fait appel à la ventilation mécanique qui est indispensable pour maintenir une oxygénation suffisante mais elle peut induire des lésions pulmonaires responsables d'une morbidité importante. Le volume pulmonaire est diminué au cours du SDRA ; sa mesure a longtemps été du domaine de la recherche clinique mais une technique de mesure au lit du patient a récemment été proposée : le lavage de l'azote. Ce travail avait pour but de tester la mesure du volume pulmonaire par la technique du lavage de l'azote dans des conditions d'utilisation comparables à celles du SDRA c'est à dire avec des niveaux de pression expiratoire positive (PEP) et de FiO2 élevés. Une fois cette étape préliminaire validée, nous avons utilisé la mesure du volume pulmonaire pour évaluer le recrutement induit par des réglages de PEP différents et lors de changements de position.Nous avons montré dans l'étude n°1 que les mesures étaient suffisamment précises et reproductibles pour une utilisation clinique. La PEP et le niveau d'oxygénation influençaient peu les mesures. Dans l'étude n°2, le recrutement induit par une PEP de type « recrutement maximal » réglée pour obtenir une pression de plateau (Pplat) entre 28 et 32 cmH2O, a été estimé à partir des mesures de volume pulmonaire comparées à l'augmentation minimale prédite du volume pulmonaire. Une bonne corrélation avec le recrutement mesuré par la technique des courbes pression - volume était trouvée sous réserve d'une élimination des mesures incohérentes.Parallèlement, la mesure du volume pulmonaire et l'oxygénation de patients en SDRA et Acute Lung Injury (ALI) ont été analysées lors de changements de position (Position demi-assise puis assise). Cette étude montre que le volume pulmonaire est augmenté lors de la verticalisation et particulièrement chez les patients augmentant leur oxygénation > 20%. Les patients ne répondant pas au positionnement avaient des volumes pulmonaires plus élevés et qui variaient peu.Les différents travaux réalisés ont permis de montrer la simplicité d'utilisation de la technique. Ceci offre des perspectives de recherche au lit du patient plus accessibles qu'avec les techniques de référence (scanner et dilution de l'hélium), et également des perspectives cliniques. Une approche de la déformation pulmonaire induite par la ventilation (strain) et potentiellement des lésions induites par la ventilation mécanique est rendue possible par la mise à disposition en clinique de cette technique