How I ventilate an obese patient Ball, Lorenzo; Pelosi, Paolo
Critical care (London, England),
05/2019, Letnik:
23, Številka:
1
Journal Article
Recenzirano
Odprti dostop
An increasing number of patients admitted to the intensive care unit are obese 1. Many of them require mechanical ventilation, which may promote ventilator-induced lung injury (VILI) when applied to ...both injured and healthy lungs. Obesity induces functional changes in the respiratory system, resulting in a reduction of the end-expiratory lung volume, increased incidence of airway closure and formation of atelectasis, and alterations in lung and chest wall mechanics 2. These alterations explain the high occurrence of gas exchange impairment, respiratory mechanics alterations, and hemodynamic compromise. To approach to the obese patient requiring mechanical ventilation, we propose a schematic algorithm (i-STAR, Fig. 1) as follows: (1) induction and intubation, (2) setting up initial mechanical ventilation, (3) titrating mechanical ventilation parameters, (4) assessing harmfulness of mechanical ventilation, and (5) rescue strategies.
A tribute to Paolo Pelosi Robba, Chiara; Battaglini, Denise; Ball, Lorenzo
Critical care (London, England),
06/2023, Letnik:
27, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Prof Pelosi served as President of the European Society of Anaesthesiology (ESA) from 2010 to 2011, and had important roles in the World Federation of Societies of Intensive Care and Critical Care ...Medicine (WFSCCM) and European Respiratory Society (ERS). Professor Pelosi made the difference in the field of mechanical ventilation and acute respiratory distress syndrome (ARDS), in particular through the work of the PROVEnet group, which allowed to create large-scale observational studies and randomized clinical trials, providing high quality evidence which revolutionised the field of anaesthesiology and intensive care medicine. Rights and permissions Open Access This 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. Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative Obituary Open Access Published:27 June 2023 A tribute to Paolo Pelosi Chiara Robba ORCID: orcid.org/0000-0003-1628-38451,2, Denise Battaglini1,2 & Lorenzo Ball1,2 Critical Care volume 27, Article number: 253 (2023) Cite this article 1040 Accesses 4 Altmetric Metrics details figure a On the 30th of May, Professor Paolo Pelosi passed away. Prof Pelosi served as President of the European Society of Anaesthesiology (ESA) from 2010 to 2011, and had important roles in the World Federation of Societies of Intensive Care and Critical Care Medicine (WFSCCM) and European Respiratory Society (ERS).
•Chest CT patterns in COVID-19 may be divided into three main phenotypes with different characteristics o In phenotype 1, respiratory mechanics are consistent with high pulmonary compliance and ...severe hypoxemia.•In phenotype 2, moderate to high PEEP as well as lateral and/or prone positioning may help recruit collapsed areas.•Phenotype 3 resembles typical ARDS and should be managed as such.•Attention should be paid to the risk of pulmonary embolism, regardless of phenotype.
Coronavirus disease 2019 (COVID-19) can cause severe respiratory failure requiring mechanical ventilation. The abnormalities observed on chest computed tomography (CT) and the clinical presentation of COVID-19 patients are not always like those of typical acute respiratory distress syndrome (ARDS) and can change over time. This manuscript aimed to provide brief guidance for respiratory management of COVID-19 patients before, during, and after mechanical ventilation, based on the recent literature and on our direct experience with this population. We identify that chest CT patterns in COVID-19 may be divided into three main phenotypes: 1) multiple, focal, possibly overperfused ground-glass opacities; 2) inhomogeneously distributed atelectasis; and 3) a patchy, ARDS-like pattern. Each phenotype can benefit from different treatments and ventilator settings. Also, peripheral macro- and microemboli are common, and attention should be paid to the risk of pulmonary embolism. We suggest use of personalized mechanical ventilation strategies based on respiratory mechanics and chest CT patterns. Further research is warranted to confirm our hypothesis.
Idiopathic pulmonary fibrosis (IPF) is a fibrotic lung disease characterized by progressive loss of lung function and poor prognosis. The so-called acute exacerbation of IPF (AE-IPF) may lead to ...severe hypoxemia requiring mechanical ventilation in the intensive care unit (ICU). AE-IPF shares several pathophysiological features with acute respiratory distress syndrome (ARDS), a very severe condition commonly treated in this setting.A review of the literature has been conducted to underline similarities and differences in the management of patients with AE-IPF and ARDS.During AE-IPF, diffuse alveolar damage and massive loss of aeration occurs, similar to what is observed in patients with ARDS. Differently from ARDS, no studies have yet concluded on the optimal ventilatory strategy and management in AE-IPF patients admitted to the ICU. Notwithstanding, a protective ventilation strategy with low tidal volume and low driving pressure could be recommended similarly to ARDS. The beneficial effect of high levels of positive end-expiratory pressure and prone positioning has still to be elucidated in AE-IPF patients, as well as the precise role of other types of respiratory assistance (e.g., extracorporeal membrane oxygenation) or innovative therapies (e.g., polymyxin-B direct hemoperfusion). The use of systemic drugs such as steroids or immunosuppressive agents in AE-IPF is controversial and potentially associated with an increased risk of serious adverse reactions.Common pathophysiological abnormalities and similar clinical needs suggest translating to AE-IPF the lessons learned from the management of ARDS patients. Studies focused on specific therapeutic strategies during AE-IPF are warranted.
A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological ...phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (V
) is a standard of care, further individualization of V
may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust V
and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.
Background Lung ultrasonography (LUS) has been used for noninvasive detection of pulmonary edema. Semiquantitative LUS visual scores (visual LUS V-LUS) based on B lines are moderately correlated with ...pulmonary capillary wedge pressure (PCWP) and extravascular lung water (EVLW). A new computer-aided quantitative LUS (Q-LUS) analysis has been recently proposed. This study investigated whether Q-LUS better correlates with PCWP and EVLW than V-LUS and to what extent positive end-expiratory pressure (PEEP) affects the assessment of pulmonary edema by Q-LUS or V-LUS. Methods Forty-eight mechanically ventilated patients with PEEP of 5 or 10 cm H2 O and monitored by PCWP (n = 28) or EVLW (n = 20) were studied. Results PCWP was significantly and strongly correlated with Q-LUS gray (Gy) unit value ( r2 = 0.70) but weakly correlated with V-LUS B-line score ( r2 = 0.20). EVLW was significantly and more strongly correlated with Q-LUS Gy unit mean value ( r2 = 0.68) than with V-LUS B-line score ( r2 = 0.34). Q-LUS showed a better diagnostic accuracy than V-LUS for the detection of PCWP >18 mm Hg or EVLW ≥ 10 mL/kg. With 5-cm H2 O PEEP, the correlations with PCWP or EVLW were stronger for Q-LUS than V-LUS. With 10-cm H2 O PEEP, the correlations with PCWP or EVLW were still significant for Q-LUS but insignificant for V-LUS. Interobserver reproducibility was better for Q-LUS than V-LUS. Conclusions Both V-LUS and Q-LUS are acceptable indicators of pulmonary edema in mechanically ventilated patients. However, at high PEEP only Q-LUS provides data that are significantly correlated with PCWP and EVLW. Computer-aided Q-LUS has the advantages of being not only independent of operator perception but also of PEEP.
See PDF. Professor Paolo Pelosi As active member of national and international societies, as past president of the European Society of Anesthesia and Intensive Care (ESAIC) and as president elect of ...the Italian Society of Anesthesia, Intensive Care and Pain Medicine (SIAARTI), he has promoted and supported the unity of our discipline in its different branches, he contributed enormously to the understanding of the pathophysiology of respiratory failure and was a pioneer in translating to the operating theatre the concepts of protective ventilation. In this context, he did not only contribute to the scientific research in the field, but he passionately shared his thoughts, intuitions and clinical experience with colleagues around the globe through countless online conferences, and with the general audience with several interviews in topnotch international broadcast networks, in a phase when the whole world was looking at Italy to understand how this disease was impacting our society. Professor Pelosi was a demanding and stimulating research chief, but always open to discussion and unceasingly keen to motivate his team in carrying on both physiological and clinical studies with the final aim of improving the quality of care of our patients.
Data on the pathology of COVID-19 are scarce; available studies show diffuse alveolar damage; however, there is scarce information on the chronologic evolution of COVID-19 lung lesions. The primary ...aim of the study is to describe the chronology of lung pathologic changes in COVID-19 by using a post-mortem transbronchial lung cryobiopsy approach. Our secondary aim is to correlate the histologic findings with computed tomography patterns. SARS-CoV-2-positive patients, who died while intubated and mechanically ventilated, were enrolled. The procedure was performed 30 min after death, and all lung lobes sampled. Histopathologic analysis was performed on thirty-nine adequate samples from eight patients: two patients (illness duration < 14 days) showed early/exudative phase diffuse alveolar damage, while the remaining 6 patients (median illness duration—32 days) showed progressive histologic patterns (3 with mid/proliferative phase; 3 with late/fibrotic phase diffuse alveolar damage, one of which with honeycombing). Immunohistochemistry for SARS-CoV-2 nucleocapsid protein was positive predominantly in early-phase lesions. Histologic patterns and tomography categories were correlated: early/exudative phase was associated with ground-glass opacity, mid/proliferative lesions with crazy paving, while late/fibrous phase correlated with the consolidation pattern, more frequently seen in the lower/middle lobes. This study uses an innovative cryobiopsy approach for the post-mortem sampling of lung tissues from COVID-19 patients demonstrating the progression of fibrosis in time and correlation with computed tomography features. These findings may prove to be useful in the correct staging of disease, and this could have implications for treatment and patient follow-up.
Modes of mechanical ventilation for the operating room Ball, Lorenzo, M.D; Dameri, Maddalena, M.D; Pelosi, Paolo, M.D., F.E.R.S
Best practice & research. Clinical anaesthesiology,
09/2015, Letnik:
29, Številka:
3
Journal Article
Recenzirano
Most patients undergoing surgical procedures need to be mechanically ventilated, because of the impact of several drugs administered at induction and during maintenance of general anaesthesia on ...respiratory function. Optimization of intraoperative mechanical ventilation can reduce the incidence of post-operative pulmonary complications and improve the patient's outcome. Preoxygenation at induction of general anaesthesia prolongs the time window for safe intubation, reducing the risk of hypoxia and overweighs the potential risk of reabsorption atelectasis. Non-invasive positive pressure ventilation delivered through different interfaces should be considered at the induction of anaesthesia morbidly obese patients. Anaesthesia ventilators are becoming increasingly sophisticated, integrating many functions that were once exclusive to intensive care. Modern anaesthesia machines provide high performances in delivering the desired volumes and pressures accurately and precisely, including assisted ventilation modes. Therefore, the physicians should be familiar with the potential and pitfalls of the most commonly used intraoperative ventilation modes: volume-controlled, pressure-controlled, dual-controlled and assisted ventilation. Although there is no clear evidence to support the advantage of any one of these ventilation modes over the others, protective mechanical ventilation with low tidal volume and low levels of positive end-expiratory pressure (PEEP) should be considered in patients undergoing surgery. The target tidal volume should be calculated based on the predicted or ideal body weight rather than on the actual body weight. To optimize ventilation monitoring, anaesthesia machines should include end-inspiratory and end-expiratory pause as well as flow-volume loop curves. The routine administration of high PEEP levels should be avoided, as this may lead to haemodynamic impairment and fluid overload. Higher PEEP might be considered during surgery longer than 3 h, laparoscopy in the Trendelenburg position and in patients with body mass index >35 kg/m2 . Large randomized trials are warranted to identify subgroups of patients and the type of surgery that can potentially benefit from specific ventilation modes or ventilation settings.
PDF
