Search Results (111)

Acute respiratory distress syndrome (ARDS) causes heterogeneous injury, with normal, unstable, and edematous tissue distributed throughout the lung. Although positive pressure ventilation initially reduced ARDS-related mortality, it became clear that the ventilator can be a double-edged sword and, if set improperly, can worsen outcomes. This uneven pathology makes the lung vulnerable to secondary ventilator-induced lung injury (VILI). In 2000, evidence showed that lowering tidal volume (V_T) and airway pressure significantly reduced mortality in patients with ARDS, suggesting that this reduction led to less overdistension of healthy lung tissue. Including respiratory system compliance (C_RS) in the calculation. It was shown that low driving pressure (ΔP = V_T/C_RS) was more strongly associated with survival than low V_T alone. This idea was further extended into measuring the mechanical power delivered to the respiratory system: MP_rs = RR × ΔV²∙[1/2∙EL_rs + RR∙(1 + I:E)/60∙I:E∙R_aw] + ΔV∙PEEP, where EL_rs is elastance, I:E is inspiratory:expiratory ratio, R_aw is airway resistance, and RR is respiratory rate. This measure helps identify when the lung is at risk of VILI. However, a recent study found no direct causal link between MP_RS and mortality; rather, it showed that MP_RS, normalized to C_RS or end-expiratory lung volume (EELV), was independently associated with outcomes. This indicates that lung size and underlying pathophysiology—rather than ΔP or MP_RS alone—are critical determinants of VILI risk. Reopening collapsed lung tissue would increase C_RS and decrease E_RS, thereby lowering ΔP or MP_RS at any given V_T, R_aw, PEEP, I:E, or RR setting. Consequently, the focus should shift from simply adjusting the ventilator to normalize C_RS and EELV that reduce ΔP or MP_RS at higher ventilator settings. Full article

Background: Early reports highlighted unique features of COVID-19-associated ARDS. The combination of prone position (PP) and positive end-expiratory pressure (PEEP)-induced lung recruitment maneuver (LRM) has demonstrated efficacy in enhancing oxygenation and improving outcomes in patients with ARDS, but it remains unknown whether there is a difference between COVID-19 ARDS and non-COVID-19 ARDS. Method: This study is a secondary analysis of a previously conducted randomized controlled trial. Patients with moderate to severe ARDS were consecutively enrolled during the study period (June–December 2023). After initiation of PP, patients received a PEEP-induced LRM followed by 12 h of daily PP. The interventions were repeated at least three times over the subsequent 3 days. Clinical outcomes, respiratory mechanics, and electrical impedance tomography (EIT) results were evaluated. Results: Twenty-eight patients were included in the final analysis, half of whom were infected with COVID-19 (50%). The PEEP-induced LRM led to greater improvement in oxygenation among COVID-19 ARDS than non-COVID-19 ARDS (∆PaO₂/FiO₂ ratio 90.5 mmHg vs. 65.5 mmHg, p < 0.05). Based on EIT measurement, compared with the non-COVID-19 ARDS group, PEEP-induced LRM resulted in a greater increase in ventilation distribution, mainly in the dorsal regions of interest 4 (ROI 4) ventilation distribution (∆ROI4 4.5% vs. 1.0%, p = 0.01) and in dorsal regional ventilation (∆dorsal regional ventilation 10.0% vs. 5.5%, p = 0.04) in the COVID-19 ARDS group. Conclusions: Compared to typical ARDS, PEEP-induced LRM combined with PP may be more effective in enhancing oxygenation in COVID-19-related ARDS. Full article

Background/Objectives: Treatment of severe traumatic brain injury (TBI) remains a major challenge in neurocritical care. The functional state of the brain largely depends on the applied ventilation strategy. Many patients develop acute respiratory distress syndrome (ARDS), for which lung-protective ventilation is recommended. However, its effect on outcomes in severe TBI remains unclear. This study aimed to assess whether a lung-protective ventilation strategy improves short-term outcomes in patients with severe TBI complicated by ARDS. Methods: This multicenter retrospective study included patients with severe TBI and ARDS treated in three Ukrainian tertiary hospitals. Lung-protective ventilation was defined as the use of a low tidal volume and moderate positive end-expiratory pressure (PEEP). The primary endpoint was 28-day mortality; secondary endpoints included the Glasgow Coma Scale (GCS) score and intracranial pressure (ICP) on day 28. Univariate and multivariate logistic regression analyses identified factors associated with mortality. Results: Mortality did not depend on arterial PaO₂ (p = 0.173) but correlated with lower GCS (p < 0.001), reduced PaO₂/FiO₂ ratio (p < 0.001), higher tidal volume (p < 0.001), and lower PEEP (p < 0.001). Lung-protective ventilation reduced mortality from 78.6% to 31.4%. Conclusions: Lung-protective ventilation is safe and effective in severe TBI with ARDS, significantly improving short-term survival without compromising cerebral outcomes. Full article

Background: Despite advances in temporary mechanical circulatory support (tMCS), patients with cardiogenic shock (CS) who are treated with a microaxial flow pump (mAFP; Impella^®, Abiomed) still have a high mortality rate. A dysregulated systemic inflammatory response significantly contributes to multiorgan failure in this population. CytoSorb^® hemadsorption has emerged as a potential adjunctive therapy for modulating inflammation, but data on its use in CS are limited. Methods: This retrospective, single-center study used propensity score matching analysis (1:1 matching; n = 15 per group) to compare the outcomes of patients receiving mAFP support with and without concomitant CytoSorb therapy. Baseline data (T0), including comorbidities and clinical status at ICU admission, were collected for all patients. In the CytoSorb group, data were collected at two additional time points: 24 h before the start of CytoSorb therapy (T1), and 24 h after its completion (T2). At these time points, laboratory values and parameters on respiratory, hemodynamic, and organ function were assessed. Corresponding data were also collected for matched patients in the non-CytoSorb group at equivalent time points relative to their matched counterparts. Results: In the propensity score-matched cohort, patients treated with CytoSorb exhibited significant improvements between T1 and T2. Specifically, reductions were observed in the vasoactive-inotropic score (p = 0.035), procalcitonin levels (p = 0.041), peak inspiratory pressure (p = 0.036), and positive end-expiratory pressure (p = 0.016). Flow rates through the mAFP declined significantly (p = 0.014), suggesting stabilization of hemodynamics. These changes were not observed in the non-CytoSorb group, where most parameters remained unchanged or exhibited less pronounced trends. We observed a lower in-hospital mortality rate in the CytoSorb group (33.3% versus 46.7%), though the difference was not significant, potentially due to limited statistical power. Conclusions: CytoSorb hemadsorption in mAFP-supported CS was associated with improved hemodynamic stability and reduced inflammatory burden. These findings suggest a potential therapeutic benefit of adjunctive hemadsorption in this high-risk population. Full article

Background and Objectives: The aim of this study is to evaluate the changes in speckle tracking velocity vector analysis (VVI) values within the descending thoracic aorta (DTA) in patients with cardiogenic shock (CS) who are on mechanical ventilation (MV), under varying levels of positive end-expiratory pressure (PEEP). Materials and Methods: Transthoracic echocardiography (TTE) was performed during incremental increases in positive end-expiratory pressure (PEEP) from 0 to 15 cmH₂O over 15 to 30 min. The effects of increased PEEP on velocities, displacement, strain (S), and strain rate (SR) were evaluated. DTA speckle tracking values were analyzed to determine their association with patient mortality. A control group of healthy individuals was used to establish normal DTA variables. Results: Sixty-two mechanically ventilated patients were included in this study. The mean age was 62.48 ± 11.22 years. The highest values for various parameters were obtained with 5 cmH₂O PEEP. The values obtained for DTA using speckle tracking at increasing PEEP levels (ZEEP, PEEP 5, PEEP 10, and PEEP 15 cm H₂O) were as follows: DTA rotational velocity [55.18 ± 14.60, 107.39 ± 19.33, 60.05 ± 0.28, and 42.11 ± 0.34°/s], DTA radial velocity [0.80 ± 0.09, 2.21 ± 0.27, 0.99 ± 0.16, 0.56 ± 0.17 cm/s], DTA rotational displacement [5.68 ± 0.40, 15.71 ± 0.13, 5.98 ± 0.35, 6.64 ± 3.45°], circumferential strain for DTA [−8.55 ± 0.92, −11.86 ± 0.07, −9.88 ± 0.25, −8.76 ± 0.6%], and DTA circumferential SR [−0.87 ± 0.1, −1.91 ± 0.03, −1.21 ± 0.12, −0.97 ± 0.05/s]; all p-values < 0.05. Logistic binary regression found left ventricular strain and DTA rotational displacement on 5 cmH₂O PEEP level were associated with death. Conclusions: Changes in PEEP levels affect the speckle tracking measurements of the DTA. Speckle tracking can be used to assess the thoracic aorta, and certain parameters, such as rotational displacement, may relate to the prognosis of cardiogenic shock. Full article

Background: Mechanical ventilation (MV) with high positive end-expiratory pressure (PEEP) is linked to ventilation-induced diaphragm dysfunction (VIDD), but the role of integrin beta-1 (ITGB1) in PEEP-associated diaphragm fibrosis remains unclear. Methods: Eighteen rabbits were divided into control (CON), MV without PEEP(MV), and MV with 8 cmH₂O PEEP (PEEP) groups. C2C12 underwent cyclic stretching (15% tension), and ITGB1 was knocked down. Fibrosis markers (TGFβ-1, α-SMA), ITGB1/ROCK1 expression, and pathway activation were analyzed via RNA sequencing, immunohistochemistry, and Western blotting. Results: The PEEP group exhibited elevated airway pressure and upregulated fibrosis markers (TGFβ-1 and α-SMA) alongside activated ITGB1/ROCK1 mechanotransduction pathways. Stretched C2C12 showed morphological shrinkage and increased fibrotic protein expression. RNA sequencing confirmed enrichment in fibrosis- and integrin-related pathways. ITGB1 knockdown attenuated TGFβ-1 and α-SMA induction. Conclusions: ITGB1 mediates PEEP-induced diaphragm fibrosis via TGFβ-1 signaling and collagen deposition, suggesting ITGB1 targeting as a potential therapeutic strategy for VIDD. These findings elucidate the mechanotransduction mechanisms underlying MV-associated diaphragm dysfunction. Full article

Acute hypoxemic respiratory failure is a critical challenge in intensive care. A substantial proportion of patients present with asymmetric acute lung injury (ALI), complicating management due to heterogeneous lung involvement. While lung-protective mechanical ventilation represents the standard of care, the optimal approach to positive end-expiratory pressure (PEEP) titration remains unclear. This study investigated the effects of transpulmonary pressure (TPP)-guided PEEP titration vs. a fixed PEEP strategy in a porcine model of unilateral ALI. A total of 14 pigs underwent ALI induction via unilateral surfactant depletion and were randomized to receive either a fixed PEEP of 5 cmH₂O or a PEEP targeting a slightly positive TPP at end-expiration. Over six hours, respiratory mechanics, high-resolution computed tomography (HRCT), histological lung injury scores (LIS), and plasma protein biomarkers were assessed. TPP-guided PEEP titration significantly lowered driving pressure and improved compliance compared to fixed low PEEP, suggesting more homogeneous tidal volume distribution. HRCT revealed less collateral injury in the initially non-injured lung in the TPP-guided group. However, histopathological LIS did not differ between groups. Exploratory cytokine profiling showed systemic inflammatory activation—including pro- and anti-inflammatory responses—only in the TPP-guided group. These findings indicate that TPP-guided PEEP titration may optimize ventilation by balancing alveolar recruitment and overdistension in asymmetric ALI, with clear effects on physiological and imaging parameters, but without parallel effects on cytokine responses. Further research is needed to assess its long-term impact and clinical relevance. Full article

Background/Objectives: Identifying the optimal positive end-expiratory pressure (PEEP) is a major challenge in implementing strategies to prevent ventilator-induced lung injury in newborns. In this study, we assessed the validity of volumetric capnography based on the neonatal patient monitor (V_cap,PM) technique and investigated the impact of PEEP on newborns. Methods: Analysis 1 evaluated the validity of the V_cap,PM technique with data from pediatric patients receiving invasive respiratory support. Linear regression and Bland–Altman analyses were performed on V_cap,PM and HAMILTON-C1 data. Analysis 2 evaluated the impact of PEEP on newborns. The PEEP level was increased from mild to high (the incremental phase) and then decreased from high to mild (the decremental phase) while performing the V_cap,PM technique on term and preterm infants. Results: Analysis 1 included 31 children (age, 9 [interquartile range (IQR), 0–36] months; weight, 6.0 [IQR, 3.8–10.5] kg). Regression and Bland–Altman analyses demonstrated the accuracy of V_cap,PM. Analysis 2 included 28 term (mean gestational age, 38 [IQR, 38–40] weeks; weight, 2924 [IQR, 2725–3109] g) and 21 preterm (mean gestational age, 33 [IQR, 31–34] weeks; weight, 1918 [IQR, 1356–2186] g) newborns. Despite no difference in tidal volume, high PEEP significantly increased airway dead space and decreased alveolar tidal volume compared to mild PEEP in each phase in term and preterm neonates. Conclusions: High PEEP induced airway dilation in newborns, as determined using a novel V_cap technique. This technique, which requires no special equipment, has the potential for wider clinical application in neonatal care. Full article

Background and Objectives: Mechanical ventilation, while essential, can precipitate ventilator-induced lung injury (VILI) due to excessive mechanical stress. Among respiratory mechanics, driving pressure (ΔP) has emerged as the most robust predictor of mortality, with mechanical power (MP) and tidal volume (TV), respiratory rate (RR), positive end-expiratory pressure (PEEP), and peak inspiratory pressure (P_peak) also potentially influencing clinical outcomes. This study primarily evaluated whether the implementation of a standardized Lung and Diaphragm Protective Ventilation (LDPV) protocol, designed to minimize ΔP, reduced intensive care unit (ICU) mortality. Secondary objectives included assessing the prognostic impact of MP, P_peak, TV, RR, and PEEP on mortality in the pre- and post-LDPV implementation periods. Materials and Methods: In this retrospective cohort study, a total of 3468 adult ICU patients receiving invasive mechanical ventilation between 2012 and 2024 were analyzed. Patients were categorized into two groups: pre-LDPV (2012–2018) and post-LDPV (2019–2024). Ventilatory data were automatically collected using the Metavision system and evaluated through receiver operating characteristic (ROC) derived cutoffs, survival modeling, and Cox proportional hazards regression. Results: Implementation of the LDPV protocol was associated with a significant reduction in ICU mortality (47.7% vs. 41.1%, p < 0.0001) and a shorter ICU length of stay. Patients in the post-LDPV cohort (2019–2024) exhibited lower ΔP (median 12.9 vs. 14.3 cmH₂O), lower MP (median 15.0 vs. 17.0 J/min), improved respiratory system compliance, and reduced peak inspiratory pressure (P_peak) and tidal volume (TV_e) compared to the pre-LDPV cohort (2012–2018). Analysis revealed that the reduction in ΔP was the most significant determinant of improved survival; median ΔP decreased by approximately 2 cmH₂O (from 14.3 to 12.9 cmH₂O). Elevated MP and P_peak were also predictive of mortality, while compliance below 34 mL/cmH₂O consistently indicated a poor prognosis across both study periods. Conclusions: Implementation of an LDPV protocol significantly reduced ICU mortality, primarily through the systematic reduction in ΔP, while MP and its components provided complementary prognostic information. These findings underscore ΔP as the primary modifiable determinant of survival, with MP, P_peak, TV, and PEEP serving as secondary indicators of VILI. Full article

Background/Objectives: To evaluate the safety and feasibility of continuous positive airway pressure (CPAP) in patients with acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF) during percutaneous coronary intervention (PCI). Non-invasive ventilation (NIV) is an established treatment for ADHF. Methods: All consecutive patients admitted to Santa Croce Hospital of Cuneo, receiving CPAP for ADHF in the cath lab during PCI for AMI, were included in a case series. Results: Between December 2018 and March 2021, 25 pts were included (median age 78 yrs, 48% female), with 64% of patients presenting with ST-elevation AMI and 17 (69%) in cardiogenic shock. At admission median left ventricular ejection fraction was 35 (20–60)% and eight (32%) patients had severe mitral regurgitation. Median PaO₂/FiO₂ was 183 (141–261) mmHg/%, lactate level 2.4 (1.3–3.8) mmol/L, and NTproBNP 7882 (3139–35,000) ng/L. CPAP was positioned and managed by nurses in all cases. Median FiO₂ was 50 (35–100)% and median positive end-expiratory pressure was 7.5 (5–12) cmH₂O. CPAP was generally well tolerated in 22 (88%) patients. One patient suffered cardiac arrest that led to CPAP interruption due to resuscitation maneuvers. No patient required orotracheal intubation in the cath lab. The post-procedural PaO₂/FiO₂ ratio substantially improved to 230 (175–356) mmHg/% (p = 0.007) and lactate decreased to 1.5 (1.0–1) mmol/L (p = 0.002). One patient died during hospital stay due to underlying disease, unrelated to the study procedure. Conclusions: CPAP during PCI in patients with AMI and ADHF seems feasible, safe, and well tolerated. Larger studies are warranted to confirm these results. Full article

Acute lower respiratory tract infections are a leading cause of death in individuals under the age of 5 years, mostly in low- and middle-income countries (LMICs). The lack of respiratory support systems contributes to the poor outcomes. Bubble CPAP is widely used for non-invasive respiratory support, but sicker children often require support over what CPAP provides in the form of BiPAP. We developed and tested a simple bubble-based bilevel ventilator (Bubble bi-vent) and compared it with a standard care BiPAP device. The bubble bilevel device consisted of a single tube submerged in a water-sealed column to maintain end-expiratory positive airway pressure. It moves vertically via an electric motor to also provide inspiratory positive airway pressure for augmentation of lung volumes, with the duration and frequency of breaths controlled by a microprocessor. We tested this novel device in passively breathing mechanical lung models for infants and small children. We compared pressure and tidal volume delivery between the novel device and a Trilogy BiPAP ventilator. The results showed that the Bubble bi-vent could deliver set pressures in a mechanical lung and was comparable to a standard Trilogy ventilator. While two different bubble-based bilevel pressure devices have been piloted for neonates and adults, our results demonstrate the feasibility of bubble bilevel ventilation for infants and small children with moderate to severe lung disease for whom this was previously not described. Full article

Background/Objectives: Lung-protective ventilation (LPV) reduces postoperative pulmonary complications (PPCs) in obese patients. While the roles of low tidal volume and positive end-expiratory pressure (PEEP) in LPV have been established in patients with healthy lungs, the protective effect of alveolar recruitment strategies (ARSs) remains a subject of debate. This study aims to evaluate the benefit of ARSs in patients with low-to-moderate risk according to the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score undergoing gynecologic cancer surgery with LPV and low tidal volume intraoperatively. Methods: A total of 88 obese patients were evaluated in this study. They were divided into two groups as the non-ARS group (non-ARS) and the ARS group (ARS). Intraoperative hemodynamics, blood gas analyses, respiratory mechanics, mechanical ventilator parameters, and postoperative outcomes were compared in these obese patients. Results: A total of 40 obese patients undergoing major gynecological cancer surgery were included in this study. Although the non-ARS group presented with higher weight (p < 0.05), body mass indexes were similar to the ARS group. Intraoperative blood gas analysis revealed higher end-tidal carbon dioxide (etCO₂) levels in the non-ARS group during the T2 and T3 time intervals (p < 0.05). In the ARS group, peak inspiratory pressure (PIP) at T3 was lower, while drive pressures at T1 and T2 and dynamic compliance at T3 were higher (p < 0.05). Radiologic atelectasis scores were higher in the non-ARS group, indicating more atelectatic lung images (p < 0.05). PPC rates were similar across both groups. Conclusions: Although the ARS demonstrated positive effects on lung mechanics and radiologic atelectasis scores in major open gynecologic cancer surgeries, it did not effectively reduce postoperative pulmonary complications. Full article

Invasive mechanical ventilation is a cornerstone therapy for supporting patients with acute respiratory distress syndrome (ARDS) by relieving respiratory muscle strain and ensuring gas exchange. Despite its life-saving benefits, mechanical ventilation can induce ventilator-induced lung injury (VILI), a critical condition characterized by mechanisms such as barotrauma, volutrauma, atelectrauma, ergotrauma, and biotrauma. This review examines the pathophysiological mechanisms of VILI and their impact on lung function, particularly in patients with ARDS. It highlights the importance of lung-protective ventilation strategies, including low tidal volume and tailored positive end-expiratory pressure, which have been shown to improve outcomes in ARDS. The role of prone positioning in enhancing lung homogeneity and improving outcomes is also discussed. Furthermore, emerging concepts such as mechanical power and individual respiratory mechanics are explored as potential avenues for personalized ventilation strategies. Despite advancements, the optimal approach to mechanical ventilation remains a subject of ongoing research. Full article

The COVID-19 pandemic raised global concerns about the shortage of ventilators and revealed the challenges of rapidly scaling up production to meet emergency needs. In response, numerous teams worldwide attempted to develop emergency and simple mechanical ventilators. Among these, the CoroVent ventilator was developed to meet the urgent need for ventilatory support in the Czech Republic. The aim of this study was to describe the innovative and simple design of the CoroVent emergency ventilator, evaluate its compliance with international safety and performance standards, verify its reliability under simulated clinical conditions, and demonstrate its suitability for use in crisis scenarios. CoroVent was designed with a focus on the clinical needs of patients with COVID-19 respiratory failure and to ensure safe ventilation while maintaining a simplified design. It features volume-controlled, pressure-limited mandatory ventilation and supports key adjustable parameters such as tidal volume, respiratory rate, inspiratory-to-expiratory time ratio, inspired oxygen fraction, and positive end-expiratory pressure (PEEP). The ventilator incorporates robust safety mechanisms, including alarms and a safety relief valve, to protect against excessive airway pressures. Results confirmed the ability to maintain consistent tidal volumes, stable PEEP, and precise pressure limitation over extended periods of use. The results showed that CoroVent met the essential international standards for accuracy, including those set by the UK Medicines and Healthcare products Regulatory Agency, U.S. Food and Drug Administration, and ISO 80601-2-12. Although production of these ventilators was stopped in 2021 as the Czech Republic managed the crisis and shortage of ventilators, the results validate their reliability as emergency ventilators and indicate their potential to support critical care needs in crisis situations. Full article

Background/Objectives: Surgical procedures in chronic obstructive pulmonary disease (COPD) patients carry a high risk of postoperative respiratory failure, often causing the need for mechanical ventilation and prolonged intensive care unit (ICU) stays. Accompanying COPD with heart failure further increases the risk of complications. This study aimed to identify predictors of mortality, prolonged ICU and hospital stays, the need for mechanical ventilation, and vasoactive drug usage in ICU patients with moderate to severe COPD undergoing elective non-cardiac surgery. Methods: This retrospective cohort study analyzed eICU-CRD data, including adult patients with moderate to severe COPD admitted to the ICU from the operating room following elective non-cardiac surgery. Spearman’s correlation analysis was performed to assess associations between intraoperative ventilation parameters and ICU/hospital length of stay, postoperative laboratory parameters, and their perioperative dynamics. Results: This study included 680 patients (21% with severe COPD). Hospital and ICU mortality were 8.6% and 4.4%, respectively. Median ICU and hospital stays were 1.9 and 6.6 days, respectively. Intraoperative tidal volume, expired minute ventilation, positive end-expiratory pressure, mean airway pressure, peak inspiratory pressure, and compliance had no statistically significant association with mortality, postoperative mechanical ventilation, its duration, or the use of vasopressors/inotropes. Tidal volume correlated positively with changes in monocyte count (R = 0.611; p = 0.016), postoperative lymphocytes (R = 0.327; p = 0.017), and neutrophil count (R = 0.332; p = 0.02). Plateau pressure showed a strong positive association with the neutrophil-to-lymphocyte ratio (R = 0.708; p = 0.001). Conclusions: Intraoperative ventilation modes and parameters in COPD patients appear to have no significant impact on the outcomes or laboratory markers, except possibly for the neutrophil-to-lymphocyte ratio, although its elevation cause remains unclear. Full article