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

Autor: Dianti J; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada., Fard S; Department of Respiratory Therapy, University Health Network, Toronto, Canada., Wong J; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada., Chan TCY; Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada., Del Sorbo L; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada., Fan E; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada., Amato MBP; Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil., Granton J; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada., Burry L; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Department of Pharmacy, Mount Sinai Hospital, Toronto, Canada.; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada., Reid WD; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Department of Physical Therapy, University of Toronto, Toronto, Canada., Zhang B; Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada., Ratano D; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada., Keshavjee S; Department of Surgery, University of Toronto, Toronto, Toronto, Canada., Slutsky AS; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada., Brochard LJ; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada., Ferguson ND; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.; Toronto General Hospital Research Institute, 9-MaRS-9024, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.; Department of Physiology, University of Toronto, Toronto, Canada., Goligher EC; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. ewan.goligher@uhn.ca.; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada. ewan.goligher@uhn.ca.; Toronto General Hospital Research Institute, 9-MaRS-9024, 585 University Avenue, Toronto, ON, M5G 2N2, Canada. ewan.goligher@uhn.ca.; Department of Physiology, University of Toronto, Toronto, Canada. ewan.goligher@uhn.ca.
Jazyk: angličtina
Zdroj: Critical care (London, England) [Crit Care] 2022 Aug 29; Vol. 26 (1), pp. 259. Date of Electronic Publication: 2022 Aug 29.
DOI: 10.1186/s13054-022-04123-9
Abstrakt: 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).
(© 2022. The Author(s).)
Databáze: MEDLINE
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