High Pleural Pressure Prevents Alveolar Overdistension and Hemodynamic Collapse in Acute Respiratory Distress Syndrome with Class III Obesity. A Clinical Trial
| Autor: | Roberta De Santis Santiago, Maddalena Teggia Droghi, Jacopo Fumagalli, Francesco Marrazzo, Gaetano Florio, Luigi G. Grassi, Susimeire Gomes, Caio C. A. Morais, Ozires P. S. Ramos, Maurizio Bottiroli, Riccardo Pinciroli, David A. Imber, Aranya Bagchi, Kenneth Shelton, Abraham Sonny, Edward A. Bittner, Marcelo B. P. Amato, Robert M. Kacmarek, Lorenzo Berra, Adriana Sayuri Hirota, Daniela Davis Madureira Iope, Carolina Eimi Kajiyama, Andrea Fonseca, Otilia Batista, Silvia Cristina Leopoldino, Carlo Valsecchi, Erick Leon, Kathryn Hibbert, Charles C. Hardin, Kim Connelly, Daniel Fisher, Grant Michael Larson, Emanuele Vassena, Raffaele Di Fenza, Stefano Gianni, Bijan Safaee Fakhr, Jeanine Wiener-Kronish, Brian Kavanagh |
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| Rok vydání: | 2021 |
| Předmět: |
Pulmonary and Respiratory Medicine
obesity medicine.medical_specialty ARDS Critical Care medicine.medical_treatment Hemodynamics Atelectasis mechanical ventilation Critical Care and Intensive Care Medicine 03 medical and health sciences 0302 clinical medicine intrathoracic pressure Internal medicine medicine.artery Tidal Volume medicine Humans 030212 general & internal medicine Mechanical ventilation Respiratory Distress Syndrome Lung business.industry Original Articles acute respiratory distress syndrome respiratory system medicine.disease Respiration Artificial medicine.anatomical_structure 030228 respiratory system Pulmonary artery Breathing Vascular resistance Cardiology business |
| Zdroj: | American Journal of Respiratory and Critical Care Medicine |
| ISSN: | 1535-4970 1073-449X |
| Popis: | Rationale: Obesity is characterized by elevated pleural pressure (Ppl) and worsening atelectasis during mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). Objectives: To determine the effects of a lung recruitment maneuver (LRM) in the presence of elevated Ppl on hemodynamics, left and right ventricular pressure, and pulmonary vascular resistance. We hypothesized that elevated Ppl protects the cardiovascular system against high airway pressure and prevents lung overdistension. Methods: First, an interventional crossover trial in adult subjects with ARDS and a body mass index ≥ 35 kg/m2 (n = 21) was performed to explore the hemodynamic consequences of the LRM. Second, cardiovascular function was studied during low and high positive end-expiratory pressure (PEEP) in a model of swine with ARDS and high Ppl (n = 9) versus healthy swine with normal Ppl (n = 6). Measurements and Main Results: Subjects with ARDS and obesity (body mass index = 57 ± 12 kg/m2) after LRM required an increase in PEEP of 8 (95% confidence interval [95% CI], 7–10) cm H2O above traditional ARDS Network settings to improve lung function, oxygenation and V./Q. matching, without impairment of hemodynamics or right heart function. ARDS swine with high Ppl demonstrated unchanged transmural left ventricular pressure and systemic blood pressure after the LRM protocol. Pulmonary arterial hypertension decreased (8 [95% CI, 13–4] mm Hg), as did vascular resistance (1.5 [95% CI, 2.2–0.9] Wood units) and transmural right ventricular pressure (10 [95% CI, 15–6] mm Hg) during exhalation. LRM and PEEP decreased pulmonary vascular resistance and normalized the V./Q. ratio. Conclusions: High airway pressure is required to recruit lung atelectasis in patients with ARDS and class III obesity but causes minimal overdistension. In addition, patients with ARDS and class III obesity hemodynamically tolerate LRM with high airway pressure. Clinical trial registered with www.clinicaltrials.gov (NCT 02503241). |
| Databáze: | OpenAIRE |
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