Implementing a bedside assessment of respiratory mechanics in patients with acute respiratory distress syndrome

Lu Chen, Guang-Qiang Chen, Kevin Shore, Orest Shklar, Concetta Martins, Brian Devenyi, Paul Lindsay, Heather McPhail, Ashley Lanys, Ibrahim Soliman, Mazin Tuma, Michael Kim, Kerri Porretta, Pamela Greco, Hilary Every, Chris Hayes, Andrew Baker, Jan O Friedrich, Laurent Brochard, Lu Chen, Guang-Qiang Chen, Kevin Shore, Orest Shklar, Concetta Martins, Brian Devenyi, Paul Lindsay, Heather McPhail, Ashley Lanys, Ibrahim Soliman, Mazin Tuma, Michael Kim, Kerri Porretta, Pamela Greco, Hilary Every, Chris Hayes, Andrew Baker, Jan O Friedrich, Laurent Brochard

Abstract

Background: Despite their potential interest for clinical management, measurements of respiratory mechanics in patients with acute respiratory distress syndrome (ARDS) are seldom performed in routine practice. We introduced a systematic assessment of respiratory mechanics in our clinical practice. After the first year of clinical use, we retrospectively assessed whether these measurements had any influence on clinical management and physiological parameters associated with clinical outcomes by comparing their value before and after performing the test.

Methods: The respiratory mechanics assessment constituted a set of bedside measurements to determine passive lung and chest wall mechanics, response to positive end-expiratory pressure, and alveolar derecruitment. It was obtained early after ARDS diagnosis. The results were provided to the clinical team to be used at their own discretion. We compared ventilator settings and physiological variables before and after the test. The physiological endpoints were oxygenation index, dead space, and plateau and driving pressures.

Results: Sixty-one consecutive patients with ARDS were enrolled. Esophageal pressure was measured in 53 patients (86.9%). In 41 patients (67.2%), ventilator settings were changed after the measurements, often by reducing positive end-expiratory pressure or by switching pressure-targeted mode to volume-targeted mode. Following changes, the oxygenation index, airway plateau, and driving pressures were significantly improved, whereas the dead-space fraction remained unchanged. The oxygenation index continued to improve in the next 48 h.

Conclusions: Implementing a systematic respiratory mechanics test leads to frequent individual adaptations of ventilator settings and allows improvement in oxygenation indexes and reduction of the risk of overdistention at the same time.

Trial registration: The present study involves data from our ongoing registry for respiratory mechanics (ClinicalTrials.gov identifier: NCT02623192 . Registered 30 July 2015).

Keywords: Esophageal pressure; Mechanical ventilation; Pulmonary function test; Quality improvement; Respiratory physiology.

Figures

Fig. 1
Fig. 1
Illustration of simplified decremental positive end-expiratory pressure (PEEP) maneuver for estimating derecruited lung volume. In this example, respiratory frequency was transiently reduced to 10 breaths per minute to allow a prolonged expiration. Afterward, PEEP was reduced from 15 to 5 cmH2O. The difference in expiratory tidal volumes (i.e., integral of flow) between the breath while decreasing PEEP (blue area) and the one before changing PEEP (red area) was referred to as the total change in lung volume. Derecruited volume was the difference between the total changes in measured vs. predicted lung volumes (see text for details). Paw Airway pressure
Fig. 2
Fig. 2
Panel a shows the clinical adjustments in positive end-expiratory pressure (PEEP) and effects on the oxygenation index (OI) (n = 59). b Patients were classified in three groups according to the change in their PEEP level. Bonferroni adjustment was not used. (Refer to main text for explanations.)
Fig. 3
Fig. 3
Individual oxygenation responses to the incremental positive end-expiratory pressure trial. PaO2/FiO2ratio Ratio of partial pressure of arterial oxygen to fraction of inspired oxygen; PEEPtot Total positive end-expiratory pressure

References

    1. Chen L, Brochard L. Lung volume assessment in acute respiratory distress syndrome. Curr Opin Crit Care. 2015;21(3):259–264. doi: 10.1097/MCC.0000000000000193.
    1. Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, et al. The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med. 2014;189(5):520–531. doi: 10.1164/rccm.201312-2193CI.
    1. Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800. doi: 10.1001/jama.2016.0291.
    1. The ARDS Definition Task Force Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526–2533.
    1. Baydur A, Behrakis PK, Zin WA, Jaeger M, Milic-Emili J. A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis. 1982;126(5):788–791.
    1. Dellamonica J, Lerolle N, Sargentini C, Beduneau G, Di Marco F, Mercat A, et al. PEEP-induced changes in lung volume in acute respiratory distress syndrome: two methods to estimate alveolar recruitment. Intensive Care Med. 2011;37(10):1595–1604. doi: 10.1007/s00134-011-2333-y.
    1. Marini JJ, Ravenscraft SA. Mean airway pressure: physiologic determinants and clinical importance—Part 1: physiologic determinants and measurements. Crit Care Med. 1992;20(10):1461–1472. doi: 10.1097/00003246-199210000-00017.
    1. Dechert RE, Park PK, Bartlett RH. Evaluation of the oxygenation index in adult respiratory failure. J Trauma Acute Care Surg. 2014;76(2):469–473. doi: 10.1097/TA.0b013e3182ab0d27.
    1. Beitler JR, Thompson BT, Matthay MA, Talmor D, Liu KD, Zhuo H, et al. Estimating dead-space fraction for secondary analyses of acute respiratory distress syndrome clinical trials. Crit Care Med. 2015;43(5):1026–1035. doi: 10.1097/CCM.0000000000000921.
    1. Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747–755. doi: 10.1056/NEJMsa1410639.
    1. Perneger TV. What’s wrong with Bonferroni adjustments. BMJ. 1998;316(7139):1236–1238. doi: 10.1136/bmj.316.7139.1236.
    1. Terragni PP, Rosboch GL, Lisi A, Viale AG, Ranieri VM. How respiratory system mechanics may help in minimising ventilator-induced lung injury in ARDS patients. Eur Respir J. 2003;22(42 Suppl):15 s–21s.
    1. Rittayamai N, Katsios CM, Beloncle F, Friedrich JO, Mancebo J, Brochard L. Pressure-controlled vs volume-controlled ventilation in acute respiratory failure: a physiology-based narrative and systematic review. Chest. 2015;148(2):340–355. doi: 10.1378/chest.14-3169.
    1. The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–1308. doi: 10.1056/NEJM200005043421801.
    1. Devaquet J, Jonson B, Niklason L, Si Larbi AG, Uttman L, Aboab J, et al. Effects of inspiratory pause on CO2 elimination and arterial PCO2 in acute lung injury. J Appl Physiol (1985). 2008;105(6):1944–9.
    1. Goligher EC, Kavanagh BP, Rubenfeld GD, Adhikari NK, Pinto R, Fan E, et al. Oxygenation response to positive end-expiratory pressure predicts mortality in acute respiratory distress syndrome: a secondary analysis of the LOVS and ExPress trials. Am J Respir Crit Care Med. 2014;190(1):70–76. doi: 10.1164/rccm.201404-0688OC.
    1. Suter PM, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med. 1975;292(6):284–289. doi: 10.1056/NEJM197502062920604.
    1. Mercat A, Richard JCM, Vielle B, Jaber S, Osman D, Diehl JL, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):646–655. doi: 10.1001/jama.299.6.646.
    1. Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):637–645. doi: 10.1001/jama.299.6.637.
    1. Monchi M, Bellenfant F, Cariou A, Joly LM, Thebert D, Laurent I, et al. Early predictive factors of survival in the acute respiratory distress syndrome: a multivariate analysis. Am J Respir Crit Care Med. 1998;158(4):1076–1081. doi: 10.1164/ajrccm.158.4.9802009.
    1. Seeley E, McAuley DF, Eisner M, Miletin M, Matthay MA, Kallet RH. Predictors of mortality in acute lung injury during the era of lung protective ventilation. Thorax. 2008;63(11):994–998. doi: 10.1136/thx.2007.093658.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe