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Optimal PEEP

Michael Westhoff, Martin Bachmann, Stephan Braune, Christian Karagiannidis, Stefan Kluge, Philipp M Lepper, Thomas Müller, Bernd Schönhofer
In acute exacerbations of COPD with acute hypercapnic respiratory failure and a pH 7.25 - 7.35, the initiation of non-invasive ventilation is the gold standard. However, absolute and relative contraindications have to be taken into account. The implementation of non-invasive ventilation in case of a severe respiratory acidosis necessitates a skilled therapeutic team and a close monitoring in order to avoid or perceive a NIV failure in time. In this case, the intubation and invasive mechanical ventilation is recommended...
November 2016: Deutsche Medizinische Wochenschrift
Po-Lan Su, Pei-Shan Kao, Wei-Chieh Lin, Pei-Fang Su, Chang-Wen Chen
BACKGROUND: If the proportional assist ventilation (PAV) level is known, muscular effort can be estimated from the difference between peak airway pressure and positive end-expiratory pressure (PEEP) (ΔP) during PAV. We conjectured that deducing muscle pressure from ΔP may be an interesting method to set PAV, and tested this hypothesis using the oesophageal pressure time product calculation. METHODS: Eleven mechanically ventilated patients with oesophageal pressure monitoring under PAV were enrolled...
November 27, 2016: Critical Care: the Official Journal of the Critical Care Forum
David G Tingay, Anushi E Rajapaksa, Emanuela Zannin, Prue M Pereira-Fantini, Raffaele Dellacà, Elizabeth Perkins, Cornelis Elroy E Zonneveld, Andy Adler, Don Black, Inez Frerichs, Anna Lavizzari, Magdy Sourial, Bartłomiej Grychtol, Fabio Mosca, Peter G Davis
Respiratory transition at birth involves rapidly clearing fetal lung liquid and preventing efflux back into the lung whilst aeration is established. We have developed a sustained inflation (SIOPT) individualized to volume-response and a dynamic tidal positive end-expiratory pressure (open lung volume, OLV) strategy that both enhance this process. We aimed to compare the effect of each with a group managed with PEEP of 8 cmH2O and no recruitment manoeuvre (No-RM), on gas exchange, lung mechanics, spatiotemporal aeration and lung injury in 127±1d preterm lambs...
November 23, 2016: American Journal of Physiology. Lung Cellular and Molecular Physiology
Carlos D Martínez-Balzano, Paulo Oliveira, Michelle O'Rourke, Luanne Hills, Andrés F Sosa
BACKGROUND: Arterial blood gas (ABG) overutilization leads to increased costs, inefficient use of staff work-hours, patient discomfort and blood loss. We developed guidelines to optimize ABG utilization in the intensive care unit (ICU). METHODS: ABG utilization guidelines were implemented on all adult ICUs in our institution: three medical, two trauma-surgery, one cardiovascular and one neurosurgical ICU. While relying on pulse oximetry, we encouraged the utilization of ABGs after an acute respiratory event or for a rational clinical concern, and discouraged obtaining ABGs for routine surveillance, after planned changes of PEEP or FiO2 on the mechanical ventilator, for spontaneous breathing trials, or when a disorder was not suspected...
November 3, 2016: Chest
Changsheng Zhang, Massimiliano Pirrone, David A E Imber, Jeanne B Ackman, Jacopo Fumagalli, Robert M Kacmarek, Lorenzo Berra
Morbidly obese, critically ill patients are prone to develop hypoxemic respiratory failure and ventilator dependency. The best method for recruiting the lungs of these patients and keeping alveoli open without causing injury remains unclear. We present the case of a 31-year-old patient with severe refractory hypoxemia reversed by lung recruitment maneuvers and subsequent application of positive end-expiratory pressure (PEEP) at a level determined by a decremental PEEP trial. The patient was extubated at a high PEEP level of 22 cm H2O followed by noninvasive ventilatory support after extubation...
October 24, 2016: A & A Case Reports
Murray Hinder, Pranav Jani, Archana Priyadarshi, Alistair McEwan, Mark Tracy
BACKGROUND: The T-piece resuscitator (TPR) is in common use worldwide to deliver positive pressure ventilation during resuscitation of infants <10 kg. Ease of use, ability to provide positive end-expiratory pressure (PEEP), availability of devices inbuilt into resuscitaires and cheaper disposable options have increased its popularity as a first-line device for term infant resuscitation. Research into its ventilation performance is limited to preterm infant and animal studies. Efficacy of providing PEEP and the use of TPR during term infant resuscitation are not established...
September 19, 2016: Archives of Disease in Childhood. Fetal and Neonatal Edition
Senem Alkan Ozdemir, Esra Arun Ozer, Ozkan Ilhan, Sumer Sutcuoglu
BACKGROUND: Mechanical ventilation is an essential therapy in the treatment of respiratory failure in preterm infants. However, optimal ventilation strategy continues to be difficult to define. OBJECTIVE: To compare the effects of volume guarantee (VG) combined with intermittent mandatory ventilation (SIMV) and VG combined with pressure support ventilation (PSV) on the pulmonary mechanics and short term prognosis in preterm infants with respiratory distress syndrome...
September 13, 2016: Pediatric Pulmonology
Vivian Rotman, Alysson Roncally Carvalho, Rosana Souza Rodrigues, Denise Machado Medeiros, Eduardo Costa Pinto, Fernando Augusto Bozza, Carlos Roberto Ribeiro Carvalho
BACKGROUND: Ventilation with low tidal volume (VT) is well recognized as a protective approach to patients with acute respiratory distress syndrome (ARDS), but the optimal level of positive end-expiratory pressure (PEEP) remains uncertain. This study aims to evaluate two protective ventilatory strategies sequentially applied in patients with early ARDS. METHODS: In this prospective cohort study, fifteen patients were ventilated during 24 h with positive end-expiratory pressure (PEEP) adjusted according to the ARDSnet low-PEEP table (ARDSnet-24 h)...
2016: BMC Anesthesiology
Ariel M Modrykamien, Omar O Hernandez, Yunhee Im, Ryan W Walters, Caleb L Schrader, Lauren E Smith, Brian Lima
Mechanical ventilation support for acute respiratory distress syndrome (ARDS) patients involves the use of low tidal volumes and positive end-expiratory pressure. Nevertheless, the optimal ventilator strategy for ARDS patients undergoing extracorporeal membrane oxygenation (ECMO) therapy remains unknown. A retrospective analysis of a consecutive series of adult ARDS patients treated with V-V ECMO from October 2012 to May 2015 was performed. Mechanical ventilation data, as well as demographic and clinical data, were collected...
September 2016: ASAIO Journal: a Peer-reviewed Journal of the American Society for Artificial Internal Organs
Richard H Kallet
Functional residual capacity (FRC) is essentially the alveolar volume and a determinant of both oxygenation and respiratory system compliance (CRS). ARDS decreases FRC, and sufficient PEEP restores FRC; thus, assessments of PEEP by its impact on oxygenation and CRS are intimately linked. PEEP also can ameliorate or aggravate ventilator-induced lung injury. Therefore, it can be argued that PEEP should be titrated primarily by its impact on CRS The pro position argues that the heterogeneous nature of lung injury and its unique presentation in individual patients results in an uncoupling between oxygenation and CRS Therefore, relying upon oxygenation alone may enhance lung injury and mortality risk, particularly in those with severe ARDS...
June 2016: Respiratory Care
P Blankman, A Shono, B J M Hermans, T Wesselius, D Hasan, D Gommers
BACKGROUND: Homogeneous ventilation is important for prevention of ventilator-induced lung injury. Electrical impedance tomography (EIT) has been used to identify optimal PEEP by detection of homogenous ventilation in non-dependent and dependent lung regions. We aimed to compare the ability of volumetric capnography and EIT in detecting homogenous ventilation between these lung regions. METHODS: Fifteen mechanically-ventilated patients after cardiac surgery were studied...
June 2016: British Journal of Anaesthesia
Xingying He, Jingjing Jiang, Yuli Liu, Haitao Xu, Shuangqiong Zhou, Shibo Yang, Xueyin Shi, Hongbin Yuan
The aim of the study is to utilize electrical impedance tomography (EIT) to guide positive end-expiratory pressure (PEEP) and to optimize oxygenation in patients undergoing laparoscopic abdominal surgery.Fifty patients were randomly assigned to the control (C) group and the EIT (E) group (n = 25 each). We set the fraction of inspired oxygen (FiO2) at 0.30. The PEEP was titrated and increased in a 2-cm H2O stepwise manner, from 6 to 14 cm H2O. Hemodynamic variables, respiratory mechanics, EIT images, analysis of blood gas, and regional cerebral oxygen saturation were recorded...
April 2016: Medicine (Baltimore)
A Vieillard-Baron, M Matthay, J L Teboul, T Bein, M Schultz, S Magder, J J Marini
RATIONALE: Acute respiratory distress syndrome (ARDS) is frequently associated with hemodynamic instability which appears as the main factor associated with mortality. Shock is driven by pulmonary hypertension, deleterious effects of mechanical ventilation (MV) on right ventricular (RV) function, and associated-sepsis. Hemodynamic effects of ventilation are due to changes in pleural pressure (Ppl) and changes in transpulmonary pressure (TP). TP affects RV afterload, whereas changes in Ppl affect venous return...
May 2016: Intensive Care Medicine
Emilie Bialais, Xavier Wittebole, Laurence Vignaux, Jean Roeseler, Marc Wysocki, Johannes Meyer, Gregory Reychler, Dominik Novotni, Thierry Sottiaux, Pierre F Laterre, Philippe Hantson
BACKGROUND: Closed-loop modes automatically adjust ventilation settings, delivering individualized ventilation over short periods of time. The objective of this randomized controlled trial was to compare safety, efficacy and workload for the health care team between IntelliVent®-ASV and conventional modes over a 48-hour period. METHODS: ICU patients admitted with an expected duration of mechanical ventilation of more than 48 hours were randomized to IntelliVent®-ASV or conventional ventilation modes...
June 2016: Minerva Anestesiologica
Changsong Wang, Xiaoyang Wang, Chunjie Chi, Libo Guo, Lei Guo, Nana Zhao, Weiwei Wang, Xin Pi, Bo Sun, Ailing Lian, Jinghui Shi, Enyou Li
To identify the best lung ventilation strategy for acute respiratory distress syndrome (ARDS), we performed a network meta-analysis. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and the Web of Science were searched, and 36 eligible articles were included. Compared with higher tidal volumes with FiO2-guided lower positive end-expiratory pressure [PEEP], the hazard ratios (HRs) for mortality were 0.624 (95% confidence interval (CI) 0.419-0.98) for lower tidal volumes with FiO2-guided lower PEEP and prone positioning and 0...
2016: Scientific Reports
Raquel S Santos, Lillian Moraes, Cynthia S Samary, Cíntia L Santos, Maíra B A Ramos, Ana P Vasconcellos, Lucas F Horta, Marcelo M Morales, Vera L Capelozzi, Cristiane S N B Garcia, John J Marini, Marcelo Gama de Abreu, Paolo Pelosi, Pedro L Silva, Patricia R M Rocco
BACKGROUND: Large tidal volume (VT) breaths or "recruitment maneuvers" (RMs) are used commonly to open collapsed lungs, but their effectiveness may depend on how the RM is delivered. We hypothesized that a stepped approach to RM delivery ("slow" RM) compared with a nonstepped ("fast" RM), when followed by decremental positive end-expiratory pressure (PEEP) titration to lowest dynamic elastance, would (1) yield a more homogeneous inflation of the lungs, thus reducing the PEEP obtained during post-RM titration; (2) produce less lung morphofunctional injury, regardless of the severity of sepsis-induced acute lung inflammation; and (3) result in less biological damage in severe, but not in moderate, acute lung inflammation...
April 2016: Anesthesia and Analgesia
Ramesh Kumar Sen, Goverdhan Dutt Puri, Indu Mohini, Anil Pratap, Nirmal Raj
BACKGROUND: Post-traumatic hypoxemia can deteriorate during operative manipulations. OBJECTIVES: In the present study, criteria-based approach was applied to determine optimum conditions for femur surgery. The aim of this study was to optimize perioperative management of post-traumatic hypoxemia. PATIENTS AND METHODS: In this prospective observational study, post-traumatic adults with PaO2 < 70 mmHg in room air were enrolled. Physiological parameters, O2 saturation (SO2), arterial blood gas (ABG) analysis, Schonfeld fat embolism index score (SS), and Murray's lung injury scores (LIS) were assessed...
June 2014: Archives of Trauma Research
Kristian Hellenkamp, Sabrina Onimischewski, Jochen Kruppa, Martin Faßhauer, Alexander Becker, Helmut Eiffert, Mark Hünlich, Gerd Hasenfuß, Rolf Wachter
BACKGROUND: While early pneumonia is common in patients after out-of-hospital cardiac arrest (OHCA), little is known about the impact of pneumonia and the optimal timing of antibiotic therapy after OHCA. METHODS: We conducted a 5-year retrospective cohort study, including patients who suffered from OHCA and were treated with therapeutic hypothermia. ICU treatment was strictly standardized with defined treatment goals and procedures. Medical records, chest radiographic images and microbiological findings were reviewed...
2016: Critical Care: the Official Journal of the Critical Care Forum
Xin Pi, Yinghua Cui, Changsong Wang, Lei Guo, Bo Sun, Jinghui Shi, Ziwei Lin, Nana Zhao, Weiwei Wang, Songbin Fu, Enyou Li
The potentially harmful effects of short-term mechanical ventilation during surgery have been examined in recent years. An optimal strategy for mechanical ventilation of patients during non-laparoscopic abdominal surgery must be devised. A total of 63 patients undergoing elective open abdominal surgery with more than 2 h of ventilation time were selected for this randomized, open-label, clinical study. They were divided into three ventilation groups: high volume of 9 ml/kg IBW (ideal body weight) with ZEEP (zero end-expiratory pressure); low volume of 7 ml/kg IBW with 8 cm H2O PEEP (positive end expiratory pressure); and low volume of 7 ml/kg IBW with 8 cm H2O PEEP and recruitment...
2015: International Journal of Clinical and Experimental Pathology
Dierk Schreiter, Nadja C Carvalho, Sebastian Katscher, Ludger Mende, Alexander P Reske, Peter M Spieth, Alysson R Carvalho, Alessandro Beda, Burkhard Lachmann, Marcelo B P Amato, Hermann Wrigge, Andreas W Reske
BACKGROUND: Uncertainty persists regarding the optimal ventilatory strategy in trauma patients developing acute respiratory distress syndrome (ARDS). This work aims to assess the effects of two mechanical ventilation strategies with high positive end-expiratory pressure (PEEP) in experimental ARDS following blunt chest trauma. METHODS: Twenty-six juvenile pigs were anesthetized, tracheotomized and mechanically ventilated. A contusion was applied to the right chest using a bolt-shot device...
January 12, 2016: BMC Anesthesiology
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