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Diagnosis and Treatment of Inhalation Injury in Burn Patients
Published in Jacob Loke, Pathophysiology and Treatment of Inhalation Injuries, 2020
Khan Z. Shirani, Joseph A. Moylan, Basil A. Pruitt
The use of controlled mechanical ventilation (CMV) combined with PEEP may adversely influence cardiac performance, particularly in patients with intravascular volume contraction (Uzawa and Ashbaugh, 1969;Colgan et al., 1971). The adverse effects of PEEP depend on elevations of the intrathoracic pressures produced by this procedure, which in turn impede venous return and lead to a depressed cardiac output (Sykes et al., 1970; Qvist et al., 1975). A reduction in left ventricular extensibility occurs with PEEP and has been explained on the basis of ventricular interdependence, that is, the volume distention of the right ventricle leading to reduced distensibility of the left ventricle through a shift in interventricular septum (Cassidy et al., 1979). Recently, however, it has been suggested that the ventricular dysfunction following use of PEEP may result from stiff ventricles. Application of 20 cmH2O PEEP in the normovolemic or volume-expanded dog reduces both right and left ventricular diastolic distensibility, indicating the requirement of higher transmural end-diastolic pressures for any given end-diastolic volume in order to distend the ventricles. Such biventricular reduction in compliance has been attributed to impaired ventricular filling due to both increased lung volume and lung stiffness as a result of application of PEEP (Santamore et al., 1984). PEEP, despite undesirable cardiovascular effects, obviously holds a prominent place in the management of patients with respiratory failure.
Clinical Workflows Supported by Patient Care Device Data
Published in John R. Zaleski, Clinical Surveillance, 2020
After surgery, the CABG patient is brought from the OR into the ICU. Once the patient has arrived, he or she is transferred to a mechanical ventilator. Adult patients are typically initiated at a level of mandatory breathing on the mechanical ventilator of between 10 and 12 breaths per minute. Each mandatory breath initiated by the ventilator causes a specific volume of mixed air to enter the lungs. The preset mandatory tidal volume is assigned by respiratory therapy at a level typically based on protocols of 5 mL/kg of ideal body weight. Normally, a small amount of positive pressure is maintained within the lungs in order to increase perfusion. This pressure, commonly referred to as positive end-expiratory pressure (PEEP) is set at the beginning of ventilation. A value of 5 cmH2O is common in patients not experiencing any pulmonary or cardiovascular problems [38] [109, pp. 468–481].
Emergency Medicine
Published in Stephan Strobel, Lewis Spitz, Stephen D. Marks, Great Ormond Street Handbook of Paediatrics, 2019
Nasal continuous positive airway pressure (CPAP) may be all that is required. In more severe cases mechanical ventilation is required. In most cases a low tidal volume lung protective strategy can be adopted with tidal volumes of 4–7 ml/kg, peak inspiratory pressure (PIP) <30 cmH2O, low respiratory rate, and permissive hypercapnia, allowing the pH to go down to 7.2. Moderate PEEP (6–8) helps to counteract intrinsic PEEP.
Ventilation management in acute respiratory failure related to COVID-19 versus ARDS from another origin – a descriptive narrative review
Published in Expert Review of Respiratory Medicine, 2021
Anissa M. Tsonas, Michela Botta, Ary Serpa Neto, Janneke Horn, Frederique Paulus, Marcus J. Schultz
The debate on what PEEP to use in patients with ARDS is ongoing, even after publication of studies that failed to show benefit [12–14], or even demonstrated harm from ventilation with higher PEEP [16]. Consequently, it is also uncertain how much PEEP to use in COVID-19 patients. In absence of randomized clinical trial evidence, it has been recommended to use ‘higher’ PEEP, following the higher PEEP/lower FiO2 table of the ARDS Network [67–69]. The substantial variation in PEEP between patients with acute respiratory failure related to COVID-19 within the studies could reflect the uncertainty of physicians in titration of PEEP. Of note, how PEEP was titrated, and whether caregivers indeed used a higher PEEP–lower FiO2 table or a lower PEEP–higher FiO2 table was not collected in the studies. Although it has been suggested that there could be two different phenotypes of acute respiratory failure related to COVID-19 [3], possibly needing different levels of PEEP, several studies failed to confirm this [66,70–72]. The use of high PEEP could also have been caused by a desperate attempt to normalize the at times severe hypoxemia, in a time when mortality from severe COVID-19 was reported to be as high as 80% [73] .
Driving pressure-guided ventilation versus protective lung ventilation in ARDS patients: A prospective randomized controlled study
Published in Egyptian Journal of Anaesthesia, 2021
Khaled M. Hamama, Sameh M. Fathy, Reda S. AbdAlrahman, Salah El-Din I. Alsherif, Sameh Abdelkhalik Ahmed
All patients were kept in a semi-recumbent position and were managed by protective lung strategy using volume-controlled (VC) mode. Tidal volume was set at 6 mL/kg, based on PBW. Plateau pressure (Pplat) was kept ≤ 30 cmH2O throughout the study by TV reduction in 1 ml/kg steps to levels down to 4 ml/kg. Accepted oxygenation levels (SpO2 88–95% or PaO2 60–80 mmHg) maintained by setting of FiO2 initially at 0.4 and then titrated if target oxygenation was not met. PEEP was set initially at 5 cmH2O, while the ventilator rate was set to keep adequate minute ventilation (7 to 9 L/min) and arterial pH >7.25–7.44. The inspiratory to expiratory ratio (I/E ratio) was set initially at 1:2. Sedation was given to all patients by continuous infusion of midazolam (0.1 mg/kg/h), and muscle relaxation with a bolus injection of 3 mg cis-atracurium on demand during titration of PEEP that was adjusted during the morning shift according to the allocated group once daily. The choice of PEEP was guided by the ARDS network [3] as in Table 1 in group I while the choice of PEEP was set to keep DP ≤ 14 cm H2O in group II through manipulating PEEP value that was increased by 2 cm H2O increments to achieve the target value of DP provided that maintaining stable hemodynamics of patients. If the target DP was not met, tidal volume was decreased by 1 ml/kg steps as low as 4 ml/kg PBW.
Severe, transient pulmonary ventilation-perfusion mismatch in the lung after porcine high velocity projectile behind armor blunt trauma
Published in Experimental Lung Research, 2020
David Rocksén, Ulf P. Arborelius, Jenny Gustavsson, Mattias Günther
Figure 3 describes general lung- and circulation parameters. pO2 decreased in BABT compared to controls during the initial 60 minutes (p < .01). No difference was detected after recruitment (Figure 3a). pCO2 increased in BABT compared to controls but did not reach statistical significance (Figure 3b). SvO2 decreased in BABT compared to controls during the initial 60 minutes but did not reach statistical significance (Figure 3c). PEEP was kept at 6 cm H2O during the first 60 minutes and increased to a maximum 11.6 cm H20 at recruitment (Figure 3d). Pressure support was kept at a mean 6.6 cm H2O during the first 60 minutes and increased to a maximum 11.6 cm H2O during recruitment (Figure 3e). Breathing frequency was triggered spontaneously during the first 60 minutes and mandatory during the recruitment phase and was between 20–40 breaths per minute during the spontaneous phase. A decrease was detected in BABT although not reaching statistical significance (Figure 3f). SaO2 decreased in BABT compared to controls during the first 60 minutes (p < .05), and during the recruitment phase (p < .05) (Figure 3g). Mean pulmonary arterial pressure (MPAP) increased in BABT compared to controls during the first 60 minutes (p < .001), and during the recruitment phase (p < .05) (Figure 3h). MAP decreased in BABT during the first 5 minutes but did not reach statistical significance when comparing the first 60 minutes, or at recruitment (Figure 3i).