Positive end-expiratory pressure limits inspiratory effort through modulation of the effort-to-drive ratio: an experimental crossover study.
Critical care
Positive-pressure respiration
Respiratory distress syndrome
Respiratory therapy
Ventilator-induced lung injury
Journal
Intensive care medicine experimental
ISSN: 2197-425X
Titre abrégé: Intensive Care Med Exp
Pays: Germany
ID NLM: 101645149
Informations de publication
Date de publication:
05 Feb 2024
05 Feb 2024
Historique:
received:
10
11
2023
accepted:
11
01
2024
medline:
5
2
2024
pubmed:
5
2
2024
entrez:
4
2
2024
Statut:
epublish
Résumé
How assisted spontaneous breathing should be used during acute respiratory distress syndrome is questioned. Recent evidence suggests that high positive end-expiratory pressure (PEEP) may limit the risk of patient self-inflicted lung injury (P-SILI). The aim of this study was to assess the effects of PEEP on esophageal pressure swings, inspiratory drive, and the neuromuscular efficiency of ventilation. We hypothesized that high PEEP would reduce esophageal pressure swings, regardless of inspiratory drive changes, by modulating the effort-to-drive ratio (EDR). This was tested retrospectively in an experimental animal crossover study. Anesthetized pigs (n = 15) were subjected to mild to moderate lung injury and different PEEP levels were applied, changing PEEP from 0 to 15 cmH Inspiratory esophageal pressure swings decreased from - 4.2 ± 3.1 cmH Higher PEEP limits inspiratory effort by modulating the EDR of the respiratory system. These findings indicate that PEEP may be used in titration of the spontaneous impact on ventilation and in P-SILI risk reduction, potentially facilitating safe assisted spontaneous breathing. Similarly, ventilation may be shifted from highly spontaneous to predominantly controlled ventilation using PEEP. These findings need to be confirmed in clinical settings.
Sections du résumé
BACKGROUND
BACKGROUND
How assisted spontaneous breathing should be used during acute respiratory distress syndrome is questioned. Recent evidence suggests that high positive end-expiratory pressure (PEEP) may limit the risk of patient self-inflicted lung injury (P-SILI). The aim of this study was to assess the effects of PEEP on esophageal pressure swings, inspiratory drive, and the neuromuscular efficiency of ventilation. We hypothesized that high PEEP would reduce esophageal pressure swings, regardless of inspiratory drive changes, by modulating the effort-to-drive ratio (EDR). This was tested retrospectively in an experimental animal crossover study. Anesthetized pigs (n = 15) were subjected to mild to moderate lung injury and different PEEP levels were applied, changing PEEP from 0 to 15 cmH
RESULTS
RESULTS
Inspiratory esophageal pressure swings decreased from - 4.2 ± 3.1 cmH
CONCLUSIONS
CONCLUSIONS
Higher PEEP limits inspiratory effort by modulating the EDR of the respiratory system. These findings indicate that PEEP may be used in titration of the spontaneous impact on ventilation and in P-SILI risk reduction, potentially facilitating safe assisted spontaneous breathing. Similarly, ventilation may be shifted from highly spontaneous to predominantly controlled ventilation using PEEP. These findings need to be confirmed in clinical settings.
Identifiants
pubmed: 38311676
doi: 10.1186/s40635-024-00597-9
pii: 10.1186/s40635-024-00597-9
doi:
Types de publication
Journal Article
Langues
eng
Pagination
10Subventions
Organisme : Hjärt-Lungfonden
ID : 20220536
Organisme : Hjärt-Lungfonden
ID : 20200841
Organisme : Hjärt-Lungfonden
ID : 20200877
Organisme : Hjärt-Lungfonden
ID : 20200825
Organisme : Hjärt-Lungfonden
ID : 20220681
Organisme : Svenska Sällskapet för Medicinsk Forskning
ID : 463402221
Organisme : Svenska Läkaresällskapet
ID : SLS-959793
Organisme : The Alvar Gullstrand research grant
ID : ALF-977974
Organisme : The Alvar Gullstrand research grant
ID : ALF-938050
Organisme : The ALF research fund
ID : ALF-977586
Organisme : Vetenskapsrådet
ID : 2018-02438
Informations de copyright
© 2024. The Author(s).
Références
van Haren F, Pham T, Brochard L, Bellani G, Laffey J, Dres M, Fan E, Goligher EC, Heunks L, Lynch J, Wrigge H, McAuley D (2019) Spontaneous breathing in early acute respiratory distress syndrome: insights from the large observational study to understand the global impact of severe acute respiratory failure study. Crit Care Med 47:229–238
doi: 10.1097/CCM.0000000000003519
pubmed: 30379668
pmcid: 6336491
Putensen C, Zech S, Wrigge H, Zinserling J, Stüber F, Von ST, Mutz N (2012) Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 164:43–49
doi: 10.1164/ajrccm.164.1.2001078
Güldner A, Braune A, Carvalho N, Beda A, Zeidler S, Wiedemann B, Wunderlich G, Andreeff M, Uhlig C, Spieth PM, Koch T, Pelosi P, Kotzerke J, de Abreu MG (2014) Higher levels of spontaneous breathing induce lung recruitment and reduce global stress/strain in experimental lung injury. Anesthesiology 120:673–682
doi: 10.1097/ALN.0000000000000124
pubmed: 24406799
Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu J, Sachdeva R, Sonnad S, Kaiser LR, Rubinstein NA, Powers SK, Shrager JB (2008) Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 358:1327–1335
doi: 10.1056/NEJMoa070447
pubmed: 18367735
Goligher EC, Dres M, Fan E, Rubenfeld GD, Scales DC, Herridge MS, Vorona S, Sklar MC, Rittayamai N, Lanys A, Murray A, Brace D, Urrea C, Reid WD, Tomlinson G, Slutsky AS, Kavanagh BP, Brochard LJ, Ferguson ND (2018) Mechanical ventilation-induced diaphragm atrophy strongly impacts clinical outcomes. Am J Respir Crit Care Med 197:204–213
doi: 10.1164/rccm.201703-0536OC
pubmed: 28930478
Brochard L, Slutsky A, Pesenti A (2017) Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med 195:438–442
doi: 10.1164/rccm.201605-1081CP
pubmed: 27626833
Yoshida T, Torsani V, Gomes S, De SRR, Beraldo MA, EL Costa V, Tucci MR, Zin WA, Kavanagh BP, Amato MBP (2013) Spontaneous effort causes occult pendelluft during mechanical ventilation. Am J Respir Crit Care Med 188:1420–1427
doi: 10.1164/rccm.201303-0539OC
pubmed: 24199628
Dianti J, Tisminetzky M, Ferreyro BL, Englesakis M, Del SL, Sud S, Talmor D, Ball L, Meade M, Hodgson C, Beitler JR, Sahetya S, Nichol A, Fan E, Rochwerg B, Brochard L, Slutsky AS, Ferguson ND, Serpa Neto A, Adhikari NK, Angriman F, Goligher EC (2022) Association of peep and lung recruitment selection strategies with mortality in acute respiratory distress syndrome: a systematic review and network meta-analysis. Am J Respir Crit Care Med 205:1300–1310
doi: 10.1164/rccm.202108-1972OC
pubmed: 35180042
Goligher EC, Jonkman AH, Dianti J, Vaporidi K, Beitler JR, Patel BK, Yoshida T, Jaber S, Dres M, Mauri T, Bellani G, Demoule A, Brochard L, Heunks L (2020) Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort. Intensive Care Med 46:2314–2326
doi: 10.1007/s00134-020-06288-9
pubmed: 33140181
pmcid: 7605467
Yoshida T, Roldan R, Beraldo MA, Torsani V, Gomes S, De SRR, EL Costa V, Tucci MR, Lima RG, Kavanagh BP, Amato MBP (2016) Spontaneous effort during mechanical ventilation: maximal injury with less positive end-expiratory pressure. Crit Care Med 44:e678–e688
doi: 10.1097/CCM.0000000000001649
pubmed: 27002273
Morais CCA, Koyama Y, Yoshida T, Plens GM, Gomes S, Lima CAS, Ramos OPS, Pereira SM, Kawaguchi N, Yamamoto H, Uchiyama A, Borges JB, Vidal Melo MF, Tucci MR, Amato MBP, Kavanagh BP, Costa ELV, Fujino Y (2018) High positive end-expiratory pressure renders spontaneous effort noninjurious. Am J Respir Crit Care Med 197:1285–1296
doi: 10.1164/rccm.201706-1244OC
pubmed: 29323536
pmcid: 5955057
Widing H, Chiodaroli E, Liggieri F, Mariotti PS, Hallén K, Perchiazzi G (2022) Homogenizing effect of PEEP on tidal volume distribution during neurally adjusted ventilatory assist: study of an animal model of acute respiratory distress syndrome. Respir Res 23:324
doi: 10.1186/s12931-022-02228-x
pubmed: 36419132
pmcid: 9685871
Jansen D, Jonkman AH, De VHJ, Wennen M, Elshof J, Hoofs MA, Van Den BM, De MAME, Keijzer C, Scheffer GJ, Van Der HJG, Girbes A, Tuinman PR, Marcus JT, Ottenheijm CAC, Heunks L (2021) Positive end-expiratory pressure affects geometry and function of the human diaphragm. J Appl Physiol 131:1328–1339
doi: 10.1152/japplphysiol.00184.2021
pubmed: 34473571
De TA, Leduc D, Cappello M, Mine B, Gevenois PA, Wilson TA (2009) Mechanisms of the inspiratory action of the diaphragm during isolated contraction. J Appl Physiol 107:1736–1742
doi: 10.1152/japplphysiol.00753.2009
Papazian L, Forel J-M, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal J-M, Perez D, Seghboyan J-M, Constantin J-M, Courant P, Lefrant J-Y, Guérin C, Prat G, Morange S, Roch A, ACURASYS Study Investigators (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107–1116
doi: 10.1056/NEJMoa1005372
pubmed: 20843245
Yoshida T, Grieco DL, Brochard L, Fujino Y (2020) Patient self-inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing. Curr Opin Crit Care 26:59–65
doi: 10.1097/MCC.0000000000000691
pubmed: 31815775
Sinderby C, Navalesi P, Beck J, Skrobik Y, Comtois N, Friberg S, Gottfried SB, Lindström L (1999) Neural control of mechanical ventilation in respiratory failure. Nat Med 5:1433–1436
doi: 10.1038/71012
pubmed: 10581089
Kampolis CF, Mermiri M, Mavrovounis G, Koutsoukou A, Loukeri AA, Pantazopoulos I (2022) Comparison of advanced closed-loop ventilation modes with pressure support ventilation for weaning from mechanical ventilation in adults: a systematic review and meta-analysis. J Crit Care 68:1–9
doi: 10.1016/j.jcrc.2021.11.010
pubmed: 34839229
Liu L, Xu X, Sun Q, Yu Y, Xia F, Xie J, Yang Y, Heunks L, Qiu H (2020) Neurally adjusted ventilatory assist versus pressure support ventilation in difficult weaning: a randomized trial. Anesthesiology 132:1482–1493
doi: 10.1097/ALN.0000000000003207
pubmed: 32217876
Committee for the update of the guide for the care and use of laboratory animals (2011) Revised guide for the care and use of laboratory animals. https://olaw.nih.gov/sites/default/files/Guide-for-the-Care-and-Use-of-Laboratory-Animals.pdf . Accessed on 7 Oct 2023
Directive 2010/63/EU of the European Parliament and of the Council of 22 September 2010 on the protection of animals used for scientific purposes (2010) https://eur-lex.europa.eu/legal-content/EN/TXT/HTML/?uri=CELEX:32010L0063 . Accessed on 7 Oct 2023.
REGULATION (EU) 2019/1010 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 5 June 2019 (2019) https://eur-lex.europa.eu/legal-content/EN/TXT/HTML/?uri=CELEX:32019R1010 . Accessed on 7 Oct 2023
Kilkenny C, Browne W, Cuthill I, Emerson M, Altman D (2010) Improving bioscience research reporting: the arrive guidelines for reporting animal research. PLOS Biol 8:e1000412
doi: 10.1371/journal.pbio.1000412
pubmed: 20613859
pmcid: 2893951
Widing CH, Pellegrini M, Larsson A, Perchiazzi G (2019) The effects of positive end-expiratory pressure on transpulmonary pressure and recruitment–derecruitment during neurally adjusted ventilator assist: a continuous computed tomography study in an animal model of acute respiratory distress syndrome. Front Physiol 10:1392
doi: 10.3389/fphys.2019.01392
pubmed: 31824326
pmcid: 6882775
Brander L, Leong-Poi H, Beck J, Brunet F, Hutchison SJ, Slutsky AS, Sinderby C (2009) Titration and implementation of neurally adjusted ventilatory assist in critically ill patients. Chest 135:695–703
doi: 10.1378/chest.08-1747
pubmed: 19017889
Yoshida T, Uchiyama A, Matsuura N, Mashimo T, Fujino Y (2012) Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury. Crit Care Med 40:1578–1585
doi: 10.1097/CCM.0b013e3182451c40
pubmed: 22430241
Yoshida T, Uchiyama A, Matsuura N, Mashimo T, Fujino Y (2013) The comparison of spontaneous breathing and muscle paralysis in two different severities of experimental lung injury. Crit Care Med 41:536–545
doi: 10.1097/CCM.0b013e3182711972
pubmed: 23263584
Firstiogusran AMF, Yoshida T, Hashimoto H, Iwata H, Fujino Y (2022) Positive end-expiratory pressure and prone position alter the capacity of force generation from diaphragm in acute respiratory distress syndrome: an animal experiment. BMC Anesthesiol 22:373
doi: 10.1186/s12871-022-01921-0
pubmed: 36460946
pmcid: 9716689
Doorduin J, Nollet JL, Roesthuis LH, Van HHWH, Brochard LJ, Sinderby CA, Van Der HJG, Heunks LMA (2017) Partial neuromuscular blockade during partial ventilatory support in sedated patients with high tidal volumes. Am J Respir Crit Care Med 195:1033–1042
doi: 10.1164/rccm.201605-1016OC
pubmed: 27748627
Hughes CG, McGrane S, Pandharipande PP (2012) Sedation in the intensive care setting. Clin Pharmacol 4:53
pubmed: 23204873
pmcid: 3508653
van der Schans CP, de Jong W, de Vries G, Postma DS, Koëter GH, van der Mark TW (1993) Effect of positive expiratory pressure on breathing pattern in healthy subjects. Eur Respir J 6:60–66
doi: 10.1183/09031936.93.06010060
pubmed: 8425596
Alberti A, Gallo F, Fongaro A, Valenti S, Rossi A (1995) P0.1 is a useful parameter in setting the level of pressure support ventilation. Intensive Care Med 21:547–553
doi: 10.1007/BF01700158
pubmed: 7593895
Pellegrini M, Hedenstierna G, Roneus A, Segelsjö M, Larsson A, Perchiazzi G (2017) The diaphragm acts as a brake during expiration to prevent lung collapse. Am J Respir Crit Care Med 195:1608–1616
doi: 10.1164/rccm.201605-0992OC
pubmed: 27922742
Allo JC, Beck JC, Brander L, Brunet F, Slutsky AS, Sinderby CA (2006) Influence of neurally adjusted ventilatory assist and positive end-expiratory pressure on breathing pattern in rabbits with acute lung injury. Crit Care Med 34:2997–3004
doi: 10.1097/01.CCM.0000242520.50665.9F
pubmed: 16957635
Schepens T, Dres M, Heunks L, Goligher EC (2019) Diaphragm-protective mechanical ventilation. Curr Opin Crit Care 25:77–85
doi: 10.1097/MCC.0000000000000578
pubmed: 30531536
Lindqvist J, Van Den BM, Van Der PR, Hooijman PE, Beishuizen A, Elshof J, De WM, Girbes A, Spoelstra-De Man A, Shi ZH, Van Den BC, Bogaards S, Shen S, Strom J, Granzier H, Kole J, Musters RJP, Paul MA, Heunks LMA, Ottenheijm CAC (2018) Positive end-expiratory pressure ventilation induces longitudinal atrophy in diaphragm fibers. Am J Respir Crit Care Med 198:472–485
doi: 10.1164/rccm.201709-1917OC
pubmed: 29578749
pmcid: 6118031
Soilemezi E, Koco E, Tsimpos C, Tsagourias M, Savvidou S, Matamis D (2016) Effects of continuous positive airway pressure on diaphragmatic kinetics and breathing pattern in healthy individuals. Respirology 21:1262–1269
doi: 10.1111/resp.12823
pubmed: 27253912
Haberthür C, Guttmann J (2005) Short-term effects of positive end-expiratory pressure on breathing pattern: an interventional study in adult intensive care patients. Crit care 9:407–415
doi: 10.1186/cc3735
NC3Rs/BBSRC/Defra/MRC/NERC/Royal Society/Wellcome Trust (2019) Responsibility in the use of animals in bioscience research: expectations of the major research councils and charitable funding bodies. https://www.nc3rs.org.uk/sites/default/files/2022-01/Responsibility-in-the-use-of-animals-in-bioscience-research-2019.pdf . Accessed on 7 Oct 2023.