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2.
PLoS One ; 16(1): e0245578, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33465155

RESUMO

COVID-19 pandemic sets the healthcare system to a shortage of ventilators. We aimed at assessing tidal volume (VT) delivery and air recirculation during expiration when one ventilator is divided into 2 test-lungs. The study was performed in a research laboratory in a medical ICU of a University hospital. An ICU (V500) and a lower-level ventilator (Elisée 350) were attached to two test-lungs (QuickLung) through a dedicated flow-splitter. A 50 mL/cmH2O Compliance (C) and 5 cmH2O/L/s Resistance (R) were set in both A and B test-lungs (A C50R5 / B C50R5, step1), A C50-R20 / B C20-R20 (step 2), A C20-R20 / B C10-R20 (step 3), and A C50-R20 / B C20-R5 (step 4). Each ventilator was set in volume and pressure control mode to deliver 800mL VT. We assessed VT from a pneumotachograph placed immediately before each lung, pendelluft air, and expiratory resistance (circuit and valve). Values are median (1st-3rd quartiles) and compared between ventilators by non-parametric tests. Between Elisée 350 and V500 in volume control VT in A/B test- lungs were 381/387 vs. 412/433 mL in step 1, 501/270 vs. 492/370 mL in step 2, 509/237 vs. 496/332 mL in step 3, and 496/281 vs. 480/329 mL in step 4. In pressure control the corresponding values were 373/336 vs. 430/414 mL, 416/185 vs. 322/234 mL, 193/108 vs. 176/ 92 mL and 422/201 vs. 481/329mL, respectively (P<0.001 between ventilators at each step for each volume). Pendelluft air volume ranged between 0.7 to 37.8 ml and negatively correlated with expiratory resistance in steps 2 and 3. The lower-level ventilator performed closely to the ICU ventilator. In the clinical setting, these findings suggest that, due to dependence of VT to C, pressure control should be preferred to maintain adequate VT at least in one patient when C and/or R changes abruptly and monitoring of VT should be done carefully. Increasing expiratory resistance should reduce pendelluft volume.


Assuntos
/terapia , Respiração Artificial/métodos , Ventiladores Mecânicos/efeitos adversos , Feminino , Humanos , Complacência Pulmonar , Medidas de Volume Pulmonar , Masculino , Pressões Respiratórias Máximas , Respiração Artificial/efeitos adversos , Respiração Artificial/instrumentação , Ventiladores Mecânicos/normas
3.
PLoS One ; 15(12): e0244963, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33378363

RESUMO

The COVID-19 pandemic disrupted the world in 2020 by spreading at unprecedented rates and causing tens of thousands of fatalities within a few months. The number of deaths dramatically increased in regions where the number of patients in need of hospital care exceeded the availability of care. Many COVID-19 patients experience Acute Respiratory Distress Syndrome (ARDS), a condition that can be treated with mechanical ventilation. In response to the need for mechanical ventilators, designed and tested an emergency ventilator (EV) that can control a patient's peak inspiratory pressure (PIP) and breathing rate, while keeping a positive end expiratory pressure (PEEP). This article describes the rapid design, prototyping, and testing of the EV. The development process was enabled by rapid design iterations using additive manufacturing (AM). In the initial design phase, iterations between design, AM, and testing enabled a working prototype within one week. The designs of the 16 different components of the ventilator were locked by additively manufacturing and testing a total of 283 parts having parametrically varied dimensions. In the second stage, AM was used to produce 75 functional prototypes to support engineering evaluation and animal testing. The devices were tested over more than two million cycles. We also developed an electronic monitoring system and with automatic alarm to provide for safe operation, along with training materials and user guides. The final designs are available online under a free license. The designs have been transferred to more than 70 organizations in 15 countries. This project demonstrates the potential for ultra-fast product design, engineering, and testing of medical devices needed for COVID-19 emergency response.


Assuntos
/terapia , Desenho de Equipamento/métodos , Respiração Artificial/instrumentação , Ventiladores Mecânicos/efeitos adversos , Animais , Humanos , Respiração Artificial/métodos , Mecânica Respiratória/fisiologia , Taxa Respiratória/fisiologia , Suínos
4.
Medicine (Baltimore) ; 99(41): e22386, 2020 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-33031274

RESUMO

BACKGROUND: This study will assess the efficacy and safety of ventilator for the management of severe pneumonia (SP). METHODS: This study will search the following electronic databases in MEDLINE, EMBASE, Web of Science, PsycINFO, Cochrane Library, CNKI, and Scopus from the beginning to present without language restrictions. Two authors will screen all records according to the eligibility criteria; assess study quality; and extract all essential data from eligible studies. If sufficient studies are included, we will pool the extracted data and carry out meta-analysis. RESULTS: This study will summarize published studies to assess the efficacy and safety of ventilator for patients with SP. CONCLUSION: The results of this study may supply a genuine understanding of perspective from a scientific basis on ventilator for the management of patients with SP.


Assuntos
Pneumonia/terapia , Respiração Artificial , Ventiladores Mecânicos , Humanos , Gravidade do Paciente , Projetos de Pesquisa , Respiração Artificial/efeitos adversos , Respiração Artificial/instrumentação , Revisões Sistemáticas como Assunto , Ventiladores Mecânicos/efeitos adversos
5.
Pharmacol Res Perspect ; 8(6): e00666, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33084232

RESUMO

Conflicting evidence exists about the effect of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) on COVID-19 clinical outcomes. We aimed to provide a comprehensive/updated evaluation of the effect of ACEIs/ARBs on COVID-19-related clinical outcomes, including exploration of interclass differences between ACEIs and ARBs, using a systematic review/meta-analysis approach conducted in Medline (OVID), Embase, Scopus, Cochrane library, and medRxiv from inception to 22 May 2020. English studies that evaluated the effect of ACEIs/ARBs among patients with COVID-19 were included. Studies' quality was appraised using the Newcastle-Ottawa Scale. Data were analyzed using the random-effects modeling stratified by exposure (ACEIs/ARBs, ACEIs, and ARBs). Heterogeneiity was assessed using I2 statistic. Several subgroup analyses were conducted to explore the impact of potential confounders. Overall, 27 studies were eligible. The pooled analyses showed nonsignificant associations between ACEIs/ARBs and death (OR:0.97, 95%CI:0.75,1.27), ICU admission (OR:1.09;95%CI:0.65,1.81), death/ICU admission (OR:0.67; 95%CI:0.52,0.86), risk of COVID-19 infection (OR:1.01; 95%CI:0.93,1.10), severe infection (OR:0.78; 95%CI:0.53,1.15), and hospitalization (OR:1.15; 95%CI:0.81,1.65). However, the subgroup analyses indicated significant association between ACEIs/ARBs and hospitalization among USA studies (OR:1.59; 95%CI:1.03,2.44), peer-reviewed (OR:1.93, 95%CI:1.38,2.71), good quality and studies which reported adjusted measure of effect (OR:1.30, 95%CI:1.10,1.50). Significant differences were found between ACEIs and ARBs with the latter being significantly associated with lower risk of acquiring COVID-19 infection (OR:0.24; 95%CI: 0.17,0.34). In conclusion, high-quality evidence exists for the effect of ACEIs/ARBs on some COVID-19 clinical outcomes. For the first time, we provided evidence, albeit of low quality, on interclass differences between ACEIs and ARBs for some of the reported clinical outcomes.


Assuntos
Antagonistas de Receptores de Angiotensina/farmacologia , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Betacoronavirus/efeitos dos fármacos , Doenças Cardiovasculares/tratamento farmacológico , Infecções por Coronavirus/mortalidade , Pneumonia Viral/mortalidade , Adulto , Idoso , Antagonistas de Receptores de Angiotensina/efeitos adversos , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Doenças Cardiovasculares/complicações , Comorbidade , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Feminino , Mortalidade Hospitalar/tendências , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Avaliação de Resultados em Cuidados de Saúde , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Medição de Risco , Ventiladores Mecânicos/efeitos adversos , Ventiladores Mecânicos/estatística & dados numéricos
7.
PLoS One ; 15(9): e0238182, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915808

RESUMO

BACKGROUND: Hospital-admitted patients are at risk of experiencing certain adverse outcomes during their hospital-stay. Patients may need to be admitted to the intensive care unit or be placed on the ventilator while there is also a possibility for complications to develop. Pre-existing comorbidity could increase the risk of these outcomes. The Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Measure (ECM), originally derived for mortality outcomes among general medical populations, are widely used for assessing these in-hospital complications even among specific injury populations. This study derived indices to specifically capture the effect of comorbidity on intensive care unit and ventilator use as well as hospital-acquired complications for injury patients. METHODS: Retrospective data on injury hospital-admissions from July 2012 to June 2014 (161,334 patients) for the state of Victoria, Australia was analysed. Results from multivariable regression analysis were used to derive the Australian Injury Comorbidity Indices (AICIs) for intensive care unit and ventilator hours and hospital-acquired complications. The AICIs, CCI and ECM were validated on data from Victoria and two other Australian states. RESULTS: Five comorbidities were significantly associated with intensive care unit hours, two with ventilator hours and fifteen with hospital-acquired complications for hospitalised injury patients. Not all diseases listed in the CCI or ECM were found to be associated with these outcomes. The AICIs performed equally well in terms of predictive ability to the long-listed ECM and in most instances outperformed the CCI. CONCLUSIONS: Associations between outcomes and comorbidities vary based on the type of outcome measure. The new comorbidity indices developed in this study provide a relevant, parsimonious and up-to-date method to capture the effect of comorbidity on in-hospital complications among admitted injury patients and is better suited for use in that context compared to the CCI and ECM.


Assuntos
Comorbidade , Bases de Dados Factuais , Adolescente , Adulto , Idoso , Austrália , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ventiladores Mecânicos/efeitos adversos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/patologia , Adulto Jovem
8.
J Laryngol Otol ; 134(8): 732-734, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32605665

RESUMO

BACKGROUND: Robust personal protective equipment is essential in preventing the transmission of coronavirus disease 2019 to head and neck surgeons who are routinely involved in aerosol generating procedures. OBJECTIVE: This paper describes the collective experience, across 3 institutes, of using a reusable half-face respirator in 72 head and neck surgery cases. METHOD: Cost analysis was performed to demonstrate the financial implications of using a reusable respirator compared to single-use filtering facepiece code 3 masks. CONCLUSION: The reusable respirator is a cost-effective alternative to disposable filtering facepiece code 3 respirators. Supplying reusable respirators to individual staff members may increase the likelihood of them having appropriate personal protective equipment during their clinical duties.


Assuntos
Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Reutilização de Equipamento/economia , Pandemias/prevenção & controle , Equipamento de Proteção Individual/economia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Aerossóis , Betacoronavirus/isolamento & purificação , Líquidos Corporais/virologia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Análise Custo-Benefício/métodos , Desenho de Equipamento , Feminino , Humanos , Masculino , Exposição Ocupacional/prevenção & controle , Exposição Ocupacional/estatística & dados numéricos , Otolaringologia/estatística & dados numéricos , Procedimentos Cirúrgicos Otorrinolaringológicos/métodos , Procedimentos Cirúrgicos Otorrinolaringológicos/normas , Equipamento de Proteção Individual/provisão & distribução , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Cirurgiões/estatística & dados numéricos , Ventiladores Mecânicos/efeitos adversos , Ventiladores Mecânicos/virologia
9.
PLoS One ; 15(7): e0236014, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32673352

RESUMO

BACKGROUND: Delirium is multifactorial. This study aimed at determining the association between different depths of sedation and the risk of delirium in adult mechanically ventilated patients. METHODS: A systematic literature retrieval was conducted in databases including Cochrane Central Register of Controlled Trials, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature for publications available till December 2019 without limitation in study type, and followed by a secondary retrieval for related literature. STATA15.1 and WinBugs 14.3 were used in statistical analyses for different sedation depths as the intervention. The main endpoint was delirium occurrence. Secondary endpoints were agitation-related adverse events and mortality. RESULTS: We included 18 studies comprising 8001 mechanically ventilated patients. Different sedation depths were not associated with the occurrence of delirium (OR = 1.00, 95%CI: 0.64-1.58, P = 0.993). Among the 18 enrolled studies, this finding was not confounded by the dosage of benzodiazepines (OR = 0.96, 95%CI: 0.79-1.17, P = 0.717) in eight randomized controlled trials(RCTs) or the patients' disease severity(OR 0.95, 95%CI: 0.79-1.13, P = 0.548) in 10 RCTs. However, contrasting results were found in non-RCTs. The deeper sedation group had a significantly increased risk for death(OR = 1.82, 95% CI: 1.23-2.69, P = 0.003), whereas lighter sedation seemed a potential risk for agitation-related adverse events (OR = 0.61, 95%CI: 0.45-0.84, P = 0.002). CONCLUSIONS: It is inconclusive whether significantly different sedation depths would change the risk of delirium in adult mechanically ventilated patients. TRIAL REGISTRATION NUMBER: The study was registered in PROSPERO(http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42019145276.


Assuntos
Sedação Consciente/efeitos adversos , Delírio/etiologia , Hipnóticos e Sedativos/efeitos adversos , Respiração Artificial/efeitos adversos , Ventiladores Mecânicos/efeitos adversos , Adulto , Delírio/patologia , Humanos , Tempo de Internação
11.
Chemosphere ; 255: 126978, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32417514

RESUMO

Bis(2-ethylhexyl) phthalate (DEHP) migration from polyvinyl chloride (PVC) has been studied with infusion, transfusion and extracorporeal oxygenation devices, but no study has been conducted to estimate its migration via respiratory medical devices (MDs). This work aims to develop an ex vivo model to quantify DEHP released doses by these MDs, which will then be used to estimate newborns DEHP exposure from respiratory assistance MDs. We followed the Frensh National Research and Safety Institute (INRS) recommendations for the validation of a collecting and analysing method of DEHP in air, which will be used to quantify DEHP in air passing through PVC respiratory assistance MDs. The developed method met all the validation criteria for DEHP determination in air. DEHP in air passing through MDs on the sixth day reached a cumulative quantity of 122.86 µg when using a flow rate of 4 L min-1 of non-humidified air while it was of 49.22 µg; 58.12 µg and 29.61 µg with flow rates of 2 L min-1 of humidified air, 2 L min-1 of dry air and 4 L min-1 of humidified air, respectively. Model application to two patients undergoing two different respiratory procedure demonstrated that noninvasive ventilation patient received higher dose of inhaled DEHP, confirmed by DEHP metabolites quantification in urine. Although the protective effect of air humidifiers on DEHP exposure was demonstrated, the effect of flow rate is difficult to be established. This developed method should be tested to verify its capacity to collect and quantify other plasticizers used in PVC MDs.


Assuntos
Dietilexilftalato/análise , Exposição Ambiental/análise , Equipamentos e Provisões/efeitos adversos , Ventiladores Mecânicos/efeitos adversos , Dietilexilftalato/metabolismo , Humanos , Recém-Nascido , Plastificantes/análise , Cloreto de Polivinila/análise , Cloreto de Polivinila/química , Equipamentos de Autoajuda/efeitos adversos
14.
Rev. esp. anestesiol. reanim ; 67(4): 195-203, abr. 2020. graf
Artigo em Espanhol | IBECS | ID: ibc-198028

RESUMO

La disfunción diafragmática inducida por ventilación mecánica (DDVI) es la pérdida de la fuerza diafragmática relacionada al uso de ventilación mecánica y se observa con frecuencia en las primeras 24 a 48 h de asistencia ventilatoria controlada. La evidencia reciente relaciona esa pérdida de función diafragmática con alteraciones de la vía del factor de crecimiento insulínico/fosfoinositol 3-cinasas/proteína cinasa B (IGF/PI3K/AKT), sobreexpresión de FOXO, señalización NF-kB, mayor función de ligasas de ubiquitina muscular y activación de la caspasa-3. La DDVI tiene un impacto negativo en los días de ventilación mecánica, la retirada de la asistencia ventilatoria, la calidad de vida y los costos hospitalarios. Es importante realizar nuevos estudios encaminados a mitigar la aparición o incidencia de esta lesión. Esta es una revisión narrativa de la literatura no sistemática, tiene por objetivo explicar con detalle las vías moleculares implicadas en el desarrollo de la disfunción diafragmática asociada al soporte ventilatorio


Ventilator-induced diaphragm dysfunction (VIDD) is the loss of diaphragmatic muscle strength'related to of mechanical ventilation, noticed during the first day or 48hours after initiating controlled mechanical ventilation. This alteration has been related to disruption on the insulin growth factor/phosphoinositol 3-kinase/kinase B protein pathway (IGF/PI3K/AKT), in addition to an overexpression of FOXO, expression of NF-kB signaling, increase function of muscular ubiquitin ligase and activation of caspasa-3. VIDD has a negative impact on quality of life, duration of mechanical ventilation, and hospitalization stance and cost. More studies are necessary to understated the process and impact of VIDD. This is a narrative review of non-systematic literature, aiming to explain the molecular pathways involved in VIDD


Assuntos
Humanos , Diafragma/fisiopatologia , Ventiladores Mecânicos/efeitos adversos , Diafragma/lesões , Paralisia Respiratória/etiologia , Fatores de Risco , Comorbidade , Estado Nutricional , Fatores Etários
15.
Sci Rep ; 10(1): 419, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31942012

RESUMO

Mechanical ventilation induces lung injury by damaging alveolar epithelial cells (AECs), but the pathogenesis remains unknown. Focal adhesion kinase (FAK) is a cytoplasmic protein tyrosine kinase that is involved in cell growth and intracellular signal transduction pathways. This study explored the potential role of FAK in AECs during lung injury induced by mechanical ventilation. High-volume mechanical ventilation (HMV) was used to create a mouse lung injury model, which was validated by analysis of lung weight, bronchoalveolar lavage fluid and histological investigation. The expression of FAK and Akt in AECs were evaluated. In addition, recombinant FAK was administered to mice via the tail vein, and then the extent of lung injury was assessed. Mouse AECs were cultured in vitro, and FAK expression in cells under stretch was investigated. The effects of FAK on cell proliferation, migration and apoptosis were investigated. The results showed that HMV decreased FAK expression in AECs of mice, while FAK supplementation attenuated lung injury, reduced protein levels/cell counts in the bronchoalveolar lavage fluid and decreased histological lung injury and oedema. The protective effect of FAK promoted AEC proliferation and migration and prevented cells from undergoing apoptosis, which restored the integrity of the alveoli through Akt pathway. Therefore, the decrease in FAK expression by HMV is essential for injury to epithelial cells and the disruption of alveolar integrity. FAK supplementation can reduce AEC injury associated with HMV.


Assuntos
Células Epiteliais Alveolares/patologia , Modelos Animais de Doenças , Quinase 1 de Adesão Focal/metabolismo , Lesão Pulmonar/prevenção & controle , Ventiladores Mecânicos/efeitos adversos , Cicatrização , Células Epiteliais Alveolares/enzimologia , Animais , Apoptose , Proliferação de Células , Células Cultivadas , Quinase 1 de Adesão Focal/genética , Lesão Pulmonar/etiologia , Lesão Pulmonar/patologia , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Transdução de Sinais
16.
Int Immunopharmacol ; 78: 106015, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31780369

RESUMO

Lymphocyte antigen 6Chigh (Ly-6Chigh) inflammatory monocytes, as novel mononuclear cells in the innate immune system, participate in infectious diseases. In this study, we investigated the potential role of these monocytes in ventilator-induced lung injury (VILI) and the possible mechanism involved in their migration to lung tissue. Our results showed that mechanical ventilation with high tidal volume (HTV) increased the accumulation of Ly-6Chigh inflammatory monocytes in lung tissues and that blocking C­C chemokine receptor 2 (CCR2) could significantly reduce Ly-6Chigh inflammatory-monocyte migration and attenuate the degree of inflammation of lung tissues. In addition, inhibition of p38 mitogen-activated protein kinase (p38 MAPK) activity could decrease the secretion of monocyte chemoattractant protein 1 (MCP-1), which in turn decreased the migration of Ly-6Chigh inflammatory monocytes into lung tissue. We also demonstrated that high ventilation caused Ly-6Chigh inflammatory monocytes in the bone marrow to migrate into and aggregate in the lungs, creating inflammation, and that the mechanism was quite different from that of infectious diseases. Ly-6Chigh inflammatory monocytes might play a pro-inflammatory role in VILI, and blocking their infiltration into lung tissue might become a new target for the treatment of this injury.


Assuntos
Anti-Inflamatórios não Esteroides/farmacologia , Quimiocina CCL2/metabolismo , Monócitos/imunologia , Lesão Pulmonar Induzida por Ventilação Mecânica/imunologia , Proteínas Quinases p38 Ativadas por Mitógeno/metabolismo , Animais , Anti-Inflamatórios não Esteroides/uso terapêutico , Antígenos Ly/metabolismo , Benzoxazinas/farmacologia , Benzoxazinas/uso terapêutico , Medula Óssea/imunologia , Medula Óssea/patologia , Movimento Celular/efeitos dos fármacos , Movimento Celular/imunologia , Modelos Animais de Doenças , Humanos , Imidazóis/farmacologia , Imidazóis/uso terapêutico , Pulmão/citologia , Pulmão/imunologia , Pulmão/patologia , Camundongos , Monócitos/metabolismo , Piridinas/farmacologia , Piridinas/uso terapêutico , Receptores CCR2/antagonistas & inibidores , Receptores CCR2/metabolismo , Compostos de Espiro/farmacologia , Compostos de Espiro/uso terapêutico , Volume de Ventilação Pulmonar , Lesão Pulmonar Induzida por Ventilação Mecânica/diagnóstico , Lesão Pulmonar Induzida por Ventilação Mecânica/tratamento farmacológico , Lesão Pulmonar Induzida por Ventilação Mecânica/patologia , Ventiladores Mecânicos/efeitos adversos , Proteínas Quinases p38 Ativadas por Mitógeno/antagonistas & inibidores
17.
Curr Opin Crit Care ; 26(1): 41-46, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31738231

RESUMO

PURPOSE OF REVIEW: Complications of mechanical ventilation, such as ventilator-induced lung injury (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD), adversely affect the outcome of critically ill patients. Although mostly studied during control ventilation, it is increasingly appreciated that VILI and VIDD also occur during assisted ventilation. Hence, current research focuses on identifying ways to monitor and deliver protective ventilation in assisted modes. This review describes the operating principles of proportional modes of assist, their implications for lung and diaphragm protective ventilation, and the supporting clinical data. RECENT FINDINGS: Proportional modes of assist, proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA, deliver a pressure assist that is proportional to the patient's effort, enabling ventilation to be better controlled by the patient's brain. This control underlies the potential of proportional modes to avoid over-assist and under-assist, improve patient--ventilator interaction, and provide protective ventilation. Indeed, in clinical studies, proportional modes have been associated with reduced asynchronies, enhanced diaphragmatic recovery, and limitation of excessive tidal volume. Additionally, proportional modes facilitate better monitoring of the delivery of protective assisted ventilation. SUMMARY: Physiological rationale and clinical data suggest a potential role for proportional modes of assist in providing and monitoring lung and diaphragm protective ventilation.


Assuntos
Diafragma , Suporte Ventilatório Interativo , Diafragma/fisiopatologia , Humanos , Respiração Artificial/efeitos adversos , Volume de Ventilação Pulmonar , Ventiladores Mecânicos/efeitos adversos
19.
Respir Res ; 20(1): 293, 2019 Dec 23.
Artigo em Inglês | MEDLINE | ID: mdl-31870367

RESUMO

BACKGROUND: Ventilator-induced diaphragmatic dysfunction is a serious complication associated with higher ICU mortality, prolonged mechanical ventilation, and unsuccessful withdrawal from mechanical ventilation. Although neurally adjusted ventilatory assist (NAVA) could be associated with lower patient-ventilator asynchrony compared with conventional ventilation, its effects on diaphragmatic dysfunction have not yet been well elucidated. METHODS: Twenty Japanese white rabbits were randomly divided into four groups, (1) no ventilation, (2) controlled mechanical ventilation (CMV) with continuous neuromuscular blockade, (3) NAVA, and (4) pressure support ventilation (PSV). Ventilated rabbits had lung injury induced, and mechanical ventilation was continued for 12 h. Respiratory waveforms were continuously recorded, and the asynchronous events measured. Subsequently, the animals were euthanized, and diaphragm and lung tissue were removed, and stained with Hematoxylin-Eosin to evaluate the extent of lung injury. The myofiber cross-sectional area of the diaphragm was evaluated under the adenosine triphosphatase staining, sarcomere disruptions by electron microscopy, apoptotic cell numbers by the TUNEL method, and quantitative analysis of Caspase-3 mRNA expression by real-time polymerase chain reaction. RESULTS: Physiological index, respiratory parameters, and histologic lung injury were not significantly different among the CMV, NAVA, and PSV. NAVA had lower asynchronous events than PSV (median [interquartile range], NAVA, 1.1 [0-2.2], PSV, 6.8 [3.8-10.0], p = 0.023). No differences were seen in the cross-sectional areas of myofibers between NAVA and PSV, but those of Type 1, 2A, and 2B fibers were lower in CMV compared with NAVA. The area fraction of sarcomere disruptions was lower in NAVA than PSV (NAVA vs PSV; 1.6 [1.5-2.8] vs 3.6 [2.7-4.3], p < 0.001). The proportion of apoptotic cells was lower in NAVA group than in PSV (NAVA vs PSV; 3.5 [2.5-6.4] vs 12.1 [8.9-18.1], p < 0.001). There was a tendency in the decreased expression levels of Caspase-3 mRNA in NAVA groups. Asynchrony Index was a mediator in the relationship between NAVA and sarcomere disruptions. CONCLUSIONS: Preservation of spontaneous breathing using either PSV or NAVA can preserve the cross sectional area of the diaphragm to prevent atrophy. However, NAVA may be superior to PSV in preventing sarcomere injury and apoptosis of myofibrotic cells of the diaphragm, and this effect may be mediated by patient-ventilator asynchrony.


Assuntos
Diafragma/lesões , Diafragma/fisiologia , Suporte Ventilatório Interativo/métodos , Mecânica Respiratória/fisiologia , Ventiladores Mecânicos , Animais , Diafragma/ultraestrutura , Suporte Ventilatório Interativo/efeitos adversos , Coelhos , Distribuição Aleatória , Ventiladores Mecânicos/efeitos adversos
20.
Respir Care ; 64(12): 1461-1468, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31641073

RESUMO

BACKGROUND: There is limited knowledge of rapid-response (RR) events and code events for children receiving home mechanical ventilation (HMV) via a tracheostomy in a non-ICU respiratory care unit. The purpose of this study was to describe the demographic and clinical factors leading to deterioration among these children and to identify the incidence and outcomes following rapid-response and code events. METHODS: A retrospective review was conducted on hospitalized HMV children who had RR/code events in a non-ICU respiratory care unit. RESULTS: There were a total of 50 RR events, and the primary clinical problem was acute respiratory distress, with 27 subjects (54%) needing ventilator adjustments. Twenty (40%) RR events occurred among children who were awaiting initial home discharge. Of 18 total code events, 7 (39%) children needed a tracheostomy-related intervention. There were 10 (56%) codes among children on mechanical ventilation awaiting initial home discharge. Children on HMV had 8.73 RR events per 1,000 patient days, whereas all other hospitalized children had 4.61 RR events per 1,000 patient days. In addition, children on HMV had 3.14 codes per 1,000 patient days, whereas all other hospitalized children had 0.74 codes per 1,000 patient days. All children were discharged from the hospital, and no deaths were associated with RR/code events for the index hospitalization. CONCLUSIONS: The overall incidence of RR/code events in children on HMV was higher than among non-HMV hospitalized children. Children on HMV preparing for their initial hospital discharge had the greatest number of RR/code events. The most prevalent interventions among children with RR events were ventilator setting adjustments, and among children with codes the most frequent actions were tracheostomy-related interventions. Developing strategies to predict risk factors for RR/code events may help decrease harm among children on HMV.


Assuntos
Equipe de Respostas Rápidas de Hospitais/estatística & dados numéricos , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/epidemiologia , Traqueostomia/efeitos adversos , Ventiladores Mecânicos/efeitos adversos , Criança , Pré-Escolar , Feminino , Serviços de Assistência Domiciliar , Hospitalização , Humanos , Incidência , Lactente , Masculino , Respiração Artificial/métodos , Unidades de Cuidados Respiratórios , Insuficiência Respiratória/etiologia , Estudos Retrospectivos
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