Highlights
- •Ventilator induced lung injuries are due to excessive stress, strain, or atelectrauma.
- •Driving pressure assesses the strain applied to the lungs during mechanical ventilation.
- •Mechanical power represents the energy load transferred from the ventilator to the respiratory system.
- •INTELLiVENT-ASV selected driving pressure and mechanical power considered in safe ranges for lung protection.
Abstract
Background
Driving pressure (ΔP) and mechanical power (MP) are predictors of the risk of ventilation-
induced lung injuries (VILI) in mechanically ventilated patients. INTELLiVENT-ASV®
is a closed-loop ventilation mode that automatically adjusts respiratory rate and
tidal volume, according to the patient's respiratory mechanics.
Objectives
This prospective observational study investigated ΔP and MP (and also transpulmonary
ΔP (ΔPL) and MP (MPL) for a subgroup of patients) delivered by INTELLiVENT-ASV.
Methods
Adult patients admitted to the ICU were included if they were sedated and met the
criteria for a single lung condition (normal lungs, COPD, or ARDS). INTELLiVENT-ASV
was used with default target settings. If PEEP was above 16 cmH2O, the recruitment
strategy used transpulmonary pressure as a reference, and ΔPL and MPL were computed. Measurements were made once for each patient.
Results
Of the 255 patients included, 98 patients were classified as normal-lungs, 28 as COPD,
and 129 as ARDS patients. The median ΔP was 8 (7 − 10), 10 (8 − 12), and 9 (8 − 11)
cmH2O for normal-lungs, COPD, and ARDS patients, respectively. The median MP was 9.1
(4.9 – 13.5), 11.8 (8.6 – 16.5), and 8.8 (5.6 – 13.8) J/min for normal-lungs, COPD,
and ARDS patients, respectively. For the 19 patients managed with transpulmonary pressure
ΔPL was 6 (4 − 7) cmH2O and MPL was 3.6 (3.1 – 4.4) J/min.
Conclusions
In this short term observation study, INTELLiVENT-ASV selected ΔP and MP considered
in safe ranges for lung protection. In a subgroup of ARDS patients, the combination
of a recruitment strategy and INTELLiVENT-ASV resulted in an apparently safe ΔPL and MPL.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Heart & Lung: The Journal of Cardiopulmonary and Acute CareAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Ventilator-induced lung injury.Clin Chest Med. 2016; 37 (Epub 2016 Oct 14): 633-646https://doi.org/10.1016/j.ccm.2016.07.004
- Should we use driving pressure to set tidal volume?.Curr Opin Crit Care. 2017; 23: 38-44https://doi.org/10.1097/MCC.0000000000000377
- Effect of end-inspiratory plateau pressure duration on driving pressure.Intensive Care Med. 2017; 43 (Epub 2016 Dec 20): 587-589https://doi.org/10.1007/s00134-016-4651-6
- The effects of low tidal ventilation on lung strain correlate with respiratory system compliance.Crit Care. 2017; 21: 23https://doi.org/10.1186/s13054-017-1600-x
- Airway driving pressure and lung stress in ards patients.Crit Care. 2016; 20: 276https://doi.org/10.1186/s13054-016-1446-7
- Driving pressure and survival in the acute respiratory distress syndrome.N Engl J Med. 2015; 372: 747-755https://doi.org/10.1056/NEJMsa1410639
- Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the lung safe study.Intensive Care Med. 2016; 42: 1865-1876https://doi.org/10.1007/s00134-016-4571-5
- Association between ventilatory settings and development of acute respiratory distress syndrome in mechanically ventilated patients due to brain injury.J Crit Care. 2017; 38 (Epub 2016 Nov 18): 341-345https://doi.org/10.1016/j.jcrc.2016.11.010
- Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data.Lancet Respir Med. 2016; 4 (Epub 2016 Mar 4): 272-280https://doi.org/10.1016/S2213-2600(16)00057-6
- Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ards.Intensive Care Med. 2016; 42 (Epub 2016 Jun 18): 1206-1213https://doi.org/10.1007/s00134-016-4403-7
- Ventilator-related causes of lung injury: the mechanical power.Intensive Care Med. 2016; 42 (Epub 2016 Sep 12): 1567-1575https://doi.org/10.1007/s00134-016-4505-2
- Dissipation of energy during the respiratory cycle: conditional importance of ergotrauma to structural lung damage.Curr Opin Crit Care. 2018; 24: 16-22https://doi.org/10.1097/MCC.0000000000000470
- Mechanical power and development of ventilator-induced lung injury.Anesthesiology. 2016; 124: 1100-1108https://doi.org/10.1097/ALN.0000000000001056
- Forel JM; investigators of the acurasys and proseva trials. effect of driving pressure on mortality in ards patients during lung protective mechanical ventilation in two randomized controlled trials.Crit Care. 2016; 20: 384
- Pulmonary mechanics and mortality in mechanically ventilated patients without acute respiratory distress syndrome: a cohort study.Shock. 2018; 49: 311-316https://doi.org/10.1097/SHK.0000000000000977
- The future of mechanical ventilation: lessons from the present and the past.Crit Care. 2017; 21: 183https://doi.org/10.1186/s13054-017-1750-x
- Safety and efficacy of a fully closed-loop control ventilation (IntelliVent-ASV®) in sedated icu patients with acute respiratory failure: a prospective randomized crossover study.Intensive Care Med. 2012; 38 (Epub 2012 Mar 30): 781-787https://doi.org/10.1007/s00134-012-2548-6
- Simple method to measure total expiratory time constant based on passive expiratory flow-volume curve.Crit Care Med. 1995; 23: 1117-1122
- Mechanics of breathing in man.J Appl Physiol. 1950; 2: 592-607
- Control of respiratory frequency.J Appli Physiol. 1960; 15: 325-336
- Evaluation of fully automated ventilation: a randomized controlled study in post-cardiac surgery patients.Intensive Care Med. 2013; 39 (Epub 2013 Jan 22): 463-471https://doi.org/10.1007/s00134-012-2799-2
- Closed-loop ventilation mode (IntelliVent®-ASV) in intensive care unit: a randomized trial.Minerva Anestesiol. 2016; 82 (Epub 2016 Mar 8): 657-668
- Feasibility study on full closed-loop control ventilation (IntelliVent-ASV™) in icu patients with acute respiratory failure: a prospective observational comparative study.Crit Care. 2013; 17: R196https://doi.org/10.1186/cc12890
- Parameters for simulation of adult subjects during mechanical ventilation.Respir Care. 2018; 63 (Epub 2017 Oct 17): 158-168https://doi.org/10.4187/respcare.05775
- Optimal duration of a sustained inflation recruitment maneuver in ards patients.Intensive Care Med. 2011; 37 (Epub 2011 Aug 20): 1588-1594https://doi.org/10.1007/s00134-011-2323-0
- Maximal recruitment open lung ventilation in acute respiratory distress syndrome (PHARLAP): a phase II, multicenter, randomized.Controlled Trial. Am J Respir Crit Care Med. 2019; ([Epub ahead of print])https://doi.org/10.1164/rccm.201901-0109OC
- The application of esophageal pressure measurement in patients with respiratory failure.Am J Respir Crit Care Med. 2014; 189: 520-531https://doi.org/10.1164/rccm.201312-2193CI
- Recruitment maneuvers: using transpulmonary pressure to help goldilocks.Intensive Care Med. 2017; 43 (Epub 2017 Apr 6): 1162-1163https://doi.org/10.1007/s00134-017-4784-2
- Mechanical ventilation guided by esophageal pressure in acute lung injury.N Engl J Med. 2008; 359 (Epub 2008 Nov 11): 2095-2104https://doi.org/10.1056/NEJMoa0708638
- Respiratory mechanics by least squares fitting in mechanically ventilated patients: applications during paralysis and during pressure support ventilation.Intensive Care Med. 1995; 21: 406-413
- Automatic selection of breathing pattern using adaptive support ventilation.Intensive Care Med. 2008; 34 (Epub 2007 Sep 11): 75-81
- Acute respiratory distress syndrome: the berlin definition.JAMA. 2012; 307: 2526-2533https://doi.org/10.1001/jama.2012.5669
- Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report: gold executive summary.Eur Respir J. 2017; 49 (pii: 1700214 Print 2017)https://doi.org/10.1183/13993003.00214-2017
- 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: 1301-1308
- Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts.Intensive Care Med. 2018; 44 (Epub 2018 Oct 5): 1914-1922https://doi.org/10.1007/s00134-018-5375-6
- Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: a preventive randomized controlled trial.Crit Care. 2010; 14 (Epub 2010 Jan 7): R1https://doi.org/10.1186/cc8230
- Impact of the driving pressure on mortality in obese and non-obese ards patients: a retrospective study of 362 cases.Intensive Care Med. 2018; 44 (Epub 2018 Jun 15): 1106-1114https://doi.org/10.1007/s00134-018-5241-6
- Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries.JAMA. 2016; 315: 788-800https://doi.org/10.1001/jama.2016.0291
Article Info
Publication History
Published online: November 14, 2019
Accepted:
November 1,
2019
Received in revised form:
October 31,
2019
Received:
June 18,
2019
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
