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  • 1.
    Acosta, Cecilia M.
    et al.
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesia, Cordoba 4545, RA-7600 Buenos Aires, DF, Argentina..
    Tusman, Gerardo
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesia, Cordoba 4545, RA-7600 Buenos Aires, DF, Argentina..
    Costantini, Mauro
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesia, Cordoba 4545, RA-7600 Buenos Aires, DF, Argentina..
    Echevarria, Camila
    Hosp Privado Comunidad Mar Del Plata, Dept Radiol, Buenos Aires, DF, Argentina..
    Pollioto, Sergio
    Hosp Privado Comunidad Mar Del Plata, Dept Pediat Surg, Buenos Aires, DF, Argentina..
    Abrego, Diego
    Hosp Privado Comunidad Mar Del Plata, Dept Pediat Surg, Buenos Aires, DF, Argentina..
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain..
    Bohm, Stephan H.
    Swisstom AG, Landquart, Switzerland..
    Doppler images of intra-pulmonary shunt within atelectasis in anesthetized children2016In: Critical Ultrasound Journal, ISSN 2036-3176, E-ISSN 2036-7902, Vol. 8, 19Article in journal (Refereed)
    Abstract [en]

    Background: Doppler images of pulmonary vessels in pulmonary diseases associated with subpleural consolidations have been described. Color Doppler easily identifies such vessels within consolidations while spectral Doppler analysis allows the differentiation between pulmonary and bronchial arteries. Thus, Doppler helps in diagnosing the nature of consolidations. To our knowledge, Doppler analysis of pulmonary vessels within anesthesia-induced atelectasis has never been described before. The aim of this case series is to demonstrate the ability of lung ultrasound to detect the shunting of blood within atelectatic lung areas in anesthetized children.

    Findings: Three anesthetized and mechanically ventilated children were scanned in the supine position using a high-resolution linear probe of 6-12 MHz. Once subpleural consolidations were detected in the most dependent posterior lung regions, the probe was rotated such that its long axis followed the intercostal space. In this oblique position, color Doppler mapping was performed to detect blood flow within the consolidation. Thereafter, pulsed waved spectral Doppler was applied in the previously identified vessels during a short expiratory pause, which prevented interferences from respiratory motion. Different flow patterns were identified which corresponded to both, pulmonary and bronchial vessels. Finally, a lung recruitment maneuver was performed which leads to the complete resolution of the aforementioned consolidation thereby confirming the pathophysiological entity of anesthesia-induced atelectasis.

    Conclusions: Lung ultrasound is a non-invasive imaging tool that not only enables the diagnosis of anesthesia-induced atelectasis in pediatric patients but also analysis of shunting blood within this consolidation.

  • 2.
    Batista Borges, João
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Santos, Arnoldo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Lucchetta, L.
    Hosp San Matteo, Pavia, Italy..
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Redistribution Of Regional Lung Perfusion During Mechanical Ventilation With An Open Lung Approach Impacts Pulmonary Vascular Mechanics2017In: American Journal of Respiratory and Critical Care Medicine, ISSN 1073-449X, E-ISSN 1535-4970, Vol. 195, A3751Article in journal (Other academic)
  • 3.
    Borges, João Batista
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Costa, Eduardo L V
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Widström, Charles
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Section of Medical Physics.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Amato, Marcelo
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Early inflammation mainly affects normally and poorly aerated lung in experimental ventilator-induced lung injury2014In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 42, no 4, e279-e287 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: The common denominator in most forms of ventilator-induced lung injury is an intense inflammatory response mediated by neutrophils. PET with [F]fluoro-2-deoxy-D-glucose can be used to image cellular metabolism, which, during lung inflammatory processes, mainly reflects neutrophil activity, allowing the study of regional lung inflammation in vivo. The aim of this study was to assess the location and magnitude of lung inflammation using PET imaging of [F]fluoro-2-deoxy-D-glucose in a porcine experimental model of early acute respiratory distress syndrome.

    DESIGN: Prospective laboratory investigation.

    SETTING: A university animal research laboratory.

    SUBJECTS: Seven piglets submitted to experimental ventilator-induced lung injury and five healthy controls.

    INTERVENTIONS: Lung injury was induced by lung lavages and 210 minutes of injurious mechanical ventilation using low positive end-expiratory pressure and high inspiratory pressures. All animals were subsequently studied with dynamic PET imaging of [F]fluoro-2-deoxy-D-glucose. CT scans were acquired at end expiration and end inspiration.

    MEASUREMENTS AND MAIN RESULTS: [F]fluoro-2-deoxy-D-glucose uptake rate was computed for the whole lung, four isogravitational regions, and regions grouping voxels with similar density. Global and intermediate gravitational zones [F]fluoro-2-deoxy-D-glucose uptakes were higher in ventilator-induced lung injury piglets compared with controls animals. Uptake of normally and poorly aerated regions was also higher in ventilator-induced lung injury piglets compared with control piglets, whereas regions suffering tidal recruitment or tidal hyperinflation had [F]fluoro-2-deoxy-D-glucose uptakes similar to controls.

    CONCLUSIONS: The present findings suggest that normally and poorly aerated regions-corresponding to intermediate gravitational zones-are the primary targets of the inflammatory process accompanying early experimental ventilator-induced lung injury. This may be attributed to the small volume of the aerated lung, which receives most of ventilation.

  • 4.
    Borges, João Batista
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Altering the mechanical scenario to decrease the driving pressure2015In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 19, no 1, 342Article in journal (Refereed)
    Abstract [en]

    Ventilator settings resulting in decreased driving pressure (ΔP) are positively associated with survival. How to further foster the potential beneficial mediator effect of a reduced ΔP? One possibility is promoting the active modification of the lung's "mechanical scenario" by means of lung recruitment and positive end-expiratory pressure selection. By taking into account the individual distribution of the threshold-opening airway pressures to achieve maximal recruitment, a redistribution of the tidal volume from overdistended to newly recruited lung occurs. The resulting more homogeneous distribution of transpulmonary pressures may induce a relief of overdistension in the upper regions. The gain in lung compliance after a successful recruitment rescales the size of the functional lung, potentially allowing for a further reduction in ΔP.

  • 5.
    Borges, João Batista
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Suarez Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Costa, Eduardo L. V.
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Amato, Marcelo
    Comment on Borges et al. "Regional lung perfusion estimated by electrical impedance tomography in a piglet model of lung collapse" Reply2012In: Journal of applied physiology, ISSN 8750-7587, E-ISSN 1522-1601, Vol. 112, no 12, 2128-2128 p.Article in journal (Refereed)
  • 6.
    Borges, João Batista
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Bohm, Stephan H
    Tusman, Gerardo
    Melo, Alexandre
    Maripuu, Enn
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science.
    Sandström, Mattias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Oncology.
    Park, Marcelo
    Costa, Eduardo L V
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Amato, Marcelo
    Regional Lung Perfusion estimated by Electrical Impedance Tomography in a piglet model of lung collapse2011In: Journal of applied physiology, ISSN 8750-7587, E-ISSN 1522-1601, Vol. 112, no 1, 225-236 p.Article in journal (Refereed)
    Abstract [en]

    The assessment of the regional match between alveolar ventilation and perfusion in critically ill patients requires simultaneous measurements of both parameters. Ideally, assessment of lung perfusion should be performed in real-time with an imaging technology which provides, through fast acquisition of sequential images, information about the regional dynamics or regional kinetics of an appropriate tracer. We present a novel electrical impedance tomography (EIT) based method that quantitatively estimates regional lung perfusion based on first-pass kinetics of a bolus of hypertonic saline contrast. Pulmonary blood flow was measured in six piglets during control and unilateral or bilateral lung collapse conditions. The first-pass kinetics method showed good agreement with the estimates obtained by single-photon-emission computerized tomography (SPECT). The mean difference (SPECT minus EIT) between fractional blood flow to lung areas suffering atelectasis was -0.6 %, with a standard deviation of 2.9 %. This method outperformed the estimates of lung perfusion based on impedance-pulsatility. In conclusion, we describe a novel method based on Electrical Impedance Tomography for estimating regional lung perfusion at the bedside. In both, healthy and injured lung conditions, the distribution of pulmonary blood flow as assessed by EIT agreed well with the one obtained by SPECT. The method proposed in this paper has the potential to contribute to a better understanding of the behavior of regional perfusion under different lung and therapeutic conditions.

  • 7.
    Ferrando, Carlos
    et al.
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Romero, Carolina
    Consorci Hosp Gen Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Tusman, Gerardo
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesiol, Mar De Plata, Argentina..
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain..
    Canet, Jaume
    Hosp Badalona Germans Trias & Pujol, Anesthesiol & Crit Care, Badalona, Spain..
    Dosda, Rosa
    Hosp Clin Univ Valencia, Dept Radiol, Valencia, Spain..
    Valls, Paola
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Villena, Abigail
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Serralta, Ferran
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Jurado, Ana
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Carrizo, Juan
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Navarro, Jose
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Parrilla, Cristina
    Hosp Clin Univ Valencia, Dept Radiol, Valencia, Spain..
    Romero, Jose E.
    Univ Politecn Valencia, ITACA Inst, Grp IBIME, Valencia, Spain..
    Pozo, Natividad
    INCLIVA Clin Res Inst, Valencia, Spain..
    Soro, Marina
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    Villar, Jesus
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ Dr Negrin, Res Unit, Las Palmas Gran Canaria, Spain..
    Belda, Francisco Javier
    Hosp Clin Univ Valencia, Anesthesiol & Crit Care, Valencia, Spain..
    The accuracy of postoperative, non-invasive Air-Test to diagnose atelectasis in healthy patients after surgery: a prospective, diagnostic pilot study2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 5, e015560Article in journal (Refereed)
    Abstract [en]

    Objective To assess the diagnostic accuracy of peripheral capillary oxygen saturation (SpO(2)) while breathing room air for 5 min (the 'Air-Test') in detecting postoperative atelectasis. Design Prospective cohort study. Diagnostic accuracy was assessed by measuring the agreement between the index test and the reference standard CT scan images. Setting Postanaesthetic care unit in a tertiary hospital in Spain. Participants Three hundred and fifty patients from 12 January to 7 February 2015; 170 patients scheduled for surgery under general anaesthesia who were admitted into the postsurgical unit were included. Intervention The Air-Test was performed in conscious extubated patients after a 30 min stabilisation period during which they received supplemental oxygen therapy via a venturi mask. The Air-Test was defined as positive when SpO(2) was >= 96% and negative when SpO(2) was >= 97%. Arterial blood gases were measured in all patients at the end of the Air-Test. In the subsequent 25 min, the presence of atelectasis was evaluated by performing a CT scan in 59 randomly selected patients. Main outcome measures The primary study outcome was assessment of the accuracy of the Air-Test for detecting postoperative atelectasis compared with the reference standard. The secondary outcome was the incidence of positive Air-Test results. Results The Air-Test diagnosed postoperative atelectasis with an area under the receiver operating characteristic curve of 0.90 (95% CI 0.82 to 0.98) with a sensitivity of 82.6% and a specificity of 87.8%. The presence of atelectasis was confirmed by CT scans in all patients (30/30) with positive and in 5 patients (17%) with negative Air-Test results. Based on the Air-Test, postoperative atelectasis was present in 36% of the patients (62 out of 170). Conclusion The Air-Test may represent an accurate, simple, inexpensive and non-invasive method for diagnosing postoperative atelectasis.

  • 8. Ferrando, Carlos
    et al.
    Soro, Marina
    Canet, Jaume
    Carmen Unzueta, Ma
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Librero, Julian
    Peiro, Salvador
    Llombart, Alicia
    Delgado, Carlos
    Leon, Irene
    Rovira, Lucas
    Ramasco, Fernando
    Granell, Manuel
    Aldecoa, Cesar
    Diaz, Oscar
    Balust, Jaume
    Garutti, Ignacio
    de la Matta, Manuel
    Pensado, Alberto
    Gonzalez, Rafael
    Eugenia Duran, Ma
    Gallego, Lucia
    Garcia del Valle, Santiago
    Redondo, Francisco J.
    Diaz, Pedro
    Pestana, David
    Rodriguez, Aurelio
    Aguirre, Javier
    Garcia, Jose M.
    Garcia, Javier
    Espinosa, Elena
    Charco, Pedro
    Navarro, Jose
    Rodriguez, Clara
    Tusman, Gerardo
    Javier Belda, Francisco
    Rationale and study design for an individualized perioperative open lung ventilatory strategy (iPROVE): study protocol for a randomized controlled trial2015In: Trials, ISSN 1745-6215, Vol. 16, 193Article in journal (Refereed)
    Abstract [en]

    Background: Postoperative pulmonary and non-pulmonary complications are common problems that increase morbidity and mortality in surgical patients, even though the incidence has decreased with the increased use of protective lung ventilation strategies. Previous trials have focused on standard strategies in the intraoperative or postoperative period, but without personalizing these strategies to suit the needs of each individual patient and without considering both these periods as a global perioperative lung-protective approach. The trial presented here aims at comparing postoperative complications when using an individualized ventilatory management strategy in the intraoperative and immediate postoperative periods with those when using a standard protective ventilation strategy in patients scheduled for major abdominal surgery. Methods: This is a comparative, prospective, multicenter, randomized, and controlled, four-arm trial that will include 1012 patients with an intermediate or high risk for postoperative pulmonary complications. The patients will be divided into four groups: (1) individualized perioperative group: intra-and postoperative individualized strategy; (2) intraoperative individualized strategy + postoperative continuous positive airway pressure (CPAP); (3) intraoperative standard ventilation + postoperative CPAP; (4) intra-and postoperative standard strategy (conventional strategy). The primary outcome is a composite analysis of postoperative complications. Discussion: The Individualized Perioperative Open-lung Ventilatory Strategy (iPROVE) is the first multicenter, randomized, and controlled trial to investigate whether an individualized perioperative approach prevents postoperative pulmonary complications.

  • 9. Ferrando, Carlos
    et al.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Gutierrez, Andrea
    Tusman, Gerardo
    Carbonell, Jose
    Garcia, Marisa
    Piqueras, Laura
    Compan, Desamparados
    Flores, Susanie
    Soro, Marina
    Llombart, Alicia
    Javier Belda, Francisco
    Adjusting tidal volume to stress index in an open lung condition optimizes ventilation and prevents overdistension in an experimental model of lung injury and reduced chest wall compliance2015In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 19, 9Article in journal (Refereed)
    Abstract [en]

    Introduction: The stress index ( SI), a parameter derived from the shape of the pressure-time curve, can identify injurious mechanical ventilation. We tested the hypothesis that adjusting tidal volume (VT) to a non-injurious SI in an open lung condition avoids hypoventilation while preventing overdistension in an experimental model of combined lung injury and low chest-wall compliance (Ccw). Methods: Lung injury was induced by repeated lung lavages using warm saline solution, and Ccw was reduced by controlled intra-abdominal air-insufflation in 22 anesthetized, paralyzed and mechanically ventilated pigs. After injury animals were recruited and submitted to a positive end-expiratory pressure (PEEP) titration trial to find the PEEP level resulting in maximum compliance. During a subsequent four hours of mechanical ventilation, VT was adjusted to keep a plateau pressure (Pplat) of 30 cmH2O (Pplat-group, n = 11) or to a SI between 0.95 and 1.05 (SI-group, n = 11). Respiratory rate was adjusted to maintain a 'normal' PaCO2 (35 to 65 mmHg). SI, lung mechanics, arterial-blood gases haemodynamics pro-inflammatory cytokines and histopathology were analyzed. In addition Computed Tomography (CT) data were acquired at end expiration and end inspiration in six animals. Results: PaCO2 was significantly higher in the Pplat-group (82 versus 53 mmHg, P = 0.01), with a resulting lower pH (7.19 versus 7.34, P = 0.01). We observed significant differences in VT (7.3 versus 5.4 mlKg-1, P = 0.002) and Pplat values (30 versus 35 cmH2O, P = 0.001) between the Pplat-group and SI-group respectively. SI (1.03 versus 0.99, P = 0.42) and end-inspiratory transpulmonary pressure (PTP) (17 versus 18 cmH2O, P = 0.42) were similar in the Pplat-and SI-groups respectively, without differences in overinflated lung areas at end-inspiration in both groups. Cytokines and histopathology showed no differences. Conclusions: Setting tidal volume to a non-injurious stress index in an open lung condition improves alveolar ventilation and prevents overdistension without increasing lung injury. This is in comparison with limited Pplat protective ventilation in a model of lung injury with low chest-wall compliance.

  • 10.
    Ferrando, Carlos
    et al.
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Inst Salud Carlos III, GIBER Enfermedades Resp, Madrid, Spain.
    Tusman, Gerardo
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesiol, Mar Del Plata, Buenos Aires, Argentina..
    Leon, Irene
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Romero, Esther
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Gracia, Estefania
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Mugarra, Ana
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Arocas, Blanca
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Pozo, Natividad
    Hosp Clin Univ, INCLIVA Clin Res Inst, Valencia, Spain..
    Soro, Marina
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Belda, Francisco J.
    Hosp Clin Univ, Dept Anesthesiol & Crit Care, Valencia, Spain..
    Open lung approach versus standard protective strategies: Effects on driving pressure and ventilatory efficiency during anesthesia - A pilot, randomized controlled trial2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 5, e0177399Article in journal (Refereed)
    Abstract [en]

    Background: Low tidal volume (VT) during anesthesia minimizes lung injury but may be associated to a decrease in functional lung volume impairing lung mechanics and efficiency. Lung recruitment (RM) can restore lung volume but this may critically depend on the post-RM selected PEEP. This study was a randomized, two parallel arm, open study whose primary outcome was to compare the effects on driving pressure of adding a RM to low-VT ventilation, with or without an individualized post-RM PEEP in patients without known previous lung disease during anesthesia.

    Methods: Consecutive patients scheduled for major abdominal surgery were submitted to low-VT ventilation (6 ml.kg(-1)) and standard PEEP of 5 cmH(2)O (pre-RM, n = 36). After 30 min estabilization all patients received a RM and were randomly allocated to either continue with the same PEEP (RM-5 group, n = 18) or to an individualized open-lung PEEP (OL-PEEP) (Open Lung Approach, OLA group, n = 18) defined as the level resulting in maximal Cdyn during a decremental PEEP trial. We compared the effects on driving pressure and lung efficiency measured by volumetric capnography.

    Results: OL-PEEP was found at 8 +/- 2 cmH(2)O. 36 patients were included in the final analysis. When compared with pre-RM, OLA resulted in a 22% increase in compliance and a 28% decrease in driving pressure when compared to pre-RM. These parameters did not improve in the RM-5. The trend of the DP was significantly different between the OLA and RM-5 groups (p = 0.002). VDalv/VTalv was significantly lower in the OLA group after the RM (p = 0.035).

    Conclusions: Lung recruitment applied during low-VT ventilation improves driving pressure and lung efficiency only when applied as an open-lung strategy with an individualized PEEP in patients without lung diseases undergoing major abdominal surgery.

  • 11.
    Höstman, Staffan
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Borges, João Batista
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Ahlgren, Kerstin M
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Engström, Joakim
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    THAM reduces CO2-associated increase in pulmonary vascular resistance: an experimental study in lung-injured piglets2015In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 19, no 1, 331Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Low tidal volume (VT) ventilation is recommended in patients with acute respiratory distress syndrome (ARDS). This may increase arterial carbon dioxide tension (PaCO2), decrease pH, and augment pulmonary vascular resistance (PVR). We hypothesized that Tris(hydroxymethyl)aminomethane (THAM), a pure proton acceptor, would dampen these effects, preventing the increase in PVR.

    METHODS: A one-hit injury ARDS model was established by repeated lung lavages in 18 piglets. After ventilation with VT of 6 ml/kg to maintain normocapnia, VT was reduced to 3 ml/kg to induce hypercapnia. Six animals received THAM for 1 h, six for 3 h, and six serving as controls received no THAM. In all, the experiment continued for 6 h. The THAM dosage was calculated to normalize pH and exhibit a lasting effect. Gas exchange, pulmonary, and systemic hemodynamics were tracked. Inflammatory markers were obtained at the end of the experiment.

    RESULTS: In the controls, the decrease in VT from 6 to 3 ml/kg increased PaCO2 from 6.0±0.5 to 13.8±1.5 kPa and lowered pH from 7.40±0.01 to 7.12±0.06, whereas base excess (BE) remained stable at 2.7±2.3 mEq/L to 3.4±3.2 mEq/L. In the THAM groups, PaCO2 decreased and pH increased above 7.4 during the infusions. After discontinuing the infusions, PaCO2 increased above the corresponding level of the controls (15.2±1.7 kPa and 22.6±3.3 kPa for 1-h and 3-h THAM infusions, respectively). Despite a marked increase in BE (13.8±3.5 and 31.2±2.2 for 1-h and 3-h THAM infusions, respectively), pH became similar to the corresponding levels of the controls. PVR was lower in the THAM groups (at 6 h, 329±77 dyn∙s/m(5) and 255±43 dyn∙s/m(5) in the 1-h and 3-h groups, respectively, compared with 450±141 dyn∙s/m(5) in the controls), as were pulmonary arterial pressures.

    CONCLUSIONS: The pH in the THAM groups was similar to pH in the controls at 6 h, despite a marked increase in BE. This was due to an increase in PaCO2 after stopping the THAM infusion, possibly by intracellular release of CO2. Pulmonary arterial pressure and PVR were lower in the THAM-treated animals, indicating that THAM may be an option to reduce PVR in acute hypercapnia.

  • 12. Karagiannidis, C.
    et al.
    Kampe, K. Aufm
    Sipmann, F. Suarez
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Hedenstierna, Görna
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Windisch, W.
    Mueller, T.
    Pathophysiology and technical Prerequisites of veno-venous extracorporal C0(2) Elimination(ECCO2R) to the treatment of difficult respiratory Acidosis2015In: MEDIZINISCHE KLINIK-INTENSIVMEDIZIN UND NOTFALLMEDIZIN, ISSN 2193-6218, Vol. 110, no 4, 311-311 p.Article in journal (Other academic)
  • 13. Karagiannidis, Christian
    et al.
    Kampe, Kristin Aufm
    Sipmann, Fernando Suarez
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Windisch, Wolfram
    Mueller, Thomas
    Veno-venous extracorporeal CO2 removal for the treatment of severe respiratory acidosis: pathophysiological and technical considerations2014In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 18, no 3, R124- p.Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION:

    While non-invasive ventilation aimed at avoiding intubation has become the modality of choice to treat mild to moderate acute respiratory acidosis, many severely acidotic patients (pH <7.20) still need intubation. Extracorporeal veno-venous CO2 removal (ECCO2R) could prove to be an alternative. The present animal study tested in a systematic fashion technical requirements for successful ECCO2R in terms of cannula size, blood and sweep gas flow.

    METHODS:

    ECCO2R with a 0.98 m2 surface oxygenator was performed in six acidotic (pH <7.20) pigs using either a 14.5 French (Fr) or a 19Fr catheter, with sweep gas flow rates of 8 and 16 L/minute, respectively. During each experiment the blood flow was incrementally increased to a maximum of 400 mL/minute (14.5Fr catheter) and 1000 mL/minute (19Fr catheter).

    RESULTS:

    Amelioration of severe respiratory acidosis was only feasible when blood flow rates of 750 to 1000 mL/minute (19Fr catheter) were used. Maximal CO2-elimination was 146.1 ± 22.6 mL/minute, while pH increased from 7.13 ± 0.08 to 7.41 ± 0.07 (blood flow of 1000 mL/minute; sweep gas flow 16 L/minute). Accordingly, a sweep gas flow of 8 L/minute resulted in a maximal CO2-elimination rate of 138.0 ± 16.9 mL/minute. The 14.5Fr catheter allowed a maximum CO2 elimination rate of 77.9 mL/minute, which did not result in the normalization of pH.

    CONCLUSIONS:

    Veno-venous ECCO2R may serve as a treatment option for severe respiratory acidosis. In this porcine model, ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 mL/minute, while an increase in sweep gas flow from 8 to 16 L/minute had less impact on ECCO2R in this setting.

  • 14.
    Longo, Silvina
    et al.
    Hosp Privado Univ Cordoba, Dept Anesthesia, Cordoba, Argentina..
    Siri, Juan
    Acosta, Cecilia
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesia, Mar Del Plata, Buenos Aires, Argentina..
    Palencia, Alberto
    Hosp Privado Univ Cordoba, Dept Cardiovasc Surg, Cordoba, Argentina..
    Echegaray, Arturo
    Chiotti, Ivan
    Hosp Privado Univ Cordoba, Dept Intens Care, Cordoba, Argentina..
    Parisi, Andres
    Ricci, Lila
    Univ Nacl Mar del Plata, Fac Ciencias Exactas, Dept Math, Mar Del Plata, Buenos Aires, Argentina..
    Natal, Marcela
    Univ Nacl Mar del Plata, Fac Ciencias Exactas, Dept Math, Mar Del Plata, Buenos Aires, Argentina..
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. CIBERES, Madrid, Spain..
    Tusman, Gerardo
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesia, Mar Del Plata, Buenos Aires, Argentina..
    Lung recruitment improves right ventricular performance after cardiopulmonary bypass A randomised controlled trial2017In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 34, no 2, 66-74 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND Atelectasis after cardiopulmonary bypass (CPB) can affect right ventricular (RV) performance by increasing its outflow impedance. OBJECTIVE The aim of this study was to determine whether a lung recruitment manoeuvre improves RV function by re-aerating the lung after CPB. DESIGN Randomised controlled study. SETTING Single-institution study, community hospital, Cordoba, Argentina. PATIENTS Forty anaesthetised patients with New York Heart Association class I or II, preoperative left ventricular ejection fraction at least 50% and Euroscore 6 or less scheduled for cardiac surgery with CPB. INTERVENTIONS Patients were assigned to receive either standard ventilation with 6 cmH(2)O of positive end-expiratory pressure (PEEP; group C, n = 20) or standard ventilation with a recruitment manoeuvre and 10 cmH(2)O of PEEP after surgery (group RM, n = 20). RV function, left ventricular cardiac index (CI) and lung aeration were assessed by transoesophageal echocardiography (TOE) before, at the end of surgery and 30 min after surgery. MAIN OUTCOME MEASURES RV function parameters and atelectasis assessed by TOE. RESULTS Haemodynamic data and atelectasis were similar between groups before surgery. At the end of surgery, CI had decreased from 2.9 +/- 1.1 to 2.6 +/- 0.9 l min(-1) m(-2) in group C (P = 0.24) and from 2.8 +/- 1.0 to 2.6 +/- 0.8 l min(-1) m +/- 2 in group RM (P = 0.32). TOE-derived RV function parameters confirmed a mild decrease in RV performance in 95% of patients, without significant differences between groups (multivariate Hotelling t-test P = 0.16). Atelectasis was present in 18 patients in group C and 19 patients in group RM (P = 0.88). After surgery, CI decreased further from 2.6 to 2.4 l min(-)1 m(-2) in group C (P = 0.17) but increased from 2.6 to 3.7 l min(-1) m(-2) in group RM (P<0.001). TOE-derived RV function parameters improved only in group RM (Hotelling t-test P<0.001). Atelectasis was present in 100% of patients in group C but only in 10% of those in group RM (P<0.001). CONCLUSION Atelectasis after CPB impairs RV function but this can be resolved by lung recruitment using 10 cm H2O of PEEP.

  • 15.
    Retamal, Jaime
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Borges, Joao Batista
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Bruhn, A
    Cao, Xiaofang
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Biochemistry and Microbiology.
    Feinstein, R
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Johansson, Staffan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Biochemistry and Microbiology.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    High respiratory rate is associated with early reduction of lung edema clearance in an experimental model of ARDS2016In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 60, no 1, 79-92 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The independent impact of respiratory rate on ventilator-induced lung injury has not been fully elucidated. The aim of this study was to investigate the effects of two clinically relevant respiratory rates on early ventilator-induced lung injury evolution and lung edema during the protective ARDSNet strategy. We hypothesized that the use of a higher respiratory rate during a protective ARDSNet ventilation strategy increases lung inflammation and, in addition, lung edema associated to strain-induced activation of transforming growth factor beta (TGF-β) in the lung epithelium.

    METHODS: Twelve healthy piglets were submitted to a two-hit lung injury model and randomized into two groups: LRR (20 breaths/min) and HRR (40 breaths/min). They were mechanically ventilated during 6 h according to the ARDSNet strategy. We assessed respiratory mechanics, hemodynamics, and extravascular lung water (EVLW). At the end of the experiment, the lungs were excised and wet/dry ratio, TGF-β pathway markers, regional histology, and cytokines were evaluated.

    RESULTS: No differences in oxygenation, PaCO2 levels, systemic and pulmonary arterial pressures were observed during the study. Respiratory system compliance and mean airway pressure were lower in LRR group. A decrease in EVLW over time occurred only in the LRR group (P < 0.05). Wet/dry ratio was higher in the HRR group (P < 0.05), as well as TGF-β pathway activation. Histological findings suggestive of inflammation and inflammatory tissue cytokines were higher in LRR.

    CONCLUSION: HRR was associated with more pulmonary edema and higher activation of the TGF-β pathway. In contrast with our hypothesis, HRR was associated with less lung inflammation.

  • 16.
    Retamal, Jaime
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Departament de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile.
    Sörensen, Jens
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Lubberink, Mark
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spai.
    Borges, João Batista
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Pulmonary Divison, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
    Feinstein, Ricardo
    The Swedish National Veterinary Institute, Sweden.
    Jalkanen, Sirpa
    MediCity Research Laboratory, Department of Medical Microbiology and Immunology, University of Turku, Turku, Finland.
    Antoni, Gunnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Medicinal Chemistry, Division of Molecular Imaging.
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Roivainen, Anne
    Turku PET Centre, University of Turku and Turku University Hospital, Turku, Finland; Turku Center for Disease Modelling, University of Turku, Furku, Finland.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Velikyan, Irina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Feasibility of 68Ga-labeled Siglec-9 peptide for the imaging of acute lung inflammation: a pilot study in a porcine model of acute respiratory distress syndrome2016In: American Journal of Nuclear Medicine and Molecular Imaging, ISSN 2160-8407, Vol. 6, no 1, 18-31 p.Article in journal (Refereed)
    Abstract [en]

    There is an unmet need for noninvasive, specific and quantitative imaging of inherent inflammatory activity. Vascular adhesion protein-1 (VAP-1) translocates to the luminal surface of endothelial cells upon inflammatory challenge. We hypothesized that in a porcine model of acute respiratory distress syndrome (ARDS), positron emission tomography (PET) with sialic acid-binding immunoglobulin-like lectin 9 (Siglec-9) based imaging agent targeting VAP-1 would allow quantification of regional pulmonary inflammation. ARDS was induced by lung lavages and injurious mechanical ventilation. Hemodynamics, respiratory system compliance (Crs) and blood gases were monitored. Dynamic examination using [(15)O]water PET-CT (10 min) was followed by dynamic (90 min) and whole-body examination using VAP-1 targeting (68)Ga-labeled 1,4,7,10-tetraaza cyclododecane-1,4,7-tris-acetic acid-10-ethylene glycol-conjugated Siglec-9 motif peptide ([(68)Ga]Ga-DOTA-Siglec-9). The animals received an anti-VAP-1 antibody for post-mortem immunohistochemistry assay of VAP-1 receptors. Tissue samples were collected post-mortem for the radioactivity uptake, histology and immunohistochemistry assessment. Marked reduction of oxygenation and Crs, and higher degree of inflammation were observed in ARDS animals. [(68)Ga]Ga-DOTA-Siglec-9 PET showed significant uptake in lungs, kidneys and urinary bladder. Normalization of the net uptake rate (Ki) for the tissue perfusion resulted in 4-fold higher uptake rate of [(68)Ga]Ga-DOTA-Siglec-9 in the ARDS lungs. Immunohistochemistry showed positive VAP-1 signal in the injured lungs. Detection of pulmonary inflammation associated with a porcine model of ARDS was possible with [(68)Ga]Ga-DOTA-Siglec-9 PET when using kinetic modeling and normalization for tissue perfusion.

  • 17.
    Retamal Montes, Jamie
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Borges, João Batista
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Bruhn, A.
    Pontificia Univ Catolica Chile, Santiago, Chile..
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Larsson, A.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Open Lung Approach Impedes Pulmonary Edema Accumulation Secondary To High Respiratory Rate In An Experimental Model Of Acute Lung Injury2015In: American Journal of Respiratory and Critical Care Medicine, ISSN 1073-449X, E-ISSN 1535-4970, Vol. 191Article in journal (Other academic)
  • 18. Sander, C. Hallsjo
    et al.
    Hallbaeck, M.
    Sipmann, Fernando Suarez
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Wallin, M.
    Oldner, A.
    Bjorne, H.
    A novel continuous capnodynamic method for cardiac output assessment in a porcine model of lung lavage2015In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 59, no 8, 1022-1031 p.Article in journal (Refereed)
    Abstract [en]

    BackgroundWe have evaluated a new method for continuous monitoring of effective pulmonary blood flow (COEPBF), i.e. cardiac output (CO) minus intra-pulmonary shunt, during mechanical ventilation. The method has shown good trending ability during severe hemodynamic challenges in a porcine model with intact lungs. In this study, we further evaluate the COEPBF method in a model of lung lavage. MethodsCO(EPBF) was compared to a reference method for CO during hemodynamic and PEEP alterations, 5 and 12cmH(2)O, before and after repeated lung lavages in 10 anaesthetised pigs. Bland-Altman, four-quadrant and polar plot methodologies were used to determine agreement and trending ability. ResultsAfter lung lavage at PEEP 5cmH(2)O, the ratio of arterial oxygen partial pressure related to inspired fraction of oxygen significantly decreased. The mean difference (limits of agreement) between methods changed from 0.2 (-1.1 to 1.5) to -0.9 (-3.6 to 1.9)l/min and percentage error increased from 34% to 70%. Trending ability remained good according to the four-quadrant plot (concordance rate 94%), whereas mean angular bias increased from 4 degrees to -16 degrees when using the polar plot methodology. ConclusionBoth agreement and precision of COEPBF were impaired in relation to CO when the shunt fraction was increased after lavage at PEEP 5cmH(2)O. However, trending ability remained good as assessed by the four-quadrant plot, whereas the mean polar angle, calculated by the polar plot, was wide.

  • 19.
    Sander, Caroline Hällsjö
    et al.
    Karolinska Univ Hosp, Dept Anesthesiol Surg Serv & Intens Care Med, S-17176 Stockholm, Sweden.;Karolinska Inst, Dept Physiol & Pharmacol, Stockholm, Sweden..
    Lönnqvist, Per-Arne
    Karolinska Univ Hosp, Astrid Lindgrens Childrens Hosp, Paediat Anesthesia & Intens Care, Stockholm, Sweden..
    Hallbäck, Magnus
    Maquet Crit Care AB, Solna, Sweden..
    Suarez Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Inst Carlos III, CIBERES, CIBER Enfermedades Resp, Madrid, Spain..
    Wallin, Mats
    Karolinska Inst, Dept Physiol & Pharmacol, Stockholm, Sweden.;Maquet Crit Care AB, Solna, Sweden..
    Oldner, Anders
    Karolinska Univ Hosp, Dept Anesthesiol Surg Serv & Intens Care Med, S-17176 Stockholm, Sweden.;Karolinska Inst, Dept Physiol & Pharmacol, Stockholm, Sweden..
    Björne, Håkan
    Karolinska Univ Hosp, Dept Anesthesiol Surg Serv & Intens Care Med, S-17176 Stockholm, Sweden.;Karolinska Inst, Dept Physiol & Pharmacol, Stockholm, Sweden..
    Capnodynamic assessment of effective lung volume during cardiac output manipulations in a porcine model2016In: Journal of clinical monitoring and computing, ISSN 1387-1307, E-ISSN 1573-2614, Vol. 30, no 6, 761-769 p.Article in journal (Refereed)
    Abstract [en]

    A capnodynamic calculation of effective pulmonary blood flow includes a lung volume factor (ELV) that has to be estimated to solve the mathematical equation. In previous studies ELV correlated to reference methods for functional residual capacity (FRC). The aim was to evaluate the stability of ELV during significant manipulations of cardiac output (CO) and assess the agreement for absolute values and trending capacity during PEEP changes at different lung conditions. Ten pigs were included. Alterations of alveolar carbon dioxide were induced by cyclic reoccurring inspiratory holds. The Sulphur hexafluoride technique for FRC measurements was used as reference. Cardiac output was altered by preload reduction and inotropic stimulation at PEEP 5 and 12 cmH(2)O both in normal lung conditions and after repeated lung lavages. ELV at baseline PEEP 5 was [mean (SD)], 810 (163) mL and decreased to 400 (42) mL after lavage. ELV was not significantly affected by CO alterations within the same PEEP level. In relation to FRC the overall bias (limits of agreement) was -35 (-271 to 201) mL, and percentage error 36 %. A small difference between ELV and FRC was seen at PEEP 5 cmH(2)O before lavage and at PEEP 12 cmH(2)O after lavage. ELV trending capability between PEEP steps, showed a concordance rate of 100 %. ELV was closely related to FRC and remained stable during significant changes in CO. The trending capability was excellent both before and after surfactant depletion.

  • 20.
    Santos, Arnoldo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Gomez-Peñalver, Eva
    Monge-Garcia, M Ignacio
    Retamal, Jaime
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Borges, João Batista
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Tusman, Gerardo
    Hedenstierna, Goran
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Effects on Pulmonary Vascular Mechanics of Two Different Lung-Protective Ventilation Strategies in an Experimental Model of Acute Respiratory Distress Syndrome.2017In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 45, no 11, e1157-e1164 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To compare the effects of two lung-protective ventilation strategies on pulmonary vascular mechanics in early acute respiratory distress syndrome.

    DESIGN: Experimental study.

    SETTING: University animal research laboratory.

    SUBJECTS: Twelve pigs (30.8 ± 2.5 kg).

    INTERVENTIONS: Acute respiratory distress syndrome was induced by repeated lung lavages and injurious mechanical ventilation. Thereafter, animals were randomized to 4 hours ventilation according to the Acute Respiratory Distress Syndrome Network protocol or to an open lung approach strategy. Pressure and flow sensors placed at the pulmonary artery trunk allowed continuous assessment of pulmonary artery resistance, effective elastance, compliance, and reflected pressure waves. Respiratory mechanics and gas exchange data were collected.

    MEASUREMENTS AND MAIN RESULTS: Acute respiratory distress syndrome led to pulmonary vascular mechanics deterioration. Four hours after randomization, pulmonary vascular mechanics was similar in Acute Respiratory Distress Syndrome Network and open lung approach: resistance (578 ± 252 vs 626 ± 153 dyn.s/cm; p = 0.714), effective elastance, (0.63 ± 0.22 vs 0.58 ± 0.17 mm Hg/mL; p = 0.710), compliance (1.19 ± 0.8 vs 1.50 ± 0.27 mL/mm Hg; p = 0.437), and reflection index (0.36 ± 0.04 vs 0.34 ± 0.09; p = 0.680). Open lung approach as compared to Acute Respiratory Distress Syndrome Network was associated with improved dynamic respiratory compliance (17.3 ± 2.6 vs 10.5 ± 1.3 mL/cm H2O; p < 0.001), driving pressure (9.6 ± 1.3 vs 19.3 ± 2.7 cm H2O; p < 0.001), and venous admixture (0.05 ± 0.01 vs 0.22 ± 0.03, p < 0.001) and lower mean pulmonary artery pressure (26 ± 3 vs 34 ± 7 mm Hg; p = 0.045) despite of using a higher positive end-expiratory pressure (17.4 ± 0.7 vs 9.5 ± 2.4 cm H2O; p < 0.001). Cardiac index, however, was lower in open lung approach (1.42 ± 0.16 vs 2.27 ± 0.48 L/min; p = 0.005).

    CONCLUSIONS: In this experimental model, Acute Respiratory Distress Syndrome Network and open lung approach affected pulmonary vascular mechanics similarly. The use of higher positive end-expiratory pressures in the open lung approach strategy did not worsen pulmonary vascular mechanics, improved lung mechanics, and gas exchange but at the expense of a lower cardiac index.

  • 21.
    Santos, Arnoldo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Lucchetta, Luca
    Monge-Garcia, M Ignacio
    Batista Borges, João
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Tusman, Gerardo
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    The Open Lung Approach Improves Pulmonary Vascular Mechanics in an Experimental Model of Acute Respiratory Distress Syndrome2017In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 45, no 3, e298-e305 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To test whether positive end-expiratory pressure consistent with an open lung approach improves pulmonary vascular mechanics compared with higher or lower positive end-expiratory pressures in experimental acute respiratory distress syndrome.

    DESIGN: Experimental study.

    SETTING: Animal research laboratory.

    SUBJECTS: Ten pigs, 35 ± 5.2 kg.

    INTERVENTIONS: Acute respiratory distress syndrome was induced combining saline lung lavages with injurious mechanical ventilation. The positive end-expiratory pressure level resulting in highest compliance during a decremental positive end-expiratory pressure trial after lung recruitment was determined. Thereafter, three positive end-expiratory pressure levels were applied in a random order: hyperinflation, 6 cm H2O above; open lung approach, 2 cm H2O above; and collapse, 6 cm H2O below the highest compliance level. High fidelity pressure and flow sensors were placed at the main pulmonary artery for measuring pulmonary artery resistance (Z0), effective arterial elastance, compliance, and reflected pressure waves.

    MEASUREMENTS AND MAIN RESULTS: After inducing acute respiratory distress syndrome, Z0 and effective arterial elastance increased (from 218 ± 94 to 444 ± 115 dyn.s.cm and from 0.27 ± 0.14 to 0.62 ± 0.22 mm Hg/mL, respectively; p < 0.001), vascular compliance decreased (from 2.76 ± 0.86 to 1.48 ± 0.32 mL/mm Hg; p = 0.003), and reflected waves arrived earlier (0.23 ± 0.07 vs 0.14 ± 0.05, arbitrary unit; p = 0.002) compared with baseline. Comparing the three positive end-expiratory pressure levels, open lung approach resulted in the lowest: 1) Z0 (297 ± 83 vs 378 ± 79 dyn.s.cm, p = 0.033, and vs 450 ± 119 dyn.s.cm, p = 0.002); 2) effective arterial elastance (0.37 ± 0.08 vs 0.50 ± 0.15 mm Hg/mL, p = 0.04, and vs 0.61 ± 0.12 mm Hg/mL, p < 0.001), and 3) reflection coefficient (0.35 ± 0.17 vs 0.48 ± 0.10, p = 0.024, and vs 0.53 ± 0.19, p = 0.005), comparisons with hyperinflation and collapse, respectively.

    CONCLUSIONS: In this experimental setting, positive end-expiratory pressure consistent with the open lung approach resulted in the best pulmonary vascular mechanics compared with higher or lower positive end-expiratory pressure settings.

  • 22.
    Santos, Arnoldo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Monge-Garcia, I
    Gomez Peñalver, E
    Borges, João Batista
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Lucchetta, L
    Retamal, Jaime
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Tusman, G
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    ARDS Decreases Pulmonary Artery Compliance in a Porcine Model2016In: American Journal of Respiratory and Critical Care Medicine, ISSN 1073-449X, E-ISSN 1535-4970, Vol. 93, A7917Article in journal (Refereed)
    Abstract [en]

    Rationale: Importance of pulmonary hemodynamic disarrangements in ARDS has been remarked recently. In this study we describe the effect of ARDS on pulmonary artery compliance and the related effect on pulmonary hemodynamics. In this way we highlight the importance of pulsatile hemodynamic evaluation beyond the classic evaluation based only on resistance.

    Methods: 17 anesthetized and muscle relaxed pigs were monitored with a transonic flow probe and high fidelity micro-tip pressure sensor placed in the pulmonary artery through a small thoracotomy. An experimental model of ARDS was induced in these animals by means of lung saline lavages followed by two hours of injurious mechanical ventilation. Pulmonary artery compliance was measured as the stroke volume divided by the pulse pressure. Waveform analysis of pulmonary artery pressure and flow signal was applied to calculate the following variables: first harmonic impedance magnitude (inversely related with arterial compliance), characteristic impedance, wave reflections (which are affected by arterial compliance) magnitude and peak and foot arrival time (normalized to cardiac period). These variables are related to the pulmonary vessels efficiency to transmit pressure and flow produced by the right ventricle. In addition, pulmonary vascular resistance was evaluated as usual. Variables were evaluated before (Baseline) and after (ARDS) development of the model.

    Results: Comparing with Baseline, ARDS provoked a decrease in pulmonary artery compliance (3.03±0.99 vs 1.53±0.41 ml/mmHg, p<0.001), and in the wave reflections arrival time of foot (0.18±0.09 vs 0.11±0.05, p<0.001) and peak (0.50±0.12 vs 0.39±0.10, p< 0.001) and an increase in the impedance magnitude of the first harmonic (80±29 vs 145±38 dyn.s.cm-5, p<0.001) and in the pulmonary vascular resistance (230±79 vs 504±129 dyn.s.cm-5, p<0.001). Characteristic impedance and wave reflections magnitude showed no differences.

    Conclusions: In this porcine model, ARDS provoked a decrease in pulmonary artery compliance. This effect was followed by a deterioration of pulmonary vascular efficiency. Our findings can be relevant for the pathophysiology of right ventricle failure during ARDS. This abstract is funded by: European Society of Intensive Care Medicine (ESICM), Basic Science Award 2012, the Swedish Heart and Lung foundation and the Swedish Research Council (K2015-99X-22731-01-4)

  • 23.
    Santos, Arnoldo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Monge-Garcia, M.
    Hosp SAS, Jerez de la Frontera, Spain..
    Batista Borges, João
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Gomez-Penalver, E.
    Hosp Gen Villalba, Villalba, Spain..
    Retamal, J.
    Pontificia Univ Catolica Chile, Santiago, Chile..
    Lucchetta, L.
    Hosp San Matteo, Pavia, Italy..
    Hedenstierna, Göran
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical Physiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Pulmonary Vascular Efficiency Worsening And Cardiac Energy Wasting During Early Stages Of Experimental Acute Respiratory Distress Syndrome2017In: American Journal of Respiratory and Critical Care Medicine, ISSN 1073-449X, E-ISSN 1535-4970, Vol. 195, no D27, A7698Article in journal (Other academic)
  • 24.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    New modes of assisted mechanical ventilation2014In: Medicina Intensiva, ISSN 0210-5691, E-ISSN 1578-6749, Vol. 38, no 4, 249-260 p.Article in journal (Refereed)
    Abstract [en]

    Recent major advances in mechanical ventilation have resulted in new exciting modes of assisted ventilation. Compared to traditional ventilation modes such as assisted-controlled ventilation or pressure support ventilation, these new modes offer a number of physiological advantages derived from the improved patient control over the ventilator. By implementing advanced closed-loop control systems and using information on lung mechanics, respiratory muscle function and respiratory drive, these modes are specifically designed to improve patient-ventilator synchrony and reduce the work of breathing. Depending on their specific operational characteristics, these modes can assist spontaneous breathing efforts synchronically in time and magnitude, adapt to changing patient demands, implement automated weaning protocols, and introduce a more physiological variability in the breathing pattern. Clinicians have now the possibility to individualize and optimize ventilatory assistance during the complex transition from fully controlled to spontaneous assisted ventilation. The growing evidence of the physiological and clinical benefits of these new modes is favoring their progressive introduction into clinical practice. Future clinical trials should improve our understanding of these modes and help determine whether the claimed benefits result in better outcomes. (C) 2013 Elsevier Espana, S.L. and SEMICYUC. All rights reserved.

  • 25.
    Suarez-Sipmann, Fernando
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Bohm, Stephan H.
    Tusman, Gerardo
    Volumetric capnography: the time has come2014In: Current Opinion in Critical Care, ISSN 1070-5295, E-ISSN 1531-7072, Vol. 20, no 3, 333-339 p.Article, review/survey (Refereed)
    Abstract [en]

    Purpose of review This review article summarizes the recent advances in electrical impedance tomography (EIT) related to cardiopulmonary imaging and monitoring on the background of the 30-year development of this technology. Recent findings EIT is expected to become a bedside tool for monitoring and guiding ventilator therapy. In this context, several studies applied EIT to determine spatial ventilation distribution during different ventilation modes and settings. EIT was increasingly combined with other signals, such as airway pressure, enabling the assessment of regional respiratory system mechanics. EIT was for the first time used prospectively to define ventilator settings in an experimental and a clinical study. Increased neonatal and paediatric use of EIT was noted. Only few studies focused on cardiac function and lung perfusion. Advanced radiological imaging techniques were applied to assess EIT performance in detecting regional lung ventilation. New approaches to improve the quality of thoracic EIT images were proposed. EIT is not routinely used in a clinical setting, but the interest in EIT is evident. The major task for EIT research is to provide the clinicians with guidelines how to conduct, analyse and interpret EIT examinations and combine them with other medical techniques so as to meaningfully impact the clinical decision-making.

  • 26.
    Suarez-Sipmann, Fernando
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Borges, Joao Batista
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    How We Stretch the Lung Matters2013In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 41, no 4, 1153-1155 p.Article in journal (Other academic)
  • 27.
    Suarez-Sipmann, Fernando
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Santos, A.
    Peces-Barba, G.
    Bohm, S. H.
    Gracia, J. L.
    Calderón, P.
    Tusman, G.
    Pulmonary artery pulsatility is the main cause of cardiogenic oscillations2013In: Journal of clinical monitoring and computing, ISSN 1387-1307, E-ISSN 1573-2614, Vol. 27, no 1, 47-53 p.Article in journal (Refereed)
    Abstract [en]

    The genesis of cardiogenic oscillations, i.e. The small waves in airway pressure (COSpaw) and flow (COSflow) signals recorded at the airway opening is under debate. We hypothesized that these waves are originated from cyclic changes in pulmonary artery (PA) pressure and flow but not from the physical transmission of heartbeats onto the lungs. The aim of this study was to test this hypothesis. In 10 anesthetized pigs, COS were evaluated during expiratory breath-holds at baseline with intact chest and during open chest conditions at: (1) close contact between heart and lungs; (2) no heart-lungs contact by lifting the heart apex outside the thoracic cavity; (3) PA clamping at the main trunk during 10 s; and (4) during manual massage after cardiac arrest maintaining the heart apex outside the thorax, with and without PA clamping. Baseline COSpaw and COSflow amplitude were 0.70 ± 0.08 cmH2O and 0.51 ± 0.06 L/min, respectively. Both COS amplitude decreased during open chest conditions in step 1 and 2 (p &lt; 0.05). However, COSpaw and COSflow amplitude did not depend on whether the heart was in contact or isolated from the surrounding lung parenchyma. COSpaw and COSflow disappeared when pulmonary blood flow was stopped after clamping PA in all animals. Manual heart massages reproduced COS but they disappeared when PA was clamped during this maneuver. The transmission of PA pulsatilty across the lungs generates COSpaw and COSflow measured at the airway opening. This information has potential applications for respiratory monitoring.

  • 28. Tusman, Gerardo
    et al.
    Boehm, Stephan H.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Dead space during one-lung ventilation2015In: Current Opinion in Anaesthesiology, ISSN 0952-7907, E-ISSN 1473-6500, Vol. 28, no 1, 10-17 p.Article, review/survey (Refereed)
    Abstract [en]

    Purpose of review Describe the importance of monitoring dead space during thoracic surgery, specifically during one-lung ventilation. Recent findings The concept of dead space has gained renewed interest among anesthesiologists ever since breath-by-breath measurement by volumetric capnography became available. Monitoring dead space during thoracic surgery assesses the ventilatory deficiencies related to increases in instrumental, airway and/or alveolar dead space, when ventilating patients with positive pressure and double-lumen tubes. Another interesting use of such monitoring is to detect ventilator-induced lung injury due to tidal overdistension. This type of injury threatens the fragile lungs especially during one-lung ventilation and can clinically be recognized as an increase in airway and alveolar dead space above normal values. To date, lung protective ventilation is based on the use of low tidal volumes and airway pressures to decrease overdistension. It has been shown to reduce the incidence of postoperative pulmonary complications after thoracic surgeries. However, such a ventilatory strategy impairs ventilation and induces hypercapnia due to increases in dead space. Therefore, continuous assessment of dead space is helpful in guiding ventilation and avoiding overdistension while maintaining the elimination of CO2 during thoracic surgery sufficiently high. Summary Monitoring dead space helps anesthesiologists monitor the status of the lung and find appropriate ventilatory settings during thoracic surgeries.

  • 29. Tusman, Gerardo
    et al.
    Gogniat, Emiliano
    Bohm, Stephan H.
    Scandurra, Adriana
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Torroba, Agustin
    Casella, Federico
    Giannasi, Sergio
    San Roman, Eduardo
    Reference values for volumetric capnography-derived non-invasive parameters in healthy individuals2013In: Journal of clinical monitoring and computing, ISSN 1387-1307, E-ISSN 1573-2614, Vol. 27, no 3, 281-288 p.Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to determine typical values for non-invasive volumetric capnography (VCap) parameters for healthy volunteers and anesthetized individuals. VCap was obtained by a capnograph connected to the airway opening. We prospectively studied 33 healthy volunteers 32 +/- A 6 years of age weighing 70 +/- A 13 kg at a height of 171 +/- A 11 cm in the supine position. Data from these volunteers were compared with a cohort of similar healthy anesthetized patients ventilated with the following settings: tidal volume (VT) of 6-8 mL/kg, respiratory rate 10-15 bpm, PEEP of 5-6 cmH(2)O and FiO(2) of 0.5. Volunteers showed better clearance of CO2 compared to anesthetized patients as indicated by (median and interquartile range): (1) an increased elimination of CO2 per mL of VT of 0.028 (0.005) in volunteers versus 0.023 (0.003) in anesthetized patients, p < 0.05; (2) a lower normalized slope of phase III of 0.26 (0.17) in volunteers versus 0.39 (0.38) in anesthetized patients, p < 0.05; and (3) a lower Bohr dead space ratio of 0.23 (0.05) in volunteers versus 0.28 (0.05) in anesthetized patients, p < 0.05. This study presents reference values for non-invasive volumetric capnography-derived parameters in healthy individuals. Mechanical ventilation and anesthesia altered these values significantly.

  • 30. Tusman, Gerardo
    et al.
    Groisman, Ivan
    Fiolo, Felipe E.
    Scandurra, Adriana
    Martinez Arca, Jorge
    Krumrick, Gustavo
    Bohm, Stephan H.
    Suarez Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Noninvasive Monitoring of Lung Recruitment Maneuvers in Morbidly Obese Patients: The Role of Pulse Oximetry and Volumetric Capnography2014In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 118, no 1, 137-144 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: We conducted this study to determine whether pulse oximetry and volumetric capnography (VCap) can determine the opening and closing pressures of lungs of anesthetized morbidly obese patients. METHODS: Twenty morbidly obese patients undergoing laparoscopic bariatric surgery with capnoperitoneum were studied. A lung recruitment maneuver was performed in pressure control ventilation as follows: (1) During an ascending limb, the lungs' opening pressure was detected. After increasing positive end-expiratory pressure (PEEP) from 8 to 16 cm H2O, fraction of inspired oxygen (Fio(2)) was decreased until pulse oximetric arterial saturation (Spo(2)) was <92%. Thereafter, end-inspiratory pressure was increased in steps of 2 cm H2O, from 36 to a maximum of 50 cm H2O. The opening pressure was attained when Spo(2) exceeded 97%. (2) During a subsequent decreasing limb, the lungs' closing pressure was identified. PEEP was decreased from 22 to 10 cm H2O in steps of 2 cm H2O. The closing pressure was determined as the PEEP value at which respiratory compliance decreased from its maximum value. We continuously recorded lung mechanics, Spo(2), and VCap. RESULTS: The lungs' opening pressures were detected at 44 (4) cm H2O (median and interquartile range) and the closing pressure at 14 (2) cm H2O. Therefore, the level of PEEP that kept the lungs without collapse was found to be 16 (3) cm H2O. Using respiratory compliance as a reference, receiver operating characteristic analysis showed that Spo(2) (area under the curve [AUC] 0.80 [SE 0.07], sensitivity 0.65, and specificity 0.94), the elimination of CO2 per breath (AUC 0.91 [SE 0.05], sensitivity 0.85, and specificity 0.98), and Bohr's dead space (AUC 0.83 [SE 0.06], sensitivity 0.70, and specificity 0.95] were relatively accurate for detecting lung collapse during the decreasing limb of a recruitment maneuver. CONCLUSIONS: Lung recruitment in morbidly obese patients could be effectively monitored by combining noninvasive pulse oximetry and VCap. Spo(2), the elimination of CO2, and Bohr's dead space detected the individual's opening and closing pressures.

  • 31. Tusman, Gerardo
    et al.
    Sipmann, Fernando Suarez
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Bohm, Stephan H.
    Rationale of Dead Space Measurement by Volumetric Capnography2012In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 114, no 4, 866-874 p.Article in journal (Refereed)
    Abstract [en]

    Dead space is the portion of a tidal volume that does not participate in gas exchange because it does not get in contact with blood flowing through the pulmonary capillaries. It is commonly calculated using volumetric capnography, the plot of expired carbon dioxide (CO2) versus tidal volume, which is an easy bedside assessment of the inefficiency of a particular ventilatory setting. Today, Bohr's original dead space can be calculated in an entirely noninvasive and breath-by-breath manner as the mean alveolar partial pressure of CO2 (PAco(2)) which can now be determined directly from the capnogram. The value derived from Enghoff's modification of Bohr's formula (using Paco(2) instead of PAco(2)) is a global index of the inefficiency of gas exchange rather than a true "dead space" because it is influenced by all causes of ventilation/perfusion mismatching, from real dead space to shunt. Therefore, the results obtained by Bohr's and Enghoff's formulas have different physiological meanings and clinicians must be conscious of such differences when interpreting patient data. In this article, we describe the rationale of dead space measurements by volumetric capnography and discuss its main clinical implications and the misconceptions surrounding it.

  • 32. Tusman, Gerardo
    et al.
    Suarez Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Bohm, Stephan H.
    Bohr Dead Space Calculation In Response2012In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 115, no 6, 1472-1473 p.Article in journal (Refereed)
  • 33.
    Tusman, Gerardo
    et al.
    Hosp Privado Comunidad Mar Del Plata, Dept Anesthesia, Mar Del Plata, Buenos Aires, Argentina..
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Confusion Between Integration and Receiver Operator Curves?: Response2016In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 123, no 5, 1332-1333 p.Article in journal (Refereed)
  • 34. Tusman, Gerardo
    et al.
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Paez, Gabriel
    Alvarez, Jorge
    Bohm, Stephan H.
    States of low pulmonary blood flow can be detected non-invasively at the bedside measuring alveolar dead space2012In: Journal of clinical monitoring and computing, ISSN 1387-1307, E-ISSN 1573-2614, Vol. 26, no 3, 183-190 p.Article in journal (Refereed)
    Abstract [en]

    We tested whether the ratio of alveolar dead space to alveolar tidal volume (VDalv/VTalv) can detect states of low pulmonary blood flow (PBF) in a non-invasive way. Fifteen patients undergoing cardiovascular surgeries with cardiopulmonary bypass (CPB) were studied. CPB is a technique that excludes the lungs from the general circulation. The weaning of CPB is a model that manipulates PBF in vivo because each time blood flow through the CPB decreases, expected PBF (ePBF) increases. Patients were liberated from CPB in steps of 20 % every 2' starting from 100 % CPB (very low ePBF) to 0 % CPB (100 % ePBF). During constant ventilation, volumetric capnograms were recorded and Bohr's dead space ratio (VDBohr/VT), VDalv/VTalv and the ratio of airway dead space to tidal volume (VDaw/VT) were calculated. Before CPB, VDBohr/VT was 0.36 +/- A 0.05, VDaw/VT 0.21 +/- A 0.04 and VDalv/VTalv 0.18 +/- A 0.06 (mean +/- A SD). During weaning from CPB, VDaw/VT remained unchanged while VDBohr/VT and VDalv/VTalv decreased with increasing ePBF. At CPB of 80, 60, 40 and 20 % VDBohr/VT was 0.64 +/- A 0.06, 0.55 +/- A 0.06, 0.47 +/- A 0.05 and 0.40 +/- A 0.04, respectively; < 0.001 and VDalv/VTalv 0.53 +/- A 0.07, 0.40 +/- A 0.07, 0.29 +/- A 0.06 and 0.25 +/- A 0.04, respectively; < 0.001). After CPB, VDBohr/VT and VDalv/VTalv reached values similar to baseline (0.37 +/- A 0.04 and 0.19 +/- A 0.06, respectively). At constant ventilation the alveolar component of VDBohr/VT increased in proportion to the deficit in lung perfusion.

  • 35.
    Villar, Jesus
    et al.
    Inst Salud Carlos III, CIBER Enfermedades Resp, Monforte de Lemos 3-5,Pabellon 11, Madrid 28029, Spain.;Hosp Univ Dr Negrin, Multidisciplinary Organ Dysfunct Evaluat Res Netw, Res Unit, Barranco Ballena S-N,4th Floor South Wing, Las Palmas Gran Canaria 35019, Spain.;St Michaels Hosp, Li Ka Shing Knowledge Inst, Keenan Res Ctr Biomed Sci, 30 Bond St, Toronto, ON M5B 1W8, Canada..
    Belda, Javier
    Hosp Clin Univ Valencia, Dept Anesthesiol, Avda Blasco Ibanez 17, Valencia 46010, Spain..
    Blanco, Jesus
    Inst Salud Carlos III, CIBER Enfermedades Resp, Monforte de Lemos 3-5,Pabellon 11, Madrid 28029, Spain.;Hosp Univ Rio Hortega, Intens Care Unit, Calle Dulzaina 2, Valladolid 47012, Spain..
    Suarez-Sipmann, Fernando
    Inst Salud Carlos III, CIBER Enfermedades Resp, Monforte de Lemos 3-5,Pabellon 11, Madrid 28029, Spain.;Univ Uppsala Hosp, Hedenstierna Lab, Dept Surg Sci, Akad Sjukhuset, Ing 40,Tr 3, SE-75185 Uppsala, Sweden..
    Manuel Anon, Jose
    Hosp Virgen de La Luz, Intens Care Unit, Hermandad de Donantes Sangre S-N, Cuenca 16002, Spain..
    Perez-Mendez, Lina
    Inst Salud Carlos III, CIBER Enfermedades Resp, Monforte de Lemos 3-5,Pabellon 11, Madrid 28029, Spain.;Hosp Univ NS Candelaria, Res Unit, Div Clin Epidemiol & Biostat, Carretera Gen Rosario 145, Santa Cruz De Tenerife 38010, Spain..
    Ferrando, Carlos
    Hosp Clin Univ Valencia, Dept Anesthesiol, Avda Blasco Ibanez 17, Valencia 46010, Spain..
    Parrilla, Dacil
    Hosp Univ NS Candelaria, Intens Care Unit, Carretera Gen Rosario 145, Santa Cruz De Tenerife 38010, Spain..
    Montiel, Raquel
    Hosp Univ NS Candelaria, Intens Care Unit, Carretera Gen Rosario 145, Santa Cruz De Tenerife 38010, Spain..
    Corpas, Ruth
    Hosp Gen NS Prado, Intens Care Unit, Carretera Madrid,Km 114, Talavera De La Reina, Toledo, Spain..
    Gonzalez-Higueras, Elena
    Hosp Virgen de La Luz, Intens Care Unit, Hermandad de Donantes Sangre S-N, Cuenca 16002, Spain..
    Pestana, David
    Hosp Univ Ramon y Cajal, Dept Anesthesiol, Carretera Colmenar Viejo,Km 9,100, Madrid 28034, Spain..
    Martinez, Domingo
    Hosp Univ Virgen de la Arrixaca, Intens Care Unit, Carretera Madrid Cartagena S-N, Murcia 30120, Spain..
    Fernandez, Lorena
    Soro, Marina
    Hosp Clin Univ Valencia, Dept Anesthesiol, Avda Blasco Ibanez 17, Valencia 46010, Spain..
    Angel Garcia-Bello, Miguel
    Hosp Univ Dr Negrin, Div Biostat, Res Unit, Barranco Ballena S-N, Las Palmas Gran Canaria 35019, Spain..
    Lidia Fernandez, Rosa
    Inst Salud Carlos III, CIBER Enfermedades Resp, Monforte de Lemos 3-5,Pabellon 11, Madrid 28029, Spain.;Hosp Univ Dr Negrin, Multidisciplinary Organ Dysfunct Evaluat Res Netw, Res Unit, Barranco Ballena S-N,4th Floor South Wing, Las Palmas Gran Canaria 35019, Spain..
    Kacmarek, Robert M.
    Massachusetts Gen Hosp, Dept Resp Care, 55 Fruit St, Boston, MA 02114 USA.;Harvard Univ, Dept Anesthesiol, 55 Fruit St Gray Bigelow 444, Boston, MA 02144 USA..
    Neurally adjusted ventilatory assist in patients with acute respiratory failure: study protocol for a randomized controlled trial2016In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 17, 500Article in journal (Refereed)
    Abstract [en]

    Background: Patient-ventilator asynchrony is a common problem in mechanically ventilated patients with acute respiratory failure. It is assumed that asynchronies worsen lung function and prolong the duration of mechanical ventilation (MV). Neurally Adjusted Ventilatory Assist (NAVA) is a novel approach to MV based on neural respiratory center output that is able to trigger, cycle, and regulate the ventilatory cycle. We hypothesized that the use of NAVA compared to conventional lung-protective MV will result in a reduction of the duration of MV. It is further hypothesized that NAVA compared to conventional lung-protective MV will result in a decrease in the length of ICU and hospital stay, and mortality. Methods/design: This is a prospective, multicenter, randomized controlled trial in 306 mechanically ventilated patients with acute respiratory failure from several etiologies. Only patients ventilated for less than 5 days, and who are expected to require prolonged MV for an additional 72 h or more and are able to breathe spontaneously, will be considered for enrollment. Eligible patients will be randomly allocated to two ventilatory arms: (1) conventional lung-protective MV (n = 153) and conventional lung-protective MV with NAVA (n = 153). Primary outcome is the number of ventilator-free days, defined as days alive and free from MV at day 28 after endotracheal intubation. Secondary outcomes are total length of MV, and ICU and hospital mortality. Discussion: This is the first randomized clinical trial examining, on a multicenter scale, the beneficial effects of NAVA in reducing the dependency on MV of patients with acute respiratory failure.

  • 36.
    Villar, Jesus
    et al.
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ Dr Negrin, Res Unit, Multidisciplinary Organ Dysfunct Evaluat Res Netw, Las Palmas Gran Canaria, Spain..
    Blanco, Jesus
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ Rio Hortega, Intens Care Unit, Valladolid, Spain..
    del Campo, Rafael
    Hosp Gen Ciudad Real, Intens Care Unit, Ciudad Real, Spain..
    Andaluz-Ojeda, David
    Univ Valladolid, Hosp Clin, Intens Care Unit, Valladolid, Spain..
    Diaz-Dominguez, Francisco J.
    Hosp Univ Gen Leon, Intens Care Unit, Leon, Spain..
    Muriel, Arturo
    Hosp Univ Rio Hortega, Intens Care Unit, Valladolid, Spain..
    Corcoles, Virgilio
    Complejo Hosp Univ Albacete, Intens Care Unit, Albacete, Spain..
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain..
    Tarancon, Concepcion
    Hosp Virgen de la Concha, Intens Care Unit, Zamora, Spain..
    Gonzalez-Higueras, Elena
    Hosp Virgen de la Luz, Intens Care Unit, Cuenca, Spain..
    Lopez, Julia
    Hosp Univ La Paz, Intens Care Unit, Madrid, Spain..
    Blanch, Lluis
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Corp Sanitaria Parc Tauli, Crit Care Ctr, Sabadell, Spain..
    Perez-Mendez, Lina
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ NS Candelaria, Res Unit, Tenerife, Spain..
    Fernandez, Rosa Lidia
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ Dr Negrin, Res Unit, Multidisciplinary Organ Dysfunct Evaluat Res Netw, Las Palmas Gran Canaria, Spain..
    Kacmarek, Robert M.
    Massachusetts Gen Hosp, Dept Resp Care, Boston, MA 02114 USA.;Harvard Univ, Dept Anesthesiol, Boston, MA 02115 USA..
    Assessment of PaO2/FiO(2) for stratification of patients with moderate and severe acute respiratory distress syndrome2015In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 3, e006812Article in journal (Refereed)
    Abstract [en]

    Objectives: A recent update of the definition of acute respiratory distress syndrome (ARDS) proposed an empirical classification based on ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO(2)) at ARDS onset. Since the proposal did not mandate PaO2/FiO(2) calculation under standardised ventilator settings (SVS), we hypothesised that a stratification based on baseline PaO2/FiO(2) would not provide accurate assessment of lung injury severity. Design: A prospective, multicentre, observational study. Setting: A network of teaching hospitals. Participants: 478 patients with eligible criteria for moderate (100<PaO2/FiO(2)<= 200) and severe (PaO2/FiO(2)<= 100) ARDS and followed until hospital discharge. Interventions: We examined physiological and ventilator parameters in association with the PaO2/FiO(2) at ARDS onset, after 24 h of usual care and at 24 h under a SVS. At 24 h, patients were reclassified as severe, moderate, mild (200<PaO2/FiO(2)<= 300) ARDS and non-ARDS (PaO2/FiO(2)>300). Primary and secondary outcomes: Group severity and hospital mortality. Results: At ARDS onset, 173 patients had a PaO2/FiO(2)<= 100 but only 38.7% met criteria for severe ARDS at 24 h under SVS. When assessed under SVS, 61.3% of patients with severe ARDS were reclassified as moderate, mild and non-ARDS, while lung severity and hospital mortality changed markedly with every PaO2/FiO(2) category (p<0.000001). Our model of risk stratification outperformed the stratification using baseline PaO2/FiO(2) and non-standardised PaO2/FiO(2) at 24 h, when analysed by the predictive receiver operating characteristic (ROC) curve: area under the ROC curve for stratification at baseline was 0.583 (95% CI 0.525 to 0.636), 0.605 (95% CI 0.552 to 0.658) at 24 h without SVS and 0.693 (95% CI 0.645 to 0.742) at 24 h under SVS (p<0.000001). Conclusions: Our findings support the need for patient assessment under SVS at 24 h after ARDS onset to assess disease severity, and have implications for the diagnosis and management of ARDS patients.

  • 37.
    Villar, Jesus
    et al.
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ Dr Negrin, Res Unit, Las Palmas Gran Canaria, Spain..
    Martin-Rodriguez, Carmen
    Hosp Gen Ciudad Real, Intens Care Unit, Ciudad Real, Spain..
    Dominguez-Berrot, Ana M.
    Complejo Asistencial Univ Leon, Intens Care Unit, Leon, Spain..
    Fernandez, Lorena
    Hosp Univ Rio Hortega, Intens Care Unit, Valladolid, Spain..
    Ferrando, Carlos
    Hosp Clin Univ, Dept Anesthesiol, Valencia, Spain..
    Soler, Juan A.
    Hosp Univ Morales Meseguer, Intens Care Unit, Murcia, Spain..
    Diaz-Lamas, Ana M.
    Hosp Univ A Coruna, Intens Care Unit, Coruna, Spain..
    Gonzalez-Higueras, Elena
    Hosp Virgen de La Luz, Intens Care Unit, Cuenca, Spain..
    Nogales, Leonor
    Hosp Clin Univ, Intens Care Unit, Valladolid, Spain..
    Ambros, Alfonso
    Hosp Gen Ciudad Real, Intens Care Unit, Ciudad Real, Spain..
    Carriedo, Demetrio
    Complejo Asistencial Univ Leon, Intens Care Unit, Leon, Spain..
    Hernandez, Monica
    Hosp Univ La Paz, Intens Care Unit, Madrid, Spain..
    Martinez, Domingo
    Hosp Univ Virgen de Arrixaca, Intens Care Unit, Murcia, Spain..
    Blanco, Jesus
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ Rio Hortega, Intens Care Unit, Valladolid, Spain..
    Belda, Javier
    Hosp Clin Univ, Dept Anesthesiol, Valencia, Spain..
    Parrilla, Dacil
    Hosp Univ NS Candelaria, Intens Care Unit, Santa Cruz De Tenerife, Spain..
    Suárez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory. Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain..
    Tarancon, Concepcion
    Hosp Virgen de la Concha, Intens Care Unit, Zamora, Spain..
    Mora-Ordonez, Juan M.
    Hosp Univ Carlos Haya, Intens Care Unit, Malaga, Spain..
    Blanch, Lluis
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Corp Sanitaria Parc Tauli, Crit Care Ctr, Sabadell, Spain..
    Perez-Mendez, Lina
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ NS Candelaria, Res Unit, Santa Cruz De Tenerife, Spain..
    Fernandez, Rosa L.
    Inst Salud Carlos III, CIBER Enfermedades Resp, Madrid, Spain.;Hosp Univ Dr Negrin, Res Unit, Las Palmas Gran Canaria, Spain..
    Kacmarek, Robert M.
    Massachusetts Gen Hosp, Dept Resp Care, Boston, MA 02114 USA.;Harvard Univ, Dept Anesthesia, Boston, MA 02115 USA..
    A Quantile Analysis of Plateau and Driving Pressures: Effects on Mortality in Patients With Acute Respiratory Distress Syndrome Receiving Lung-Protective Ventilation2017In: Critical Care Medicine, ISSN 0090-3493, E-ISSN 1530-0293, Vol. 45, no 5, 843-850 p.Article in journal (Refereed)
    Abstract [en]

    Objectives: The driving pressure (plateau pressure minus positive end-expiratory pressure) has been suggested as the major determinant for the beneficial effects of lung-protective ventilation. We tested whether driving pressure was superior to the variables that define it in predicting outcome in patients with acute respiratory distress syndrome.

    Design: A secondary analysis of existing data from previously reported observational studies.

    Setting: A network of ICUs.

    Patients: We studied 778 patients with moderate to severe acute respiratory distress syndrome.

    Interventions: None.

    Measurements and Main Results: We assessed the risk of hospital death based on quantiles of tidal volume, positive end-expiratory pressure, plateau pressure, and driving pressure evaluated at 24 hours after acute respiratory distress syndrome diagnosis while ventilated with standardized lung-protective ventilation. We derived our model using individual data from 478 acute respiratory distress syndrome patients and assessed its replicability in a separate cohort of 300 acute respiratory distress syndrome patients. Tidal volume and positive end-expiratory pressure had no impact on mortality. We identified a plateau pressure cut-off value of 29 cm H2O, above which an ordinal increment was accompanied by an increment of risk of death. We identified a driving pressure cut-off value of 19 cm H2O where an ordinal increment was accompanied by an increment of risk of death. When we cross tabulated patients with plateau pressure less than 30 and plateau pressure greater than or equal to 30 with those with driving pressure less than 19 and driving pressure greater than or equal to 19, plateau pressure provided a slightly better prediction of outcome than driving pressure in both the derivation and validation cohorts (p < 0.0000001).

    Conclusions: Plateau pressure was slightly better than driving pressure in predicting hospital death in patients managed with lung-protective ventilation evaluated on standardized ventilator settings 24 hours after acute respiratory distress syndrome onset.

  • 38.
    Waldmann, Andreas D.
    et al.
    Swisstom AG, Landquart, Switzerland..
    Ferrando Ortola, Carlos
    Hosp Clin Univ, Dept Anesthesia & Crit Care, Valencia, Spain..
    Munoz Martinez, Manuel
    Hosp Univ Princesa, Dept Anesthesiol, Madrid, Spain..
    Vidal, Anxela
    Inst Invest Sanitaria Fdn Jimenez Diaz, Dept Crit Care, Madrid, Spain..
    Santos, Arnoldo
    Inst Invest Sanitaria Fdn Jimenez Diaz, Dept Crit Care, Madrid, Spain..
    Perez Marquez, Manuel
    Inst Invest Sanitaria Fdn Jimenez Diaz, Dept Crit Care, Madrid, Spain..
    Roka, Peter L.
    Swisstom AG, Landquart, Switzerland..
    Bohm, Stephan H.
    Swisstom AG, Landquart, Switzerland..
    Suarez-Sipmann, Fernando
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Hedenstierna laboratory.
    Position-dependent distribution of lung ventilation - A feasability study2015In: 2015 IEEE Sensors Applications Symposium (SAS), 2015, 429-434 p.Conference paper (Refereed)
    Abstract [en]

    The aim of this feasibility study was to determine whether the measurement setup and study protocol were able to show the effect that lung disease, body position and different levels of positive end expiratory pressure (PEEP) have on lung function. By means of a motorized rotation table and gravity sensors six pigs were rotated in steps of 30 degrees from left to right lateral position. Regional ventilation distributions, measured by electrical impedance tomography (EIT), oxygenation and compliance measurements were performed at each position. Both, experimental and measurement setup as well as the parameters chosen to characterize lung function appear suitable for analyzing the effects of PEEP and rotation in healthy and injured lungs. The initial results show that the distribution of regional ventilation was highly gravity-dependent especially in sick lungs. Furthermore lateral rotation showed significant recruitment effects on previously collapsed lung tissue as witnessed by the increases in oxygenation at all PEEPs.

1 - 38 of 38
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