292 research outputs found
Lung-Protective Ventilation With Low Tidal Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data Analysis.
No full textOBJECTIVE:
Protective mechanical ventilation with low tidal volumes is standard of care for patients with acute respiratory distress syndrome. The aim of this individual patient data analysis was to determine the association between tidal volume and the occurrence of pulmonary complications in ICU patients without acute respiratory distress syndrome and the association between occurrence of pulmonary complications and outcome in these patients.
DESIGN:
Individual patient data analysis.
PATIENTS:
ICU patients not fulfilling the consensus criteria for acute respiratory distress syndrome at the onset of ventilation.
INTERVENTIONS:
Mechanical ventilation with low tidal volume.
MEASUREMENTS AND MAIN RESULTS:
The primary endpoint was development of a composite of acute respiratory distress syndrome and pneumonia during hospital stay. Based on the tertiles of tidal volume size in the first 2 days of ventilation, patients were assigned to a "low tidal volume group" (tidal volumes≤ 7 mL/kg predicted body weight), an "intermediate tidal volume group" (> 7 and < 10 mL/kg predicted body weight), and a "high tidal volume group" (≥ 10 mL/kg predicted body weight). Seven investigations (2,184 patients) were included. Acute respiratory distress syndrome or pneumonia occurred in 23% of patients in the low tidal volume group, in 28% of patients in the intermediate tidal volume group, and in 31% of the patients in the high tidal volume group (adjusted odds ratio [low vs high tidal volume group], 0.72; 95% CI, 0.52-0.98; p = 0.042). Occurrence of pulmonary complications was associated with a lower number of ICU-free and hospital-free days and alive at day 28 (10.0 ± 10.9 vs 13.8 ± 11.6 d; p < 0.01 and 6.1 ± 8.1 vs 8.9 ± 9.4 d; p < 0.01) and an increased hospital mortality (49.5% vs 35.6%; p < 0.01).
CONCLUSIONS:
Ventilation with low tidal volumes is associated with a lower risk of development of pulmonary complications in patients without acute respiratory distress syndrome
The PROtective VEntilation (PROVE) Network-advancing research and collaboration in mechanical ventilation
No full text: The PROtective VEntilation (PROVE) Network is a globally-recognized collaborative research group dedicated to advancing research, education, and collaboration in the field of mechanical ventilation. Established to address critical questions in intraoperative and intensive care ventilation, the network focuses on improving outcomes for patients undergoing mechanical ventilation in diverse settings, including operating rooms, intensive care units, burn units, and resource-limited environments in low- and middle-income countries. The PROVE Network is committed to generating high-quality evidence through a comprehensive portfolio of investigations, including randomized clinical trials, observational research, and meta-analyses. Its work has significantly contributed to understanding optimal ventilation strategies in critically ill patients, such as those with COVID-19, and in exploring innovative approaches like closed-loop ventilation systems. The network has spearheaded pioneering studies that have shaped clinical practice worldwide by integrating expertise from a wide range of disciplines. A defining feature of the PROVE Network is its emphasis on mentorship and collaboration. It fosters a supportive environment where junior researchers are guided by experienced mentors, ensuring the transfer of knowledge and promoting inclusivity. The network prioritizes gender balance and diversity, recognizing the value of varied perspectives in driving meaningful innovation and advancing research excellence. This paper reviews the history, key projects, and leadership of the PROVE Network, highlighting its impactful contributions to the field of mechanical ventilation. By uniting researchers globally, the PROVE Network exemplifies the power of collaboration in addressing complex clinical challenges, including personalized ventilation and the use of Artificial Intelligence, and improving patient care
Lung and Diaphragm-Protective Ventilation
No full textMechanical ventilation can cause acute diaphragm atrophy and injury and this is associated with poor clinical outcomes. While the importance and impact of lung-protective ventilation is widely appreciated and well-established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by the Pleural Pressure Working Group of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung and diaphragm-protective approach to mechanical ventilation based on growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that where conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision support systems may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging owing to the complexity of the intervention. The concept of lung and diaphragm-protective ventilation presents a compelling new opportunity to substantially improve clinical outcomes for critically ill patients
Variable Tidal Volumes Improve Lung Protective Ventilation Strategies in Experimental Lung Injury.
No full textRATIONALE:
Noisy ventilation with variable Vt may improve respiratory function in acute lung injury.
OBJECTIVES:
To determine the impact of noisy ventilation on respiratory function and its biological effects on lung parenchyma compared with conventional protective mechanical ventilation strategies.
METHODS:
In a porcine surfactant depletion model of lung injury, we randomly combined noisy ventilation with the ARDS Network protocol or the open lung approach (n = 9 per group).
MEASUREMENTS AND MAIN RESULTS:
Respiratory mechanics, gas exchange, and distribution of pulmonary blood flow were measured at intervals over a 6-hour period. Postmortem, lung tissue was analyzed to determine histological damage, mechanical stress, and inflammation. We found that, at comparable minute ventilation, noisy ventilation (1) improved arterial oxygenation and reduced mean inspiratory peak airway pressure and elastance of the respiratory system compared with the ARDS Network protocol and the open lung approach, (2) redistributed pulmonary blood flow to caudal zones compared with the ARDS Network protocol and to peripheral ones compared with the open lung approach, (3) reduced histological damage in comparison to both protective ventilation strategies, and (4) did not increase lung inflammation or mechanical stress.
CONCLUSIONS:
Noisy ventilation with variable Vt and fixed respiratory frequency improves respiratory function and reduces histological damage compared with standard protective ventilation strategies.
PMID: 19151194 [PubMed - indexed for MEDLINE] Free full tex
From a small local audit to a regional quality improvement project – Improving lung protective ventilation
No full textBackground Lung protective ventilation with tidal volumes (VT) of 6–8 ml per kg ideal body weight have been shown to reduce mortality in patients with acute respiratory distress syndrome and reduce post-operative pulmonary complications in major abdominal surgery. Following a local audit on weight recording, the Southcoast Perioperative Audit and Research Collaboration (SPARC) conducted a regional multi-disciplinary survey on the current practice in lung protective ventilation in the Wessex region. This resulted in a quality improvement project improving lung protective ventilation across these intensive care units. Methods Over one-week period in January over two consecutive years, lung protective ventilation parameters of mandatory ventilated patients (above the age of 18 years) were audited in intensive care units in the Wessex region. Results A total 1843 hours of mandatory ventilation were audited. The quality improvement project led to an improvement of lung protective ventilation with an average of 30% higher duration of ventilation with VT < 8 ml/kg ideal body weight. There was a suggestion that documentation of height and weight on admission to intensive care units improved compliance with lung protective ventilation. Conclusions Adherence to lung protective ventilation is variable across intensive care units but can be improved by recording patient’s weight and height accurately and using simple chart to help calculate the appropriate tidal volume. Additionally, this project demonstrates how a regional audit and quality improvement network can help to facilitate regional quality improvement. </jats:sec
Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison
No full textObjective: To synthesise the available evidence and estimate the comparative efficacy of control strategies to prevent total hip replacement (THR)-related surgical site infections (SSIs) using a mixed treatment comparison.\ud
Design: Systematic review and mixed treatment comparison.\ud
Setting: Hospital and other healthcare settings.\ud
Participants: Patients undergoing THR.\ud
Primary and secondary outcome measures: The number of THR-related SSIs occurring following the surgical operation.\ud
Results: 12 studies involving 123 788 THRs and 9 infection control strategies were identified. The strategy of ‘systemic antibiotics+antibiotic-impregnated cement +conventional ventilation’ significantly reduced the risk of THR-related SSI compared with the referent strategy (no systemic antibiotics+plain cement+conventional ventilation), OR 0.13 (95% credible interval (CrI) 0.03–0.35), and had the highest probability (47–64%) and\ud
highest median rank of being the most effective strategy. There was some evidence to suggest that ‘systemic antibiotics+antibiotic-impregnated cement +laminar airflow’ could potentially increase infection risk compared with ‘systemic antibiotics+antibiotic impregnated cement+conventional ventilation’, 1.96 (95% CrI 0.52–5.37). There was no high-quality evidence that antibiotic-impregnated cement without\ud
systemic antibiotic prophylaxis was effective in reducing infection compared with plain cement with systemic antibiotics, 1.28 (95% CrI 0.38–3.38). Conclusions: We found no convincing evidence in favour of the use of laminar airflow over conventional ventilation for prevention of THR-related SSIs, yet laminar airflow is costly and widely used. Antibiotic-impregnated cement without systemic antibiotics may not be effective\ud
in reducing THR-related SSIs. The combination with the highest confidence for reducing SSIs was ‘systemic antibiotics+antibiotic-impregnated cement+conventional ventilation’. Our evidence synthesis underscores the need to review current guidelines based on the available\ud
evidence, and to conduct further high-quality doubleblind randomised controlled trials to better inform the current clinical guidelines and practice for prevention of THR-related SSIs
A complete audit cycle to assess adherence to a lung protective ventilation strategy
No full textThere is clear evidence for the use of a protective ventilation protocol in patients with acute respiratory distress syndrome (ARDS). There is evidence to suggest that protective ventilation is beneficial in patients at risk of ARDS. A protective ventilation strategy was implemented on our intensive care unit in critical care patients who required mechanical ventilation for over 48 h, with and at risk for ARDS. A complete audit cycle was performed over 13 months to assess compliance with a safe ventilation protocol in intensive care. The ARDS network mechanical ventilation protocol was used as the standard for our protective ventilation strategy. This recommends ventilation with a tidal volume (V t) of 6 ml/kg of ideal body weight (IBW) and plateau airway pressure of ≤30 cm H2O. The initial audit failed to meet this standard with V t's of 9.5 ml/kg of IBW. Following the implementation of a ventilation strategy and an educational program, we demonstrate a significant improvement in practice with V t's of 6.6 ml/kg of IBW in the re-audit. This highlights the importance of simple interventions and continuous education in maintaining high standards of care.</p
Individualized Perioperative Open Lung Approach versus Standard Protective Ventilation in Abdominal Surgery. A Multicenter Randomized Trial (iPROVE).
No full textBackground: The effects of individualised perioperative lung-protective ventilation (based on the open-lung approach [OLA]) on postoperative complications is unknown. We aimed to investigate the effects of intraoperative and postoperative ventilatory management in patients scheduled for abdominal surgery, compared with standard protective ventilation.
Methods: We did this prospective, multicentre, randomised controlled trial in 21 teaching hospitals in Spain. We enrolled patients who were aged 18 years or older, were scheduled to have abdominal surgery with an expected time of longer than 2 h, had intermediate-to-high-risk of developing postoperative pulmonary complications, and who had a body-mass index less than 35 kg/m2. Patients were randomly assigned (1:1:1:1) online to receive one of four lung-protective ventilation strategies using low tidal volume plus positive end-expiratory pressure (PEEP): open-lung approach (OLA)-iCPAP (individualised intraoperative ventilation [individualised PEEP after a lung recruitment manoeuvre] plus individualised postoperative continuous positive airway pressure [CPAP]), OLA-CPAP (intraoperative individualised ventilation plus postoperative CPAP), STD-CPAP (standard intraoperative ventilation plus postoperative CPAP), or STD-O2 (standard intraoperative ventilation plus standard postoperative oxygen therapy). Patients were masked to treatment allocation. Investigators were not masked in the operating and postoperative rooms; after 24 h, data were given to a second investigator who was masked to allocations. The primary outcome was a composite of pulmonary and systemic complications during the first 7 postoperative days. We did the primary analysis using the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02158923.
Findings: Between Jan 2, 2015, and May 18, 2016, we enrolled 1012 eligible patients. Data were available for 967 patients, whom we included in the final analysis. Risk of pulmonary and systemic complications did not differ for patients in OLA-iCPAP (110 [46%] of 241, relative risk 0·89 [95% CI 0·74-1·07; p=0·25]), OLA-CPAP (111 [47%] of 238, 0·91 [0·76-1·09; p=0·35]), or STD-CPAP groups (118 [48%] of 244, 0·95 [0·80-1·14; p=0·65]) when compared with patients in the STD-O2 group (125 [51%] of 244). Intraoperatively, PEEP was increased in 69 (14%) of patients in the standard perioperative ventilation groups because of hypoxaemia, and no patients from either of the OLA groups required rescue manoeuvres.
Interpretation: In patients who have major abdominal surgery, the different perioperative open lung approaches tested in this study did not reduce the risk of postoperative complications when compared with standard lung-protective mechanical ventilation.INSTITUTO SALUD CARLOS IIIGrants Programme of the European Society of AnaesthesiologyDepto. de Farmacología y ToxicologíaFac. de MedicinaTRUEpu
Adherence to protective mechanical ventilation parameters in patients over 18 years of age, with invasive mechanical ventilation at the Central Military Hospital
No full textLa ventilacion mecanica hace referencia al uso de dispositivos para asistir parcial o totalmente la respiracion del paciente, herramienta utilizada en los pacientes cuya dinamica ventilatoria no es adecuada.Llimitar el daño producido por las difernetes variables que componen el soporte, proporcionando una estrategia de ventilacion fisiologicamente segura, se conoce como estratgia de ventilacion protectora. El objetivo de esta estudio es determinar la adherencia al protocolo de ventilacion mecanica protectora en los pacientes mayores de 18 años que requieren ventilacion mecanica en el Hospital Militar Central.Mechanical ventilation refers to the use of devices to partially or fully assist the patient's breathing, a tool used in patients whose ventilatory dynamics are not adequate. Limit the damage caused by the different deferred components that make up the support, providing a physiologically ventilated strategy Sure, it is known as protective ventilation strategy. The objective of this study is to determine the adherence to the protective mechanical ventilation protocol in patients older than 18 years who require mechanical ventilation in the Central Military HospitalTABLA DE CONTENIDO
1. Resumen………………………………………………………………………………………4
1.1 Introducción………………………………………………………………………………….4
1.2 Metodos……………………………………………………………………………………...4
1.3 Resultados…………………………………………………………………………………..4
2. Identificación y formulación del problema…………………………………………………7
3. Objetivos e hipotesis……………………………………………………………………….10
3.1 Objetvo general……………………………………………………………………………10
3.2 Objetivos especificos……………………………………………………………………..10
3.3 Hipotesis……………………………………………………………………………………10
4. Metodología propuesta……...……………………………………………………………..11
4.1 Clasificación del estudio………………………………………………………………….11
4.2 Lugar………………………………………………………………………………………..11
4.3 Caracteristicas de la población…………………………………………………………..11
4.4 Variables……………………………………………………………………………………11
4.5 Aspectos del proceso de medición y seguimineto…………………………………….15
4.6 Muestra…………………………………………………………………………………….15
4.7 Mediciones e instrumentos.……………………………………………………………...16
5. Plan de análisis……………………………………………………………………………..17
6. Aspectos éticos……………………………………………………………………………..19
7. Resultados…………………………………………………………………………………..20
8. Discusión…………………………………………………………………………………….29
9. Conclusiones………………………………………………………………………………..33
10. Bibliografía…………………………………………………………………………………34Especializació
Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): study protocol for a randomized controlled trial
No full textBackground: Postoperative pulmonary complications (PPC) may result in longer duration of in-hospital stay and even mortality. Both thoracic surgery and intraoperative mechanical ventilation settings add considerably to the risk of PPC. It is unclear if one-lung ventilation (OLV) for thoracic surgery with a strategy of intraoperative high positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM) reduces PPC, compared to low PEEP without RM. Methods: PROTHOR is an international, multicenter, randomized, controlled, assessor-blinded, two-arm trial initiated by investigators of the PROtective VEntilation NETwork. In total, 2378 patients will be randomly assigned to one of two different intraoperative mechanical ventilation strategies. Investigators screen patients aged 18 years or older, scheduled for open thoracic or video-assisted thoracoscopic surgery under general anesthesia requiring OLV, with a maximal body mass index of 35 kg/m2, and a planned duration of surgery of more than 60 min. Further, the expected duration of OLV shall be longer than two-lung ventilation, and lung separation is planned with a double lumen tube. Patients will be randomly assigned to PEEP of 10 cmH2O with lung RM, or PEEP of 5 cmH2O without RM. During two-lung ventilation tidal volume is set at 7 mL/kg predicted body weight and, during OLV, it will be decreased to 5 mL/kg. The occurrence of PPC will be recorded as a collapsed composite of single adverse pulmonary events and represents the primary endpoint. Discussion: PROTHOR is the first randomized controlled trial in patients undergoing thoracic surgery with OLV that is adequately powered to compare the effects of intraoperative high PEEP with RM versus low PEEP without RM on PPC. The results of the PROTHOR trial will support anesthesiologists in their decision to set intraoperative PEEP during protective ventilation for OLV in thoracic surgery. Trial registration: The trial was registered in clinicaltrials.gov (NCT02963025) on 15 November 2016
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