Flow-controlled ventilation in moderate acute respiratory distress syndrome due to COVID-19: an open-label repeated-measures controlled trial
Tóm tắt
Flow-controlled ventilation (FCV), a novel mode of mechanical ventilation characterised by constant flow during active expiration, may result in more efficient alveolar gas exchange, better lung recruitment and might be useful in limiting ventilator-induced lung injury. However, data regarding FCV in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome (ARDS) are scarce. We hypothesised that the use of FCV is feasible and would improve oxygenation in moderate COVID-19 ARDS compared to conventional ventilation. Open-label repeated-measures controlled trial. From February to April 2021, patients with moderate COVID-19 ARDS were recruited in a tertiary referral intensive care unit. Patients with moderate ARDS (PaO2/FIO2 ratio 100–200 mmHg, SpO2 88–94% and PaO2 60–80 mmHg) were considered eligible. Exclusion criteria were: extremes of age (< 18 years, > 80 years), obesity (body mass index > 40 kg/m2), prone positioning at the time of intervention, mechanical ventilation for more than 10 days and extracorporeal membrane oxygenation. Eleven patients were recruited. Participants were ventilated in FCV mode for 30 min, and subsequently in volume-control mode (VCV) for 30 min. Feasibility of FCV to maintain oxygenation was assessed by the PaO2/FiO2 ratio (mmHg) as a primary outcome parameter. Secondary outcomes included ventilator parameters, PaCO2 and haemodynamic data. All adverse events were recorded. FCV was feasible in all patients and no adverse events were observed. There was no difference in the PaO2/FIO2 ratio after 30 min of ventilation in FCV mode (169 mmHg) compared to 30 min of ventilation in VCV mode subsequently (168 mmHg, 95% CI of pseudo-medians (− 10.5, 3.6), p = 0.56). The tidal volumes (p < 0.01) and minute ventilation were lower during FCV (p = 0.01) while PaCO2 was similar at the end of the 30-min ventilation periods (p = 0.31). Mean arterial pressure during FCV was comparable to baseline. Thirty minutes of FCV in patients with moderate COVID-19 ARDS receiving neuromuscular blocking agents resulted in similar oxygenation, compared to VCV. FCV was feasible and did not result in adverse events. Trial registration: Clinicaltrials.gov identifier: NCT04894214.
Tài liệu tham khảo
Slutsky AS, Ranieri VM (2013) Ventilator-induced lung injury. N Engl J Med 369:2126–2136
Briel M, Meade M, Mercat A et al (2010) Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 303:865–873
Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA et al (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308
Cavalcanti AB, Suzumura ÉA, Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators et al (2017) Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA 318:1335–1345
Yasuda H, Nishimura T, Kamo T et al (2017) Optimal plateau pressure for patients with acute respiratory distress syndrome: a protocol for a systematic review and meta-analysis with meta-regression. BMJ Open 7:e015091. https://doi.org/10.1136/bmjopen-2016-015091
Amato MBP, Meade MO, Slutsky AS et al (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372:747–755
Gattinoni L, Tonetti T, Quintel M (2017) Regional physiology of ARDS. Crit Care. https://doi.org/10.1186/s13054-017-1905-9
Tonetti T, Vasques F, Rapetti F et al (2017) Driving pressure and mechanical power: new targets for VILI prevention. Ann Transl Med 5:286
Barnes T, van Asseldonk D, Enk D (2018) Minimisation of dissipated energy in the airways during mechanical ventilation by using constant inspiratory and expiratory flows—Flow-controlled ventilation (FCV). Med Hypotheses 121:167–176
Schumann S, Goebel U, Haberstroh J et al (2014) Determination of respiratory system mechanics during inspiration and expiration by FLow-controlled EXpiration (FLEX): a pilot study in anesthetized pigs. Minerva Anestesiol 80:19–28
Schmidt J, Wenzel C, Mahn M et al (2018) Improved lung recruitment and oxygenation during mandatory ventilation with a new expiratory ventilation assistance device: a controlled interventional trial in healthy pigs. Eur J Anaesthesiol 35:736–744
Wirth S, Springer S, Spaeth J et al (2017) Application of the novel ventilation mode flow-controlled expiration (FLEX): a crossover proof-of-principle study in lung-healthy patients. Anesth Analg 125:1246–1252
Borgmann S, Schmidt J, Goebel U et al (2018) Dorsal recruitment with flow-controlled expiration (FLEX): an experimental study in mechanically ventilated lung-healthy and lung-injured pigs. Crit Care 22:245
Schmidt J, Wenzel C, Spassov S et al (2020) Flow-controlled ventilation attenuates lung injury in a porcine model of acute respiratory distress syndrome: a preclinical randomized controlled study. Crit Care Med 48:e241–e248
Weber J, Straka L, Borgmann S et al (2020) Flow-controlled ventilation (FCV) improves regional ventilation in obese patients - a randomized controlled crossover trial. BMC Anesthesiol 20:24
Weber J, Schmidt J, Straka L et al (2020) Flow-controlled ventilation improves gas exchange in lung-healthy patients- a randomized interventional cross-over study. Acta Anaesthesiol Scand 64:481–488
Höhne T, Wenzel C, Schumann S (2021) Flow-controlled expiration (FLEX) homogenizes pressure distribution in a four compartment physical model of the respiratory system with chest wall compliance. Physiol Meas. https://doi.org/10.1088/1361-6579/ac0ff8
Bergold M, Otterburg T, Woitzik J et al (2020) Flow-controlled ventilation—a novel approach to treating acute respiratory distress syndrome. Trends Anaesth Crit Care 30:e93. https://doi.org/10.1016/j.tacc.2019.12.231
Roehrig S, Hssain AA, Al Hamid Shallik N et al (2020) Flow controlled ventilation in Acute Respiratory Distress Syndrome associated with COVID-19: a structured summary of a study protocol for a randomised controlled trial. Trials. https://doi.org/10.1186/s13063-020-04708-1
Spraider P, Putzer G, Breitkopf R et al (2021) A case report of individualized ventilation in a COVID-19 patient—new possibilities and caveats to consider with flow-controlled ventilation. BMC Anesthesiol 21:145
Ranieri VM, Rubenfeld GD, ARDS Definition Task Force et al (2012) Acute respiratory distress syndrome: the Berlin Definition. JAMA 307:2526–2533
Faul F, Erdfelder E, Lang A-G et al (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191
Wickham H, Averick M, Bryan J et al (2019) Welcome to the Tidyverse. J Open Source Softw 4:1686. https://doi.org/10.21105/joss.01686
Nasa P, Azoulay E, Khanna AK et al (2021) Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method. Crit Care 25:106
Moss M, Huang DT, National Heart, Lung, and Blood Institute PETAL Clinical Trials Network et al (2019) Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med 380:1997–2008
Alhazzani W, Belley-Cote E, Møller MH et al (2020) Neuromuscular blockade in patients with ARDS: a rapid practice guideline. Intensive Care Med 46:1977–1986
Henneberg S, Söderberg D, Groth T, Stjernström H, Wiklund L (1987) Carbon dioxide production during mechanical ventilation. Crit Care Med 15(1):8–13
Guttmann J, Eberhard L, Fabry B et al (1993) Continuous calculation of intratracheal pressure in tracheally intubated patients. Anesthesiology 79:503–513. https://doi.org/10.1097/00000542-199309000-00014
Wittenstein J, Scharffenberg M, Ran X et al (2020) Comparative effects of flow vs. volume-controlled one-lung ventilation on gas exchange and respiratory system mechanics in pigs. Intensive Care Med Exp 8:24
Verscheure S, Massion PB, Verschuren F, Damas P, Magder S (2016) Volumetric capnography: lessons from the past and current clinical applications. Crit Care 20(1):184
Ventinova Medical: Instructions for use Evone. https://www.ventinovamedical.com/wp-content/uploads/2021/02/MSS076.10_IFUEvone-English.pdf. Accessed 3 Apr 2022.