Department of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, the Netherlands.
Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, the Netherlands.
Crit Care Med. 2022 Feb 1;50(2):192-203. doi: 10.1097/CCM.0000000000005395.
Lung- and diaphragm-protective ventilation is a novel concept that aims to limit the detrimental effects of mechanical ventilation on the diaphragm while remaining within limits of lung-protective ventilation. The premise is that low breathing effort under mechanical ventilation causes diaphragm atrophy, whereas excessive breathing effort induces diaphragm and lung injury. In a proof-of-concept study, we aimed to assess whether titration of inspiratory support based on diaphragm effort increases the time that patients have effort in a predefined "diaphragm-protective" range, without compromising lung-protective ventilation.
Randomized clinical trial.
Mixed medical-surgical ICU in a tertiary academic hospital in the Netherlands.
Patients (n = 40) with respiratory failure ventilated in a partially-supported mode.
In the intervention group, inspiratory support was titrated hourly to obtain transdiaphragmatic pressure swings in the predefined "diaphragm-protective" range (3-12 cm H2O). The control group received standard-of-care.
Transdiaphragmatic pressure, transpulmonary pressure, and tidal volume were monitored continuously for 24 hours in both groups. In the intervention group, more breaths were within "diaphragm-protective" range compared with the control group (median 81%; interquartile range [64-86%] vs 35% [16-60%], respectively; p < 0.001). Dynamic transpulmonary pressures (20.5 ± 7.1 vs 18.5 ± 7.0 cm H2O; p = 0.321) and tidal volumes (7.56 ± 1.47 vs 7.54 ± 1.22 mL/kg; p = 0.961) were not different in the intervention and control group, respectively.
Titration of inspiratory support based on patient breathing effort greatly increased the time that patients had diaphragm effort in the predefined "diaphragm-protective" range without compromising tidal volumes and transpulmonary pressures. This study provides a strong rationale for further studies powered on patient-centered outcomes.
肺和膈肌保护通气是一种新的概念，旨在限制机械通气对膈肌的有害影响，同时保持肺保护通气的限制范围内。前提是机械通气下的低呼吸努力导致膈肌萎缩，而过度的呼吸努力会引起膈肌和肺损伤。在一项概念验证研究中，我们旨在评估基于膈肌努力的吸气支持滴定是否会增加患者在预设的“膈肌保护”范围内有努力的时间，而不会损害肺保护通气。
随机临床试验。
荷兰一家三级学术医院的混合内科-外科重症监护病房。
呼吸衰竭并接受部分支持通气的患者（n = 40）。
在干预组中，每小时滴定吸气支持以获得预设的“膈肌保护”范围内的跨膈肌压力波动（3-12 厘米 H2O）。对照组接受标准护理。
两组均连续监测 24 小时的膈肌压力、肺内压力和潮气量。与对照组相比，干预组更多的呼吸处于“膈肌保护”范围内（中位数 81%[64-86%]与 35%[16-60%]，分别；p < 0.001）。动态肺内压力（20.5 ± 7.1 与 18.5 ± 7.0 厘米 H2O；p = 0.321）和潮气量（7.56 ± 1.47 与 7.54 ± 1.22 毫升/千克；p = 0.961）在干预组和对照组之间没有差异。
基于患者呼吸努力的吸气支持滴定大大增加了患者在预设的“膈肌保护”范围内有努力的时间，而不会影响潮气量和肺内压力。这项研究为进一步以患者为中心的结局研究提供了强有力的依据。
