A Retrospective Observational Study to Analyze Recruitment Paradigms in the Treatment of Hypoxemic COVID-19 Patients Admitted in the Intensive Care Unit of a Tertiary Care Institute in India
Citation Information :
Saseedharan S, Kadam V, Patil S, Soni A, Yadav A, Bagade R, Panigrahi I, Miglani N. A Retrospective Observational Study to Analyze Recruitment Paradigms in the Treatment of Hypoxemic COVID-19 Patients Admitted in the Intensive Care Unit of a Tertiary Care Institute in India. Indian J Respir Care 2022; 11 (3):246-252.
Introduction: This retrospective study attempted to assess the recruitability of the lungs that were affected by acute respiratory distress syndrome (ARDS) due to COVID-19. This was done with the combined use of transpulmonary pressure monitoring (to limit the stress), measurement of end.expiratory lung volume (EELV) (to measure the actual volume gain and be within limits of strain), electrical impedance tomography (EIT), and compliance (to diagnose overdistension). Recruitment was judged clinically by an increase in the SpO2 values.
Methods: Retrospective data from the charts and progress sheets were collected from 27 patients admitted to the intensive care unit (between February 2021 and June 2021) with a ratio of arterial Partial pressure of oxygen (PaO2 in mmHg) to fractional inspired oxygen (FiO2) <150 (i.e., PaO2/FiO2 <150) with a diagnosis of ARDS. The esophageal pressure was monitored using the polyfunctional nasogastric tube (Nutrivent.). The end.expiratory volume was measured using the Carescape R860 (GE Healthcare) by the nitrogen multiple breath wash.out/wash.in (EELV) at a positive end.expiratory pressure of 5. EIT measurements were performed using the Pulmo Vista 500. We performed a recruitment maneuver using the “staircase maneuver.
Results: As per the results of our study, we found that almost 2/3rd (66.7%) of the patients affected with COVID lungs affected with ARDS were recruitable.
Conclusion: The results of our study again make us believe that majority of COVID-19 lungs affected with ARDS may be recruitable in the earlier stage of the illness (within the 1st week of ARDS). Thus, in such patients, safe, monitored lung recruitment should be attempted to improve oxygenation rather than directly proning the patient, which is fraught with its own set of complications.
Griffiths MJ, McAuley DF, Perkins GD, Barrett N, Blackwood B, Boyle A, et al. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res 2019;6:e000420.
Hasan SS, Capstick T, Ahmed R, Kow CS, Mazhar F, Merchant HA, et al. Mortality in COVID-19 patients with acute respiratory distress syndrome and corticosteroids use: A systematic review and meta-analysis. Expert Rev Respir Med 2020;14:1149-63.
Xie J, Covassin N, Fan Z, Singh P, Gao W, Li G, et al. Association between hypoxemia and mortality in patients with COVID-19. Mayo Clin Proc 2020;95:1138-47.
Tusman G, Böhm S, Vazquez de Anda G, do Campo J, Lachmann B. ‘Alveolar recruitment strategy’ improves arterial oxygenation during general anaesthesia. Br J Anaesth 1999;82:8-13.
Gattinoni L, Carlesso E, Cadringher P, Valenza F, Vagginelli F, Chiumello D. Physical and biological triggers of ventilator-induced lung injury and its prevention. Eur Respir J Suppl 2003;47:15s-25s.
González-López A, García-Prieto E, Batalla-Solís E, Amado-Rodríguez L, Avello N, Blanch L, et al. Lung strain and biological response in mechanically ventilated patients. Intensive Care Med 2012;38:240-7.
Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, et al. The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 2014;189:520-31.
Baedorf Kassis E, Talmor D. Clinical application of esophageal manometry: How I do it. Crit Care 2021;25.
Patroniti N, Saini M, Zanella A, Weismann D, Isgrò S, Bellani G, et al. Measurement of end-expiratory lung volume by oxygen washin-washout in controlled and assisted mechanically ventilated patients. Intensive Care Med 2008;34:2235-40.
Olegård C, Söndergaard S, Houltz E, Lundin S, Stenqvist O. Estimation of functional residual capacity at the bedside using standard monitoring equipment: A modified nitrogen washout/washin technique requiring a small change of the inspired oxygen fraction. Anesth Analg 2005;101:206-12.
Richard JC, Pouzot C, Pinzón AM, González JS, Orkisz M, Neyran B, et al. Reliability of the nitrogen washin-washout technique to assess end-expiratory lung volume at variable PEEP and tidal volumes. Intensive Care Med Exp 2014;2:10.
Kobylianskii J, Murray A, Brace D, Goligher E, Fan E. Electrical impedance tomography in adult patients undergoing mechanical ventilation: A systematic review. J Crit Care 2016;35:33-50.
Costa EL, Borges JB, Melo A, Suarez-Sipmann F, Toufen C Jr., Bohm SH, et al. Bedside estimation of recruitable alveolar collapse and hyperdistension by electrical impedance tomography. Intensive Care Med 2009;35:1132-7.
Wrigge H, Zinserling J, Muders T, Varelmann D, Günther U, von der Groeben C, et al. Electrical impedance tomography compared with thoracic computed tomography during a slow inflation maneuver in experimental models of lung injury. Crit Care Med 2008;36:903-9.
Liu S, Tan L, Möller K, Frerichs I, Yu T, Liu L, et al. Identification of regional overdistension, recruitment and cyclic alveolar collapse with electrical impedance tomography in an experimental ARDS model. Crit Care 2016;20:119.
Goligher EC, Hodgson CL, Adhikari NK, Meade MO, Wunsch H, Uleryk E, et al. Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 2017;14:S304-11.
Levine M, Gilbert R, Auchincloss JH Jr. A comparison of the effects of sighs, large tidal volumes, and positive end expiratory pressure in assisted ventilation. Scand J Respir Dis 1972;53:101-8.
Oczenski W, Hörmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, et al. Recruitment maneuvers after a positive end-expiratory pressure trial do not induce sustained effects in early adult respiratory distress syndrome. Anesthesiology 2004;101:620-5.
Rzezinski AF, Oliveira GP, Santiago VR, Santos RS, Ornellas DS, Morales MM, et al. Prolonged recruitment manoeuvre improves lung function with less ultrastructural damage in experimental mild acute lung injury. Respir Physiol Neurobiol 2009;169:271-81.
Santos RS, Silva PL, Pelosi P, Rocco PR. Recruitment maneuvers in acute respiratory distress syndrome: The safe way is the best way. World J Crit Care Med 2015;4:278-86.
Garnero A, Tuxen D, Corno G, Durand-Gasselin J, Hodgson C, Arnal JM. Dynamics of end expiratory lung volume after changing positive end-expiratory pressure in acute respiratory distress syndrome patients. Crit Care 2015;19:340.
Chiumello D, Cressoni M, Chierichetti M, Tallarini F, Botticelli M, Berto V, et al. Nitrogen washout/washin, helium dilution and computed tomography in the assessment of end expiratory lung volume. Crit Care 2008;12:R150.
Beitler JR, Sarge T, Banner-Goodspeed VM, Gong MN, Cook D, Novack V, et al. Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure-guided strategy vs. an empirical high PEEP-Fio2 strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: A randomized clinical trial. JAMA 2019;321:846-57.
Ge H, Pan Q, Zhou Y, Xu P, Zhang L, Zhang J, et al. Lung mechanics of mechanically ventilated patients with COVID-19: Analytics with high-granularity ventilator waveform data. Front Med (Lausanne) 2020;7:541.
Sinha P, Calfee CS, Cherian S, Brealey D, Cutler S, King C, et al. Prevalence of phenotypes of acute respiratory distress syndrome in critically ill patients with COVID-19: A prospective observational study. Lancet Respir Med 2020;8:1209-18.
Bos LD, Paulus F, Vlaar AP, Beenen LF, Schultz MJ. Subphenotyping acute respiratory distress syndrome in patients with COVID-19: Consequences for ventilator management. Ann Am Thorac Soc 2020;17:1161-3.
Carsetti A, Damia Paciarini A, Marini B, Pantanetti S, Adrario E, Donati A. Prolonged prone position ventilation for SARS-CoV-2 patients is feasible and effective. Crit Care 2020;24:225.
Thompson B, Chambers R, Liu K. Acute respiratory distress syndrome. N Engl J Med 2017;377:562-72.
Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8.
Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159-68.
Guo L, Xie J, Huang Y, Pan C, Yang Y, Qiu H, et al. Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: A systematic review and meta-analysis. BMC Anesthesiol 2018;18:172.
ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Mackle D, Bellomo R, Bailey M, Beasley R, Deane A, et al. Conservative oxygen therapy during mechanical ventilation in the ICU. N Engl J Med 2020;382:989-98.
Young P, Mackle D, Bellomo R, Bailey M, Beasley R, Deane A, et al. Conservative oxygen therapy for mechanically ventilated adults with sepsis: A post hoc analysis of data from the intensive care unit randomized trial comparing two approaches to oxygen therapy (ICU-ROX). Intensive Care Med 2020;46:17-26.
Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, et al. Effect of conservative vs. conventional oxygen therapy on mortality among patients in an intensive care unit: The oxygen-ICU randomized clinical trial. JAMA 2016;316:1583-9.
Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, et al. Liberal or conservative oxygen therapy for acute respiratory distress syndrome. N Engl J Med 2020;382:999-1008.
Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.
Sang L, Zheng X, Zhao Z, Zhong M, Jiang L, Huang Y, et al. Lung recruitment, individualized PEEP, and prone position ventilation for COVID-19-Associated Severe ARDS: A single center observational study. Front Med (Lausanne) 2020;7:603943.
Pan C, Chen L, Lu C, Zhang W, Xia JA, Sklar MC, et al. Lung recruitability in COVID-19-associated acute respiratory distress syndrome: A single-center observational study. Am J Respir Crit Care Med 2020;201:1294-7.
Talmor D, Sarge T, O'Donnell CR, Ritz R, Malhotra A, Lisbon A, et al. Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med 2006;34:1389-94.
Pelosi P, Goldner M, McKibben A, Adams A, Eccher G, Caironi P, et al. Recruitment and derecruitment during acute respiratory failure: An experimental study. Am J Respir Crit Care Med 2001;164:122-30.
Ranieri VM, Eissa NT, Corbeil C, Chassé M, Braidy J, Matar N, et al. Effects of positive end-expiratory pressure on alveolar recruitment and gas exchange in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1991;144:544-51.
Mergoni M, Volpi A, Bricchi C, Rossi A. Lower inflection point and recruitment with PEEP in ventilated patients with acute respiratory failure. J Appl Physiol (1985) 2001;91:441-50.
Malbouisson LM, Muller JC, Constantin JM, Lu Q, Puybasset L, Rouby JJ, et al. Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2001;163:1444-50.
Brown BH, Barber DC, Seagar AD. Applied potential tomography: Possible clinical applications. Clin Phys Physiol Meas 1985;6:109-21.
Brunner JX, Wolff G. Physical model of the lung. Pulmonary function indices in critical care patients. Berlin Heidelberg, New York: Springer; 1988. p. 58-61.