Acute and Critical Care

Original Articles

Pulmonary
Relationship between positive end-expiratory pressure levels, central venous pressure, systemic inflammation and acute renal failure in critically ill ventilated COVID-19 patients: a monocenter retrospective study in France: Pierre Basse, Louis Morisson, Romain Barthélémy, Nathan Julian, Manuel Kindermans, Magalie Collet, Benjamin Huot, Etienne Gayat, Alexandre Mebazaa, Benjamin G. Chousterman; Acute Crit Care. 2023;38(2):172-181. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.01494

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Abstract PDF Supplementary Material: Background
The role of positive pressure ventilation, central venous pressure (CVP) and inflammation on the occurrence of acute kidney injury (AKI) have been poorly described in mechanically ventilated patient secondary to coronavirus disease 2019 (COVID-19). Methods: This was a monocenter retrospective cohort study of consecutive ventilated COVID-19 patients admitted in a French surgical intensive care unit between March 2020 and July 2020. Worsening renal function (WRF) was defined as development of a new AKI or a persistent AKI during the 5 days after mechanical ventilation initiation. We studied the association between WRF and ventilatory parameters including positive end-expiratory pressure (PEEP), CVP, and leukocytes count. Results: Fifty-seven patients were included, 12 (21%) presented WRF. Daily PEEP, 5 days mean PEEP and daily CVP values were not associated with occurrence of WRF. 5 days mean CVP was higher in the WRF group compared to patients without WRF (median [IQR], 12 mm Hg [11-13] vs. 10 mm Hg [9–12]; P=0.03). Multivariate models with adjustment on leukocytes and Simplified Acute Physiology Score (SAPS) II confirmed the association between CVP value and risk of WRF (odd ratio, 1.97; 95% confidence interval, 1.12–4.33). Leukocytes count was also associated with occurrence of WRF in the WRF group (14 G/L [11–18]) and the no-WRF group (9 G/L [8–11]) (P=0.002). Conclusions: In mechanically ventilated COVID-19 patients, PEEP levels did not appear to influence occurrence of WRF. High CVP levels and leukocytes count are associated with risk of WRF.

Pulmonary
The Effect of Positive End-Expiratory Pressure on Air Leakage: Comparison of Cuff Designs: Junyong In, Gyung Serk Shim, Seunghyun Chung; Korean J Crit Care Med. 2014;29(1):3-6. Published online February 28, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.1.3

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Background
Recently developed taper-shaped cuffs (TG cuffs) of endotracheal tubes (ETTs) are known to have a more potent sealing effect than cylindrical high-volume low-pressure cuffs (HL cuffs) of conventional ETTs. The aim of this study was to compare TG cuffs with HL cuffs of ETTs in a bench-top model with regard to air leakage under various positive end-expiratory pressures (PEEP).
Methods
HL cuffs and TG cuffs made from PVC were included (HL group vs. TG group). A model trachea with an internal diameter (ID) of 22 mm was attached to a test lung. The test lung was ventilated using an anesthesia respirator with volume controlled mode and PEEPs of 0, 5, 10, or 15 cm H₂O. Using spirometry, percentages of expired to inspired tidal volumes (TVe/i) were calculated as a measure of air leakage.
Results
With regard to PEEPs, the HL group showed significantly higher air leakage compared to the TG group (p < 0.0001), and a higher PEEP resulted in greater air leakage (p < 0.0001). Air leakage with higher PEEP was greater in the HL group than in the TG group at ID 7.0 mm and 7.5 mm (p = 0.0467, p = 0.0045)
Conclusions
This study shows the superior sealing ability of the TG cuff during ventilation at various PEEPs.

Citations

Citations to this article as recorded by

Impact of Low‐Volume, Low‐Pressure Tracheostomy Cuffs on Acute Mucosal Injury in Swine
Alexandra J. Berges, Ioan A. Lina, Rafael Ospino, Hsiu‐Wen Tsai, Dacheng Ding, Jessica M. Izzi, Alexander T. Hillel
Otolaryngology–Head and Neck Surgery.2022; 167(4): 716. CrossRef
Tidal Volume Delivery and Endotracheal Tube Leak during Cardiopulmonary Resuscitation in Intubated Newborn Piglets with Hypoxic Cardiac Arrest Exposed to Different Modes of Ventilatory Support
Marc R. Mendler, Claudia Weber, Mohammad A. Hassan, Li Huang, Benjamin Mayer, Helmut D. Hummler
Neonatology.2017; 111(2): 100. CrossRef

Effects of Ventilation Modes and Levels of PEEP on Respiratory Mechanics during Controlled Ventilation under General Anesthesia: Jong Cook Park, Sang Hyun Park, Hyun Jun Kwag, Soo Young Park; Korean J Crit Care Med. 2006;21(2):89-94.

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Abstract PDF: BACKGROUND
Application of PEEP increases lung volume and improves oxygenation. High PEEP levels may cause alveolar overdistension or barotrauma. It was hypothesized that there will be an effect of level of PEEP on respiratory resistance and an effect of ventilatory mode on respiratory compliance. This study aimed to investigate the effects of ventilation modes and levels of PEEP on respiratory mechanics during controlled ventilation under general anesthesia.
METHODS
In 14 mechanically ventilated patients without cardiopulmonary symptoms and signs, we measured the respiratory mechanics using the inspiration interrupter technique during a constant flow. Dynamic and static compliance, airway resistance, visco-elastic tissue and total respiratory system resistance were calculated at 0, 5, 10, 15, and 20 cmH2O of positive end-expiratory pressure (PEEP) in VCV mode, VCV with inspiratory pause mode, and PCV mode, respectively.
RESULTS
The dynamic compliance of the PCV mode was higher than that of the VCV mode. The highest static compliance was at 10 cmH2O PEEP. At 20 cmH2O PEEP, pulmonary compliance was decreased and the tissue resistance was increased.
CONCLUSIONS
These results suggest that the respiratory mechanics including respiratory resistance should be monitored for applying PEEP. Further studies on clinical condition such as acute lung injury and ARDS were needed.

Effect of Positive End-Expiratory Pressure on the Concentration of Sodium and Potassium in Plasma and Urine, Plasma Creatinine and Urine Output in Mechanically Ventilated Patients: Bong Jae Lee, Kyu Suk Suh, Dong Ok Kim, Dong Soo Kim; Korean J Crit Care Med. 1999;14(2):154-160.

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Abstract PDF: BACKGOUND: It has been suggested that the addition of positive end-expiratory pressure (PEEP) to the patients with ventilator support leads to an impairment on renal hemodynamics and water- and sodium-retaining hormonal systems, such as plasma renin activity (PRA), plasma aldosterone, urinary antidiuretic hormone (ADH).
METHODS
To evaluate the effects of 5 cmH2O and 10 cmH2O PEEP on renal function, we measured the plasma concentration of sodium (Na+), potassium (K+) and creatinine, urinary excretion of Na+, K+ and urine output in eight normovolemic male patients requiring ventilator support. Also changes in mean arterial pressure, pulse rate, arterial oxygen tension (PaO2) and carbon dioxide tension (PaCO2) during the experimental period were measured in these patients.
RESULTS
Both 5 and 10 cmH2O PEEP showed no significant effect on the mean arterial pressure, heart rate, PaO2, and PaCO2. Both 5 and 10 cmH2O PEEP showed no significant effect on the plasma concentration of sodium, potassium and creatinine. 5 cmH2O PEEP showed no significant effect on the urinary excretion of sodium, potassium and urine output, but 10 cmH2O PEEP showed significant effect on the urinary excretion of sodium (19% decrease, p<0.05), and urine output (12.5% decrease, p<0.05) respectively.
CONCLUSIONS
10 cmH2O PEEP was revealed to decrease urinary sodium excretion along with urinary output and this phenomenon was likely to relate with water- and sodium-retaining hormonal systems. These results suggested that it was preferable to apply high PEEP cautiously in patients with impaired renal function.

Effect of Positive End-Expiratory Pressure on Intraocular Pressure in the Critically Ill and Mechanically Ventilated Patients: Ju Tae Sohn, Heon Young Ahn, Ji Hong Bae, Heon Keun Lee, Sang Hwy Lee, Young Kyun Chung; Korean J Crit Care Med. 1997;12(2):151-158.

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Abstract PDF: BACKGOUND: The purpose of this study was to examine the effect of various levels of positive end-expiratory pressure (PEEP) on the intraocular pressure in the patients receiving positive pressure ventilation.
METHODS
Twenty, critically ill sedated and hemodynamically stable patients without history of glaucoma were placed on controlled positive pressure ventilation. Measured variables included intraocular pressure (IOP), mean arterial pressure (MAP), central venous pressure (CVP), peak inspiratory pressure (PIP) and arterial blood gas analysis (ABGA), and were recorded at zero end-expiratory pressure (ZEEP), and at 5, 10, 15, 20 cmH2O PEEP, applied in random order.
RESULTS
IOP increased significantly from 13+/-3 to 16+/-3 mmHg at 15 cmH2O PEEP and from 14+/-4 to 17+/-6 mmHg at 20 cmH2O PEEP. CVP increased significantly from its corresponding ZEEP measurements at all PEEP levels and from 14+/-4 cmH2O at 5 cmH2O PEEP to 21+/-4 cmH2O at 20 cmH2O PEEP. There was a positive correlation between PEEP levels and PIP or CVP but no relationship between PEEP levels and IOP was observed.
CONCLUSIONS
The application of PEEP levels > or = 15 cmH2O resulted in a significant increase in the IOP of patients with normal basal ocular tonometry. This study suggests that further increase in IOP may occur in the mechanically ventilated patients with already increased IOP or normal-tension glaucoma, when higher levels of PEEP are used.

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