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Luciano Gattinoni - One of the best experts on this subject based on the ideXlab platform.
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Ultra-protective ventilation and hypoxemia
Critical Care, 2016Co-Authors: Luciano GattinoniAbstract:Partial extracorporeal CO2 removal allows a decreasing tidal volume without Respiratory Acidosis in patients with acute Respiratory distress syndrome. This, however, may be associated with worsening hypoxemia, due to several mechanisms, such as gravitational and reabsorption atelectasis, due to a decrease in mean airway pressure and a critically low ventilation-perfusion ratio, respectively. In addition, an imbalance between alveolar and artificial lung partial pressures of nitrogen may accelerate the process. Finally, the decrease in the Respiratory quotient, leading to unrecognized alveolar hypoxia and monotonous low plateau pressures preventing critical opening, may contribute to hypoxemia.
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Tidal volume lower than 6 ml/kg enhances lung protection: Role of extracorporeal carbon dioxide removal
Anesthesiology, 2009Co-Authors: V. Marco Ranieri, Lorenzo Del Sorbo, Rosario Urbino, Alberto Birocco, Chiara Faggiano, Erica L. Martin, Pierpaolo Terragni, Luciana Mascia, Michael Quintel, Luciano GattinoniAbstract:BACKGROUND: Tidal hyperinflation may occur in patients with acute Respiratory distress syndrome who are ventilated with a tidal volume (VT) of 6 ml/kg of predicted body weight develop a plateau pressure (PPLAT) of 28 < or = PPLAT < or = 30 cm H2O. The authors verified whether VT lower than 6 ml/kg may enhance lung protection and that consequent Respiratory Acidosis may be managed by extracorporeal carbon dioxide removal. METHODS: PPLAT, lung morphology computed tomography, and pulmonary inflammatory cytokines (bronchoalveolar lavage) were assessed in 32 patients ventilated with a VT of 6 ml/kg. Data are provided as mean +/- SD or median and interquartile (25th and 75th percentile) range. In patients with 28 < or = PPLAT < or = 30 cm H2O (n = 10), VT was reduced from 6.3 +/- 0.2 to 4.2 +/- 0.3 ml/kg, and PPLAT decreased from 29.1 +/- 1.2 to 25.0 +/- 1.2 cm H2O (P < 0.001); consequent Respiratory Acidosis (Paco2 from 48.4 +/- 8.7 to 73.6 +/- 11.1 mmHg and pH from 7.36 +/- 0.03 to 7.20 +/- 0.02; P < 0.001) was managed by extracorporeal carbon dioxide removal. Lung function, morphology, and pulmonary inflammatory cytokines were also assessed after 72 h. RESULTS: Extracorporeal assist normalized Paco2 (50.4 +/- 8.2 mmHg) and pH (7.32 +/- 0.03) and allowed use of VT lower than 6 ml/kg for 144 (84-168) h. The improvement of morphological markers of lung protection and the reduction of pulmonary cytokines concentration (P < 0.01) were observed after 72 h of ventilation with VT lower than 6 ml/kg. No patient-related complications were observed. CONCLUSIONS: VT lower than 6 ml/Kg enhanced lung protection. Respiratory Acidosis consequent to low VT ventilation was safely and efficiently managed by extracorporeal carbon dioxide removal.
Christian Karagiannidis - One of the best experts on this subject based on the ideXlab platform.
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impact of membrane lung surface area and blood flow on extracorporeal co 2 removal during severe Respiratory Acidosis
Intensive Care Medicine Experimental, 2017Co-Authors: Christian Karagiannidis, Anders Larsson, Stephan Strassmann, Daniel Brodie, Philine Ritter, Ralf Borchardt, Wolfram WindischAbstract:Veno-venous extracorporeal CO2 removal (vv-ECCO2R) is increasingly being used in the setting of acute Respiratory failure. Blood flow rates through the device range from 200 ml/min to more than 1500 ml/min, and the membrane surface areas range from 0.35 to 1.3 m2. The present study in an animal model with similar CO2 production as an adult patient was aimed at determining the optimal membrane lung surface area and technical requirements for successful vv-ECCO2R. Four different membrane lungs, with varying lung surface areas of 0.4, 0.8, 1.0, and 1.3m2 were used to perform vv-ECCO2R in seven anesthetized, mechanically ventilated, pigs with experimentally induced severe Respiratory Acidosis (pH 7.0–7.1) using a 20Fr double-lumen catheter with a sweep gas flow rate of 8 L/min. During each experiment, the blood flow was increased stepwise from 250 to 1000 ml/min. Amelioration of severe Respiratory Acidosis was only feasible when blood flow rates from 750 to 1000 ml/min were used with a membrane lung surface area of at least 0.8 m2. Maximal CO2 elimination was 150.8 ml/min, with pH increasing from 7.01 to 7.30 (blood flow 1000 ml/min; membrane lung 1.3 m2). The membrane lung with a surface of 0.4 m2 allowed a maximum CO2 elimination rate of 71.7 mL/min, which did not result in the normalization of pH, even with a blood flow rate of 1000 ml/min. Also of note, an increase of the surface area above 1.0 m2 did not result in substantially higher CO2 elimination rates. The pressure drop across the oxygenator was considerably lower (<10 mmHg) in the largest membrane lung, whereas the smallest revealed a pressure drop of more than 50 mmHg with 1000 ml blood flow/min. In this porcine model, vv-ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 ml/min, with a membrane lung surface of at least 0.8 m2. In contrast, low blood flow rates (250–500 ml/min) were not sufficient to completely correct severe Respiratory Acidosis, irrespective of the surface area of the membrane lung being used. The converse was also true, low surface membrane lungs (0.4 m2) were not capable of completely correcting severe Respiratory Acidosis across the range of blood flows used in this study.
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Impact of membrane lung surface area and blood flow on extracorporeal CO2 removal during severe Respiratory Acidosis
SpringerOpen, 2017Co-Authors: Christian Karagiannidis, Anders Larsson, Stephan Strassmann, Daniel Brodie, Philine Ritter, Ralf Borchardt, Wolfram WindischAbstract:Abstract Background Veno-venous extracorporeal CO2 removal (vv-ECCO2R) is increasingly being used in the setting of acute Respiratory failure. Blood flow rates through the device range from 200 ml/min to more than 1500 ml/min, and the membrane surface areas range from 0.35 to 1.3 m2. The present study in an animal model with similar CO2 production as an adult patient was aimed at determining the optimal membrane lung surface area and technical requirements for successful vv-ECCO2R. Methods Four different membrane lungs, with varying lung surface areas of 0.4, 0.8, 1.0, and 1.3m2 were used to perform vv-ECCO2R in seven anesthetized, mechanically ventilated, pigs with experimentally induced severe Respiratory Acidosis (pH 7.0–7.1) using a 20Fr double-lumen catheter with a sweep gas flow rate of 8 L/min. During each experiment, the blood flow was increased stepwise from 250 to 1000 ml/min. Results Amelioration of severe Respiratory Acidosis was only feasible when blood flow rates from 750 to 1000 ml/min were used with a membrane lung surface area of at least 0.8 m2. Maximal CO2 elimination was 150.8 ml/min, with pH increasing from 7.01 to 7.30 (blood flow 1000 ml/min; membrane lung 1.3 m2). The membrane lung with a surface of 0.4 m2 allowed a maximum CO2 elimination rate of 71.7 mL/min, which did not result in the normalization of pH, even with a blood flow rate of 1000 ml/min. Also of note, an increase of the surface area above 1.0 m2 did not result in substantially higher CO2 elimination rates. The pressure drop across the oxygenator was considerably lower (
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veno venous extracorporeal co2 removal for the treatment of severe Respiratory Acidosis pathophysiological and technical considerations
Critical Care, 2014Co-Authors: Christian Karagiannidis, Kristin Aufm Kampe, Fernando Suarez Sipmann, Anders Larsson, Goran Hedenstierna, Wolfram Windisch, Thomas F MuellerAbstract:While non-invasive ventilation aimed at avoiding intubation has become the modality of choice to treat mild to moderate acute Respiratory Acidosis, many severely acidotic patients (pH <7.20) still need intubation. Extracorporeal veno-venous CO2 removal (ECCO2R) could prove to be an alternative. The present animal study tested in a systematic fashion technical requirements for successful ECCO2R in terms of cannula size, blood and sweep gas flow. ECCO2R with a 0.98 m2 surface oxygenator was performed in six acidotic (pH <7.20) pigs using either a 14.5 French (Fr) or a 19Fr catheter, with sweep gas flow rates of 8 and 16 L/minute, respectively. During each experiment the blood flow was incrementally increased to a maximum of 400 mL/minute (14.5Fr catheter) and 1000 mL/minute (19Fr catheter). Amelioration of severe Respiratory Acidosis was only feasible when blood flow rates of 750 to 1000 mL/minute (19Fr catheter) were used. Maximal CO2-elimination was 146.1 ± 22.6 mL/minute, while pH increased from 7.13 ± 0.08 to 7.41 ± 0.07 (blood flow of 1000 mL/minute; sweep gas flow 16 L/minute). Accordingly, a sweep gas flow of 8 L/minute resulted in a maximal CO2-elimination rate of 138.0 ± 16.9 mL/minute. The 14.5Fr catheter allowed a maximum CO2 elimination rate of 77.9 mL/minute, which did not result in the normalization of pH. Veno-venous ECCO2R may serve as a treatment option for severe Respiratory Acidosis. In this porcine model, ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 mL/minute, while an increase in sweep gas flow from 8 to 16 L/minute had less impact on ECCO2R in this setting.
Wolfram Windisch - One of the best experts on this subject based on the ideXlab platform.
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impact of membrane lung surface area and blood flow on extracorporeal co 2 removal during severe Respiratory Acidosis
Intensive Care Medicine Experimental, 2017Co-Authors: Christian Karagiannidis, Anders Larsson, Stephan Strassmann, Daniel Brodie, Philine Ritter, Ralf Borchardt, Wolfram WindischAbstract:Veno-venous extracorporeal CO2 removal (vv-ECCO2R) is increasingly being used in the setting of acute Respiratory failure. Blood flow rates through the device range from 200 ml/min to more than 1500 ml/min, and the membrane surface areas range from 0.35 to 1.3 m2. The present study in an animal model with similar CO2 production as an adult patient was aimed at determining the optimal membrane lung surface area and technical requirements for successful vv-ECCO2R. Four different membrane lungs, with varying lung surface areas of 0.4, 0.8, 1.0, and 1.3m2 were used to perform vv-ECCO2R in seven anesthetized, mechanically ventilated, pigs with experimentally induced severe Respiratory Acidosis (pH 7.0–7.1) using a 20Fr double-lumen catheter with a sweep gas flow rate of 8 L/min. During each experiment, the blood flow was increased stepwise from 250 to 1000 ml/min. Amelioration of severe Respiratory Acidosis was only feasible when blood flow rates from 750 to 1000 ml/min were used with a membrane lung surface area of at least 0.8 m2. Maximal CO2 elimination was 150.8 ml/min, with pH increasing from 7.01 to 7.30 (blood flow 1000 ml/min; membrane lung 1.3 m2). The membrane lung with a surface of 0.4 m2 allowed a maximum CO2 elimination rate of 71.7 mL/min, which did not result in the normalization of pH, even with a blood flow rate of 1000 ml/min. Also of note, an increase of the surface area above 1.0 m2 did not result in substantially higher CO2 elimination rates. The pressure drop across the oxygenator was considerably lower (<10 mmHg) in the largest membrane lung, whereas the smallest revealed a pressure drop of more than 50 mmHg with 1000 ml blood flow/min. In this porcine model, vv-ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 ml/min, with a membrane lung surface of at least 0.8 m2. In contrast, low blood flow rates (250–500 ml/min) were not sufficient to completely correct severe Respiratory Acidosis, irrespective of the surface area of the membrane lung being used. The converse was also true, low surface membrane lungs (0.4 m2) were not capable of completely correcting severe Respiratory Acidosis across the range of blood flows used in this study.
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Impact of membrane lung surface area and blood flow on extracorporeal CO2 removal during severe Respiratory Acidosis
SpringerOpen, 2017Co-Authors: Christian Karagiannidis, Anders Larsson, Stephan Strassmann, Daniel Brodie, Philine Ritter, Ralf Borchardt, Wolfram WindischAbstract:Abstract Background Veno-venous extracorporeal CO2 removal (vv-ECCO2R) is increasingly being used in the setting of acute Respiratory failure. Blood flow rates through the device range from 200 ml/min to more than 1500 ml/min, and the membrane surface areas range from 0.35 to 1.3 m2. The present study in an animal model with similar CO2 production as an adult patient was aimed at determining the optimal membrane lung surface area and technical requirements for successful vv-ECCO2R. Methods Four different membrane lungs, with varying lung surface areas of 0.4, 0.8, 1.0, and 1.3m2 were used to perform vv-ECCO2R in seven anesthetized, mechanically ventilated, pigs with experimentally induced severe Respiratory Acidosis (pH 7.0–7.1) using a 20Fr double-lumen catheter with a sweep gas flow rate of 8 L/min. During each experiment, the blood flow was increased stepwise from 250 to 1000 ml/min. Results Amelioration of severe Respiratory Acidosis was only feasible when blood flow rates from 750 to 1000 ml/min were used with a membrane lung surface area of at least 0.8 m2. Maximal CO2 elimination was 150.8 ml/min, with pH increasing from 7.01 to 7.30 (blood flow 1000 ml/min; membrane lung 1.3 m2). The membrane lung with a surface of 0.4 m2 allowed a maximum CO2 elimination rate of 71.7 mL/min, which did not result in the normalization of pH, even with a blood flow rate of 1000 ml/min. Also of note, an increase of the surface area above 1.0 m2 did not result in substantially higher CO2 elimination rates. The pressure drop across the oxygenator was considerably lower (
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veno venous extracorporeal co2 removal for the treatment of severe Respiratory Acidosis pathophysiological and technical considerations
Critical Care, 2014Co-Authors: Christian Karagiannidis, Kristin Aufm Kampe, Fernando Suarez Sipmann, Anders Larsson, Goran Hedenstierna, Wolfram Windisch, Thomas F MuellerAbstract:While non-invasive ventilation aimed at avoiding intubation has become the modality of choice to treat mild to moderate acute Respiratory Acidosis, many severely acidotic patients (pH <7.20) still need intubation. Extracorporeal veno-venous CO2 removal (ECCO2R) could prove to be an alternative. The present animal study tested in a systematic fashion technical requirements for successful ECCO2R in terms of cannula size, blood and sweep gas flow. ECCO2R with a 0.98 m2 surface oxygenator was performed in six acidotic (pH <7.20) pigs using either a 14.5 French (Fr) or a 19Fr catheter, with sweep gas flow rates of 8 and 16 L/minute, respectively. During each experiment the blood flow was incrementally increased to a maximum of 400 mL/minute (14.5Fr catheter) and 1000 mL/minute (19Fr catheter). Amelioration of severe Respiratory Acidosis was only feasible when blood flow rates of 750 to 1000 mL/minute (19Fr catheter) were used. Maximal CO2-elimination was 146.1 ± 22.6 mL/minute, while pH increased from 7.13 ± 0.08 to 7.41 ± 0.07 (blood flow of 1000 mL/minute; sweep gas flow 16 L/minute). Accordingly, a sweep gas flow of 8 L/minute resulted in a maximal CO2-elimination rate of 138.0 ± 16.9 mL/minute. The 14.5Fr catheter allowed a maximum CO2 elimination rate of 77.9 mL/minute, which did not result in the normalization of pH. Veno-venous ECCO2R may serve as a treatment option for severe Respiratory Acidosis. In this porcine model, ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 mL/minute, while an increase in sweep gas flow from 8 to 16 L/minute had less impact on ECCO2R in this setting.
Lorenzo Del Sorbo - One of the best experts on this subject based on the ideXlab platform.
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Extracorporeal carbon dioxide removal in acute exacerbations of chronic obstructive pulmonary disease.
Annals of translational medicine, 2018Co-Authors: Tommaso Pettenuzzo, Eddy Fan, Lorenzo Del SorboAbstract:Extracorporeal carbon dioxide removal (ECCO 2 R) has been proposed as an adjunctive intervention to avoid worsening Respiratory Acidosis, thereby preventing or shortening the duration of invasive mechanical ventilation (IMV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD). This review will present a comprehensive summary of the pathophysiological rationale and clinical evidence of ECCO 2 R in patients suffering from severe COPD exacerbations.
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Tidal volume lower than 6 ml/kg enhances lung protection: Role of extracorporeal carbon dioxide removal
Anesthesiology, 2009Co-Authors: V. Marco Ranieri, Lorenzo Del Sorbo, Rosario Urbino, Alberto Birocco, Chiara Faggiano, Erica L. Martin, Pierpaolo Terragni, Luciana Mascia, Michael Quintel, Luciano GattinoniAbstract:BACKGROUND: Tidal hyperinflation may occur in patients with acute Respiratory distress syndrome who are ventilated with a tidal volume (VT) of 6 ml/kg of predicted body weight develop a plateau pressure (PPLAT) of 28 < or = PPLAT < or = 30 cm H2O. The authors verified whether VT lower than 6 ml/kg may enhance lung protection and that consequent Respiratory Acidosis may be managed by extracorporeal carbon dioxide removal. METHODS: PPLAT, lung morphology computed tomography, and pulmonary inflammatory cytokines (bronchoalveolar lavage) were assessed in 32 patients ventilated with a VT of 6 ml/kg. Data are provided as mean +/- SD or median and interquartile (25th and 75th percentile) range. In patients with 28 < or = PPLAT < or = 30 cm H2O (n = 10), VT was reduced from 6.3 +/- 0.2 to 4.2 +/- 0.3 ml/kg, and PPLAT decreased from 29.1 +/- 1.2 to 25.0 +/- 1.2 cm H2O (P < 0.001); consequent Respiratory Acidosis (Paco2 from 48.4 +/- 8.7 to 73.6 +/- 11.1 mmHg and pH from 7.36 +/- 0.03 to 7.20 +/- 0.02; P < 0.001) was managed by extracorporeal carbon dioxide removal. Lung function, morphology, and pulmonary inflammatory cytokines were also assessed after 72 h. RESULTS: Extracorporeal assist normalized Paco2 (50.4 +/- 8.2 mmHg) and pH (7.32 +/- 0.03) and allowed use of VT lower than 6 ml/kg for 144 (84-168) h. The improvement of morphological markers of lung protection and the reduction of pulmonary cytokines concentration (P < 0.01) were observed after 72 h of ventilation with VT lower than 6 ml/kg. No patient-related complications were observed. CONCLUSIONS: VT lower than 6 ml/Kg enhanced lung protection. Respiratory Acidosis consequent to low VT ventilation was safely and efficiently managed by extracorporeal carbon dioxide removal.
Ian K Taylor - One of the best experts on this subject based on the ideXlab platform.
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anemia and performance status as prognostic markers in acute hypercapnic Respiratory failure due to chronic obstructive pulmonary disease
International Journal of Chronic Obstructive Pulmonary Disease, 2013Co-Authors: Helmy Haja Mydin, Stephen Murphy, Howell Clague, Kishore Sridharan, Ian K TaylorAbstract:Background: In patients with acute hypercapnic Respiratory failure (AHRF) during exacerbations of COPD, mortality can be high despite noninvasive ventilation (NIV). For some, AHRF is terminal and NIV is inappropriate. However there is no definitive method of identifying patients who are unlikely to survive. The aim of this study was to identify factors associated with inpatient mortality from AHRF with Respiratory Acidosis due to COPD. Methods: COPD patients presenting with AHRF and who were treated with NIV were studied prospectively. The forced expiratory volume in 1 second (FEV 1 ), World Health Organization performance status (WHO-PS), clinical observations, a composite physiological score (Early Warning Score), routine hematology and biochemistry, and arterial blood gases prior to commencing NIV, were recorded. Results: In total, 65 patients were included for study, 29 males and 36 females, with a mean age of 71 ± 10.5 years. Inpatient mortality in the group was 33.8%. Mortality at 30 days and 12 months after admission were 38.5% and 58.5%, respectively. On univariate analysis, the variables associated with inpatient death were: WHO-PS $ 3, long-term oxygen therapy, anemia, diastolic blood pressure , 70 mmHg, Early Warning Score $ 3, severe Acidosis (pH , 7.20), and serum albumin , 35 g/L. On multivariate analysis, only anemia and WHO-PS $ 3 were significant. The presence of both predicted 68% of inpatient deaths, with a specificity of 98%. Conclusion: WHO-PS $ 3 and anemia are prognostic factors in AHRF with Respiratory Acidosis due to COPD. A combination of the two provides a simple method of identifying patients unlikely to benefit from NIV.
