Spontaneous cyclical fluctuation in respiratory minute volume during prone position ventilation in a patient with COVID-19,Critical Care

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Spontaneous cyclical fluctuation in respiratory minute volume during prone position ventilation in a patient with COVID-19
Critical Care ( IF 15.1 ) Pub Date : 2022-07-01 , DOI: 10.1186/s13054-022-04072-3
Olivier van Minnen ₁ , Joep M Droogh ₁

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Prone positioning of patients with acute respiratory distress syndrome (ARDS) has been used for many years. During the ongoing COVID-19 pandemic, prone position has largely been adopted by clinicians. Improvement in oxygenation and reduction in mortality are the main reasons to apply prone position in ARDS patients. The change from supine to prone position gives a better distribution of the gas/tissue ratio and a more homogeneous distribution of lung stress and damage. The reason for the reduced mortality is less overdistention of the lungs and less cyclical opening and closing of the alveoli [1].

A 74-year-old male patient, who was admitted to the intensive care unit (ICU) for respiratory failure due to severe COVID-19 ARDS, required invasive mechanical ventilation in prone position because of severely impaired oxygenation. The patient was treated with pressure-controlled ventilation, was deeply sedated and continuous neuromuscular blockade was achieved. We noticed a spontaneous cyclical fluctuation in respiratory minute volume and expiratory tidal volume with constant ventilator settings. The expiratory tidal volume fluctuated between 306 and 428 ml (mean 380.94 ml, standard deviation (SD) 27.15 ml) every 7.5 min. The respiratory minute volume fluctuated between 7.9 l/min and 10.9 l/min (mean 9.90 l/min, SD 0.70 l/min).

Patients admitted to our ICU are positioned on an air-cushion anti-decubitus mattress (Wissner-Bosserhoff, Vituoso 2®). This mattress consists of 17 air-filled cells and uses alternating pressure therapy, in which 1/3 of the cells alternately deflate and inflate every 7.5 min to prevent pressure ulcers of the skin. We hypothesized that the fluctuation in tidal volumes and respiratory minute volume were caused by the alternating inflation of the cells of the mattress.

To determine the influence of the alternating pressure therapy on the tidal volume, we set the mattress to the 'max inflate' mode, which is normally used during patient care. All cells are fully inflated in this modality. During the use of the max inflate modality, we observed a stable respiratory minute volume (min 8.9 l/min, max 10.2 l/min, Mean 9.97 l/min, SD 0.24 l/min) and expiratory tidal volume (min 372.6 ml, max 398.6 ml, Mean 385.62, SD 6.22), which started to fluctuate again after restarting the alternating pressure therapy (Fig. 1). These findings were not observed in supine position.

A possible explanation for the fluctuation in respiratory minute volume might be the pressure changes on the thorax and abdomen caused by the mattress, resulting in a reduction of chest wall compliance. This emphasizes the need for optimal positioning of patients in the prone position. Since driving pressures in severely ARDS patients are preferably set to values below 15 cm H2O and as a consequence, pH values are accepted down to 7.22 accordingly [2], minute ventilation volumes should be closely monitored. Therefore, one should be aware of the described changes in minute ventilation volumes due to the mattress settings. On the other hand, some preclinical models showed improved oxygenation and reduced histological lung damage when variable tidal volumes were used during pressure control ventilation in ARDS [3,4,5]. Therefore, the fluctuation in tidal volumes caused by the mattress could have had beneficial effects for this patient. However, more research is needed.

The dataset used and analyzed during this current study are available from the corresponding author on reasonable request.

Guérin C, Albert RK, Beitler J, Gattinoni L, Jaber S, Marini JJ, et al. Prone position in ARDS patients: why, when, how and for whom. Intensive Care Med. 2020;46(12):2385–96. https://doi.org/10.1007/s00134-020-06306-w.
CAS Article PubMed PubMed Central Google Scholar
Kondili E, Makris D, Georgopoulos D, Rovina N, Kotanidou A, Koutsoukou A. COVID-19 ARDS: points to be considered in mechanical ventilation and weaning. J Pers Med. 2021;11(11):1109.
Article Google Scholar
Güldner A, Huhle R, Beda A, Kiss T, Bluth T, Rentzsch I, et al. Periodic fluctuation of tidal volumes further improves variable ventilation in experimental acute respiratory distress syndrome. Front Physiol. 2018;9:905.
Article Google Scholar
Spieth PM, Carvalho AR, Pelosi P, Hoehn C, Meissner C, Kasper M, et al. Variable tidal volumes improve lung protective ventilation strategies in experimental lung injury. Am J Respir Crit Care Med. 2009;179(8):684–93.
Article Google Scholar
Dos Santos RA, Fodor GH, Kassai M, Degrugilliers L, Bayat S, Petak F, et al. Physiologically variable ventilation reduces regional lung inflammation in a pediatric model of acute respiratory distress syndrome. Respir Res. 2020;21(1):288.
Article Google Scholar

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Authors and Affiliations

Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
Olivier van Minnen & Joep M. Droogh

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Olivier van MinnenView author publications
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OVM collected the data. OVM and JMD analyzed the data and wrote the manuscript. All authors reviewed and approved the manuscript.

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Correspondence to Olivier van Minnen.

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van Minnen, O., Droogh, J.M. Spontaneous cyclical fluctuation in respiratory minute volume during prone position ventilation in a patient with COVID-19. Crit Care 26, 194 (2022). https://doi.org/10.1186/s13054-022-04072-3

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Received: 29 April 2022
Accepted: 07 June 2022
Published: 01 July 2022
DOI: https://doi.org/10.1186/s13054-022-04072-3

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Keywords

Mechanical ventilation
Prone position
ARDS

中文翻译：

COVID-19患者俯卧位通气期间每分钟呼吸量的自发周期性波动

亲爱的编辑，

急性呼吸窘迫综合征 (ARDS) 患者的俯卧位已使用多年。在持续的 COVID-19 大流行期间，临床医生在很大程度上采用了俯卧位。改善氧合和降低死亡率是在 ARDS 患者中应用俯卧位的主要原因。从仰卧位到俯卧位的变化提供了更好的气体/组织比分布和更均匀的肺应力和损伤分布。死亡率降低的原因是肺部过度膨胀较少和肺泡周期性打开和关闭较少[1]。

一名 74 岁男性患者因严重的 COVID-19 ARDS 呼吸衰竭而住进重症监护室 (ICU)，由于氧合严重受损，需要在俯卧位进行有创机械通气。患者接受压力控制通气治疗，深度镇静并实现持续的神经肌肉阻滞。我们注意到在恒定的呼吸机设置下，每分钟呼吸量和呼气潮气量会出现自发的周期性波动。呼气潮气量每 7.5 分钟在 306 和 428 毫升之间波动（平均 380.94 毫升，标准差 (SD) 27.15 毫升）。每分钟呼吸量在 7.9 l/min 和 10.9 l/min 之间波动（平均 9.90 l/min，SD 0.70 l/min）。

入住我们 ICU 的患者被放置在气垫防褥疮床垫（Wissner-Bosserhoff，Vituoso 2®）上。这款床垫由 17 个充气单元组成，采用交替压力疗法，其中 1/3 的单元每 7.5 分钟交替放气和充气，以防止皮肤压疮。我们假设潮气量和每分钟呼吸量的波动是由床垫细胞的交替膨胀引起的。

为了确定交替压力疗法对潮气量的影响，我们将床垫设置为“最大充气”模式，这通常在患者护理期间使用。在这种模式下，所有细胞都完全膨胀。在使用最大充气模式期间，我们观察到稳定的每分钟呼吸量（最小 8.9 升/分钟，最大 10.2 升/分钟，平均 9.97 升/分钟，标准差 0.24 升/分钟）和呼气潮气量（最小 372.6 毫升，最大 398.6 毫升，平均 385.62，标准差 6.22），重新开始交替压力治疗后再次开始波动（图 1）。在仰卧位未观察到这些发现。

每分钟呼吸量波动的一个可能解释可能是床垫引起的胸部和腹部压力变化，导致胸壁顺应性降低。这强调了将患者最佳定位在俯卧位的必要性。由于严重 ARDS 患者的驱动压力优选设置为低于 15 cm H2O 的值，因此，可接受的 pH 值相应降至 7.22 [2]，因此应密切监测每分钟通气量。因此，应注意所述因床垫设置而导致的每分钟通气量变化。另一方面，一些临床前模型显示，在 ARDS 的压力控制通气期间使用可变潮气量时，氧合得到改善，组织学肺损伤减少 [3,4,5]。所以，床垫引起的潮气量波动可能对该患者产生有益影响。然而，还需要更多的研究。

本研究中使用和分析的数据集可根据合理要求从相应作者处获得。

Guérin C、Albert RK、Beitler J、Gattinoni L、Jaber S、Marini JJ 等。ARDS 患者的俯卧位：为什么、何时、如何以及为谁。重症监护医学。2020；46（12）：2385-96。https://doi.org/10.1007/s00134-020-06306-w。
CAS 文章 PubMed PubMed Central Google Scholar
Kondili E, Makris D, Georgopoulos D, Rovina N, Kotanidou A, Koutsoukou A. COVID-19 ARDS：机械通气和断奶时需要考虑的要点。J Pers Med。2021；11（11）：1109。
文章谷歌学术
Güldner A、Huhle R、Beda A、Kiss T、Bluth T、Rentzsch I 等。潮气量的周期性波动进一步改善了实验性急性呼吸窘迫综合征的可变通气。前生理学。2018；9:905。
文章谷歌学术
Spieth PM、Carvalho AR、Pelosi P、Hoehn C、Meissner C、Kasper M 等。可变潮气量可改善实验性肺损伤中的肺保护性通气策略。Am J Respir Crit Care Med。2009;179(8):684-93。
文章谷歌学术
Dos Santos RA、Fodor GH、Kassai M、Degrugilliers L、Bayat S、Petak F 等。生理变化通气可减少急性呼吸窘迫综合征儿科模型中的局部肺部炎症。呼吸水库 2020；21（1）：288。
文章谷歌学术

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Olivier van Minnen & Joep M. Droogh

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