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In patients with chronic obstructive pulmonary disease (COPD), single lung transplantation (SLT) is sometimes performed as an alternative to bilateral lung transplantation due to limited organ availability. However, the postoperative management of SLT presents challenges, including complications related to the distinct compliance of each lung. This case report presents the case of a 65-year-old male patient who underwent SLT and was in the weaning period from mechanical ventilation. High-flow oxygen therapy (HFOT) was administered, and the physiological effects were measured using electrical impedance tomography (EIT). The results demonstrated that the application of HFOT increased air trapping and overdistention in the native lung without benefiting the transplanted lung. HFOT through a tracheostomy tube or nasal cannula resulted in a more heterogeneous distribution of ventilation, with increased end expiratory lung impedance, prolonged expiratory time constants, and an increase in silent spaces. The drop in tidal impedance after applying HFOT did not indicate hypoventilation but rather overdistention and air trapping in the native lung, while the transplanted lung showed evidence of hypoventilation. These findings suggest that HFOT may not be beneficial for SLT patients and could potentially worsen outcomes. However, due to the limited scope of this case report, further prospective studies with larger patient cohorts are needed to confirm these results.

En pacientes con enfermedad pulmonar obstructiva crónica (EPOC), el trasplante pulmonar unilateral (SLT, por sus siglas en inglés) se realiza como alternativa a la disponibilidad limitada de donantes para el trasplante pulmonar bilateral. Sin embargo, el manejo postoperatorio del SLT presenta desafíos, incluyendo complicaciones relacionadas con la distinta complacencia de cada pulmón. Este reporte presenta el caso de un paciente varón de 65 años que fue sometido a un SLT y se encontraba en el proceso de destete de la ventilación mecánica. Se administró terapia de oxígeno de alto flujo (HFOT, por sus siglas en inglés) y se midieron los efectos fisiológicos utilizando la tomografía de impedancia eléctrica (EIT, por sus siglas en inglés). Los resultados demostraron que la aplicación de HFOT aumentó la retención de aire y la hiperinflación en el pulmón nativo sin beneficiar al pulmón trasplantado. Tanto la HFOT a través de un tubo de traqueostomía como a través de cánula nasal resultaron en una distribución más heterogénea de la ventilación, con un aumento en la impedancia pulmonar al final de la espiración, prolongación de las constantes de tiempo espiratorias y un aumento en los espacios silentes. La disminución de la impedancia tidal después de aplicar HFOT no indicó hipoventilación, sino más bien hiperinsuflación y retención de gas en el pulmón nativo, mientras que el pulmón trasplantado mostró evidencia de hipoventilación. Estos hallazgos sugieren que el HFOT puede no ser beneficioso para los pacientes con SLT y podría empeorar los resultados. Sin embargo, debido al alcance limitado de este informe de caso, se necesitan estudios prospectivos con cohortes de pacientes más amplias para confirmar estos resultados.

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Abstract In patients with chronic obstructive pulmonary dis ease (COPD), single lung transplantation (SLT) is some times performed as an alternative to bilateral lung trans plantation due to limited organ availability. However, the postoperative management of SLT presents challenges, including complications related to the distinct compli ance of each lung. This case report presents the case of a 65-year-old male patient who underwent SLT and was in the weaning period from mechanical ventilation. High-flow oxygen therapy (HFOT) was administered, and the physiological effects were measured using electrical impedance tomography (EIT). The results demonstrated that the application of HFOT increased air trapping and overdistention in the native lung without benefiting the transplanted lung. HFOT through a tracheostomy tube or nasal cannula resulted in a more heterogeneous distri bution of ventilation, with increased end expiratory lung impedance, prolonged expiratory time constants, and an increase in silent spaces. The drop in tidal impedance after applying HFOT did not indicate hypoventilation but rather overdistention and air trapping in the native lung, while the transplanted lung showed evidence of hypoventilation. These findings suggest that HFOT may not be beneficial for SLT patients and could potentially worsen outcomes. However, due to the limited scope of this case report, further prospective studies with larger patient cohorts are needed to confirm these results.

Resumen En pacientes con enfermedad pulmonar obstructiva crónica (EPOC), el trasplante pulmonar unilateral (SLT, por sus siglas en inglés) se realiza como alternativa a la disponibilidad limitada de donantes para el trasplante pulmonar bilateral. Sin embargo, el manejo postoperato rio del SLT presenta desafíos, incluyendo complicaciones relacionadas con la distinta complacencia de cada pul món. Este reporte presenta el caso de un paciente varón de 65 años que fue sometido a un SLT y se encontraba en el proceso de destete de la ventilación mecánica. Se administró terapia de oxígeno de alto flujo (HFOT, por sus siglas en inglés) y se midieron los efectos fisiológicos utilizando la tomografía de impedancia eléctrica (EIT, por sus siglas en inglés). Los resultados demostraron que la aplicación de HFOT aumentó la retención de aire y la hiperinflación en el pulmón nativo sin beneficiar al pulmón trasplantado. Tanto la HFOT a través de un tubo de traqueostomía como a través de cánula nasal resultaron en una distribución más heterogénea de la ventilación, con un aumento en la impedancia pulmonar al final de la espiración, prolongación de las constantes de tiempo espiratorias y un aumento en los espacios silentes. La disminución de la impedancia tidal después de aplicar HFOT no indicó hipoventilación, sino más bien hiperinsuflación y retención de gas en el pulmón nativo, mientras que el pulmón trasplantado mostró evidencia de hipoventilación. Estos hallazgos sugieren que el HFOT puede no ser beneficioso para los pacientes con SLT y podría empeorar los resultados. Sin embargo, debido al alcance limitado de este informe de caso, se necesitan estudios prospectivos con cohortes de pacientes más amplias para confirmar estos resultados.

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BACKGROUND: To analyze the role of PEEP on dynamic relative regional strain (DRRS) in a model of ARDS, respective maps were generated by electrical impedance tomography (EIT). METHODS: Eight ARDS pigs submitted to PEEP steps of 0, 5, 10, and 15 cm H2O at fixed ventilation were evaluated by EIT images. DRRS was calculated as (VT-EIT/EELI)/(VT-EIT[15PEEP]/EELI[15PEEP]), where the tidal volume (VT)-EIT and end-expiratory lung impedance (EELI) are the tidal and end-expiratory change in lung impedance, respectively. The measurement at 15 PEEP was taken as reference (end-expiratory transpulmonary pressure > 0 cm H2O). The relationship between EIT variables (center of ventilation, EELI, and DRRS) and airway pressures was assessed with mixed-effects models using EIT measurements as dependent variables and PEEP as fixed-effect variable. RESULTS: At constant ventilation, respiratory compliance increased progressively with PEEP (lowest value at zero PEEP 10 ± 3 mL/cm H2O and highest value at 15 PEEP 16 ± 6 mL/cm H2O; P < .001), whereas driving pressure decreased with PEEP (highest value at zero PEEP 34 ± 6 cm H2O and lowest value at 15 PEEP 21 ± 4 cm H2O; P < .001). The mixed-effect regression models showed that the center of ventilation moved to dorsal lung areas with a slope of 1.81 (1.44-2.18) % points by each cm H2O of PEEP; P < .001. EELI increased with a slope of 0.05 (0.02-0.07) (arbitrary units) for each cm H2O of PEEP; P < .001. DRRS maps showed that local strain in ventral lung areas decreased with a slope of -0.02 (-0.24 to 0.15) with each cm H2O increase of PEEP; P < .001. CONCLUSIONS: EIT-derived DRRS maps showed high strain in ventral lung zones at low levels of PEEP. The findings suggest overdistention of the baby lung.

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To evaluate the use of non-invasive variables for monitoring an open-lung approach (OLA) strategy in bariatric surgery. Twelve morbidly obese patients undergoing bariatric surgery received a baseline protective ventilation with 8 cmH2O of positive-end expiratory pressure (PEEP). Then, the OLA strategy was applied consisting in lung recruitment followed by a decremental PEEP trial, from 20 to 8 cmH2O, in steps of 2 cmH2O to find the lung's closing pressure. Baseline ventilation was then resumed setting open lung PEEP (OL-PEEP) at 2 cmH2O above this pressure. The multimodal non-invasive variables used for monitoring OLA consisted in pulse oximetry (SpO2), respiratory compliance (Crs), end-expiratory lung volume measured by a capnodynamic method (EELVCO2), and esophageal manometry. OL-PEEP was detected at 15.9 ± 1.7 cmH2O corresponding to a positive end-expiratory transpulmonary pressure (PL,ee) of 0.9 ± 1.1 cmH2O. ROC analysis showed that SpO2 was more accurate (AUC 0.92, IC95% 0.87-0.97) than Crs (AUC 0.76, IC95% 0.87-0.97) and EELVCO2 (AUC 0.73, IC95% 0.64-0.82) to detect the lung's closing pressure according to the change of PL,ee from positive to negative values. Compared to baseline ventilation with 8 cmH2O of PEEP, OLA increased EELVCO2 (1309 ± 517 vs. 2177 ± 679 mL) and decreased driving pressure (18.3 ± 2.2 vs. 10.1 ± 1.7 cmH2O), estimated shunt (17.7 ± 3.4 vs. 4.2 ± 1.4%), lung strain (0.39 ± 0.07 vs. 0.22 ± 0.06) and lung elastance (28.4 ± 5.8 vs. 15.3 ± 4.3 cmH2O/L), respectively; all p < 0.0001. The OLA strategy can be monitored using noninvasive variables during bariatric surgery. This strategy decreased lung strain, elastance and driving pressure compared with standard protective ventilatory settings.Clinical trial number NTC03694665.

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BACKGROUND: The difference between Bohr and Enghoff dead space are not well described in ARDS patients. We aimed to analyze the effect of PEEP on the Bohr and Enghoff dead spaces in a model of ARDS. METHODS: 10 pigs submitted to randomized PEEP steps of 0, 5, 10, 15, 20, 25 and 30 cm H2O were evaluated with the use of lung ultrasound images, alveolar-arterial oxygen difference (P(A-a)O2 ), transpulmonary mechanics, and volumetric capnography at each PEEP step. RESULTS: At PEEP ≥ 15 cm H2O, atelectasis and P(A-a)O2 progressively decreased while end-inspiratory transpulmonary pressure (PL), end-expiratory PL, and driving PL increased (all P < .001). Bohr dead space (VDBohr /VT), airway dead space (VDaw /VT), and alveolar dead space (VDalv /VTalv ) reached their highest values at PEEP 30 cm H2O (0.69 ± 0.10, 0.53 ± 0.13 and 0.35 ± 0.06, respectively). At PEEP <15 cm H2O, the increases in atelectasis and P(A-a)O2 were associated with negative end-expiratory PL and highest driving PL. VDBohr /VT and VDaw /VT showed the lowest values at PEEP 0 cm H2O (0.51 ± 0.08 and 0.32 ± 0.08, respectively), whereas VDalv /VTalv increased to 0.27 ± 0.05. Enghoff dead space and its derived VDalv /VTalv showed high values at low PEEPs (0.86 ± 0.02 and 0.79 ± 0.04, respectively) and at high PEEPs (0.84 ± 0.04 and 0.65 ± 0.12), with the lowest values at 15 cm H2O (0.77 ± 0.05 and 0.61 ± 0.11, respectively; all P < .001). CONCLUSIONS: Bohr dead space was associated with lung stress, whereas Enghoff dead space was partially affected by the shunt effect.

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Asynchrony due to reverse-triggering (RT) may appear in ARDS patients. The objective of this study is to validate an algorithm developed to detect these alterations in patient-ventilator interaction. We developed an algorithm that uses flow and airway pressure signals to classify breaths as normal, RT with or without breath stacking (BS) and patient initiated double-triggering (DT). The diagnostic performance of the algorithm was validated using two datasets of breaths, that are classified as stated above. The first dataset classification was based on visual inspection of esophageal pressure (Pes) signal from 699 breaths recorded from 11 ARDS patients. The other classification was obtained by vote of a group of 7 experts (2 physicians and 5 respiratory therapists, who were trained in ICU), who evaluated 1881 breaths gathered from recordings from 99 subjects. Experts used airway pressure and flow signals for breaths classification. The RT with or without BS represented 19% and 37% of breaths in Pes dataset while their frequency in the expert's dataset were 3% and 12%, respectively. The DT was very infrequent in both datasets. Algorithm classification accuracy was 0.92 (95% CI 0.89-0.94, P < 0.001) and 0.96 (95% CI 0.95-0.97, P < 0.001), in comparison with Pes and experts' opinion. Kappa statistics were 0.86 and 0.84, respectively. The algorithm precision, sensitivity and specificity for individual asynchronies were excellent. The algorithm yields an excellent accuracy for detecting clinically relevant asynchronies related to RT.

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To determine whether a classification based on the contour of the photoplethysmography signal (PPGc) can detect changes in systolic arterial blood pressure (SAP) and vascular tone. Episodes of normotension (SAP 90-140 mmHg), hypertension (SAP > 140 mmHg) and hypotension (SAP < 90 mmHg) were analyzed in 15 cardiac surgery patients. SAP and two surrogates of the vascular tone, systemic vascular resistance (SVR) and vascular compliance (Cvasc = stroke volume/pulse pressure) were compared with PPGc. Changes in PPG amplitude (foot-to-peak distance) and dicrotic notch position were used to define 6 classes taking class III as a normal vascular tone with a notch placed between 20 and 50% of the PPG amplitude. Class I-to-II represented vasoconstriction with notch placed > 50% in a small PPG, while class IV-to-VI described vasodilation with a notch placed < 20% in a tall PPG wave. 190 datasets were analyzed including 61 episodes of hypertension [SAP = 159 (151-170) mmHg (median 1st-3rd quartiles)], 84 of normotension, SAP = 124 (113-131) mmHg and 45 of hypotension SAP = 85(80-87) mmHg. SAP were well correlated with SVR (r = 0.78, p < 0.0001) and Cvasc (r = 0.84, p < 0.0001). The PPG-based classification correlated well with SAP (r = - 0.90, p < 0.0001), SVR (r = - 0.72, p < 0.0001) and Cvasc (r = 0.82, p < 0.0001). The PPGc misclassified 7 out of the 190 episodes, presenting good accuracy (98.4% and 97.8%), sensitivity (100% and 94.9%) and specificity (97.9% and 99.2%) for detecting episodes of hypotension and hypertension, respectively. Changes in arterial pressure and vascular tone were closely related to the proposed classification based on PPG waveform.Clinical Trial Registration NTC02854852.

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OBJECTIVE: To evaluate a novel physiological approach for setting the tidal volume in mechanical ventilation according to inspiratory capacity, and to determine if it results in an appropriate mechanical and gas exchange measurements in healthy and critically ill dogs. METHODS: Twenty healthy animals were included in the study to assess the tidal volume expressed as a percentage of inspiratory capacity. For inspiratory capacity measurement, the mechanical ventilator was set as follows: pressure control mode with 35cmH2O of inspired pressure and zero end-expiratory pressure for 5 seconds. Subsequently, the animals were randomized into four groups and ventilated with a tidal volume corresponding to the different percentages of inspiratory capacity. Subsequently, ten critically ill dogs were studied. RESULTS: Healthy dogs ventilated with a tidal volume of 17% of the inspiratory capacity showed normal respiratory mechanics and presented expected PaCO2 values more frequently than the other groups. The respiratory system and transpulmonary driving pressure were significantly higher among the critically ill dogs but below 15 cmH2O in all cases. CONCLUSIONS: The tidal volume based on the inspiratory capacity of each animal has proven to be a useful and simple tool when setting ventilator parameters. A similar approach should also be evaluated in other species, including human beings, if we consider the potential limitations of tidal volume titration based on the calculated ideal body weight.

OBJETIVO: Avaliar uma nova abordagem fisiológica para a determinação do volume corrente em ventilação mecânica, de acordo com a capacidade inspiratória, e determinar se isso resulta em medidas mecânicas e de troca gasosa adequadas em cães saudáveis e em estado crítico. MÉTODOS: Incluíram-se, neste estudo, 24 animais para avaliar o volume corrente expresso como porcentagem da capacidade inspiratória. Para mensuração da capacidade inspiratória, o ventilador mecânico foi regulado como segue: modo controle de pressão, com 35cmH2O de pressão de inspiração e pressão expiratória final de zero, por 5 segundos. Subsequentemente, estudaram-se dez cães em condições clínicas críticas. RESULTADOS: Cães saudáveis ventilados com volume corrente que correspondia a 17% da capacidade inspiratória demonstraram mecânica respiratória normal e apresentaram os valores previstos de PaCO2 mais frequentemente do que os animais nos demais grupos. A pressão no sistema respiratório e a pressão transpulmonar foram significantemente mais elevadas nos cães em condição crítica, porém em todos os casos, estiveram abaixo de 15cmH2O. CONCLUSÕES: O volume corrente calculado com base na capacidade inspiratória de cada animal comprovou ser uma ferramenta útil e simples para o estabelecimento dos parâmetros do ventilador. Convém também realizar abordagem semelhante em outras espécies, inclusive no ser humano, quando se consideram as potenciais limitações da titulação do volume corrente, com base no peso corpóreo ideal calculado.

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RESUMO Objetivo: Avaliar uma nova abordagem fisiológica para a determinação do volume corrente em ventilação mecânica, de acordo com a capacidade inspiratória, e determinar se isso resulta em medidas mecânicas e de troca gasosa adequadas em cães saudáveis e em estado crítico. Métodos: Incluíram-se, neste estudo, 24 animais para avaliar o volume corrente expresso como porcentagem da capacidade inspiratória. Para mensuração da capacidade inspiratória, o ventilador mecânico foi regulado como segue: modo controle de pressão, com 35cmH2O de pressão de inspiração e pressão expiratória final de zero, por 5 segundos. Subsequentemente, estudaram-se dez cães em condições clínicas críticas. Resultados: Cães saudáveis ventilados com volume corrente que correspondia a 17% da capacidade inspiratória demonstraram mecânica respiratória normal e apresentaram os valores previstos de PaCO2 mais frequentemente do que os animais nos demais grupos. A pressão no sistema respiratório e a pressão transpulmonar foram significantemente mais elevadas nos cães em condição crítica, porém em todos os casos, estiveram abaixo de 15cmH2O. Conclusões: O volume corrente calculado com base na capacidade inspiratória de cada animal comprovou ser uma ferramenta útil e simples para o estabelecimento dos parâmetros do ventilador. Convém também realizar abordagem semelhante em outras espécies, inclusive no ser humano, quando se consideram as potenciais limitações da titulação do volume corrente, com base no peso corpóreo ideal calculado.

ABSTRACT Objective: To evaluate a novel physiological approach for setting the tidal volume in mechanical ventilation according to inspiratory capacity, and to determine if it results in an appropriate mechanical and gas exchange measurements in healthy and critically ill dogs. Methods: Twenty healthy animals were included in the study to assess the tidal volume expressed as a percentage of inspiratory capacity. For inspiratory capacity measurement, the mechanical ventilator was set as follows: pressure control mode with 35cmH2O of inspired pressure and zero end-expiratory pressure for 5 seconds. Subsequently, the animals were randomized into four groups and ventilated with a tidal volume corresponding to the different percentages of inspiratory capacity. Subsequently, ten critically ill dogs were studied. Results: Healthy dogs ventilated with a tidal volume of 17% of the inspiratory capacity showed normal respiratory mechanics and presented expected PaCO2 values more frequently than the other groups. The respiratory system and transpulmonary driving pressure were significantly higher among the critically ill dogs but below 15 cmH2O in all cases. Conclusions: The tidal volume based on the inspiratory capacity of each animal has proven to be a useful and simple tool when setting ventilator parameters. A similar approach should also be evaluated in other species, including human beings, if we consider the potential limitations of tidal volume titration based on the calculated ideal body weight.

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PURPOSE: To analyze the effects of positive end-expiratory pressure (PEEP) on Bohr's dead space (VDBohr/VT) in patients with acute respiratory distress syndrome (ARDS). MATERIAL AND METHODS: Fourteen ARDS patients under lung protective ventilation settings were submitted to 4 different levels of PEEP (0, 6, 10, 16 cmH2O). Respiratory mechanics, hemodynamics and volumetric capnography were recorded at each protocol step. RESULTS: Two groups of patients responded differently to PEEP when comparing baseline with 16-PEEP: those in which driving pressure increased > 15% (∆P˃15%, n = 7, p = .016) and those in which the change was ≤15% (∆P≤15%, n = 7, p = .700). VDBohr/VT was higher in ∆P≤15% than in ∆P≤15% patients at baseline ventilation [0.58 (0.49-0.60) vs 0.46 (0.43-0.46) p = .018], at 0-PEEP [0.50 (0.47-0.54) vs 0.41 (0.40-0.43) p = .012], at 6-PEEP [0.55 (0.49-0.57) vs 0.44 (0.42-0.45) p = .008], at 10-PEEP [0.59 (0.51-0.59) vs 0.45 (0.44-0.46) p = .006] and at 16-PEEP [0.61 (0.56-0.65) vs 0.47 (0.45-0.48) p = .001]. We found a good correlation between ∆P and VDBohr/VT only in the ∆P˃15% group (r = 0.74, p < .001). CONCLUSIONS: Increases in PEEP result in higher VDBohr/VT only when associated with an increase in driving pressure.

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AIM: During manual positive pressure ventilation (PPV), delivering a recommended respiratory rate (RR) is operator dependent. We tested the efficacy of a metronome as a standardised method to improve the accuracy of delivered RR during manual PPV in a neonatal resuscitation simulation. METHODS: We conducted a blinded simulation in two consecutive stages. Using a self-inflating bag, 36 CPR trained operators provided PPV to a modified neonatal manikin via an endotracheal tube. Pressure and flow signals were captured by a respiratory function monitor. In the first standard stage, participants delivered RR as they would in delivery room. Prior to the second stage, they were asked about what their target RR had been and a metronome was set to that target. Subsequently, operators repeated PPV attempting to coordinate their delivered RR with the metronome. To evaluate accuracy we generated the variable RR Gap as the absolute difference between delivered and target RR. The primary outcome was the difference in RR Gap between stages. RESULTS: Mean (SD) target RR was 50 (8.7) inflations/min. During the initial stage, median (IQR) RR Gap was 11.6 (4.7-18.3) inflations/min and 20/36 participants (55.5%) had a mean delivered RR beyond the recommended range. When paced by the metronome, RR Gap was reduced to 0.2 (0.1-0.4) inflations/min and 32/36 participants (89%) fell within the recommended range. CONCLUSIONS: The use of a metronome improved the accuracy of delivered RR during manual PPV. Novel approaches to deliver an accurate RR during manual PPV need to be tested in more realistic scenarios.

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BACKGROUND: Selection of the PEEP associated with the best compliance of the respiratory system during decremental PEEP titration can be used for the treatment of patients suffering from ARDS. We describe changes in transpulmonary pressure (Ptp) and gas exchange during a decremental PEEP titration maneuver in subjects with pulmonary ARDS. METHODS: Eleven subjects with early ARDS were included. After a recruitment maneuver they were ventilated in volume-controlled ventilation and PEEP was decreased from 30 to 0 cm H2O by steps of 3 cm H2O. Static airway pressure (Paw), esophageal pressure (Pes), Ptp (Paw - Pes), the ratio of dead space to tidal volume (VD/VT), and PaO2 were recorded at each step. RESULTS: A linear correlation was found between Paw and Ptp. Expiratory Ptp became negative in all subjects when PEEP decreased below 8.9 ± 5.2 cm H2O. VD/VT was 0.67 ± 0.06 with 30 cm H2O of PEEP, and decreased 15.4 ± 8.5% during the maneuver, when PEEP and expiratory Ptp were 10.6 ± 4.1 cm H2O and 1.2 ± 2.8 cm H2O, respectively. VD/VT was significantly higher during ventilation at high (> 18 cm H2O), compared to low, inspiratory Ptp values (P < .001). PaO2 decreased when expiratory Ptp became negative (P < .001). CONCLUSIONS: During decremental PEEP titration we sequentially observed high inspiratory Ptp that stressed lung tissue and increased VD/VT, and negative Ptp, indicating high risk of alveolar collapse, explaining worse oxygenation. PEEP selection based on Ptp and VD/VT in ARDS may help to avoid these situations.

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Model and simulation of biological systems help to better understand these systems. In ICUs patients often reach a complex situation where supportive maneuvers require special expertise. Among them, mechanical ventilation in patients suffering from acuter respiratory distress syndrome (ARDS) is specially challenging. This work presents a model which can be simulated and use to help in training of physicians and respiratory therapists to analyze the respiratory mechanics in this kind of patients. We validated the model in 2 ARDS patients.

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