Publications by authors named "Davide Chiumello"

165 Publications

Nutrition Support in Patients With Acute Respiratory Distress Syndrome COVID-19.

Nutr Clin Pract 2021 Mar 5. Epub 2021 Mar 5.

Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.

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http://dx.doi.org/10.1002/ncp.10645DOI Listing
March 2021

Sevoflurane sedation and nephrogenic diabetes insipidus in patients affected with severe acute respiratory syndrome coronavirus 2.

Eur J Anaesthesiol 2021 04;38(4):438-441

From the SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo Carlo (CS, CD), Dipartimento di Scienze della Salute, Università degli Studi di Milano (CS, CM, CD), Centro ricerca coordinata di insufficienza respiratoria (CD) and SC Nefrologia e Dialisi ASST Santi Paolo Carlo, Milan, Italy (CM).

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http://dx.doi.org/10.1097/EJA.0000000000001318DOI Listing
April 2021

The furosemide stress test, electrolyte response and renal index in critically ill patients.

Minerva Anestesiol 2021 Feb 16. Epub 2021 Feb 16.

SC Anestesia e Rianimazione, Ospedale San Paolo Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.

Background: Acute kidney injury (AKI) is a common syndrome in critically ill patients. The diagnostic ability of traditional markers such as serum creatinine has recently been questioned, and the use of newer tests such as the furosemide stress test or the ultrasound assessment of renal resistive index have been proposed. Aim of the present study was to compare the response to a furosemide stress test, the renal index in mechanically ventilated patients with and without acute kidney injury at admission, and who did or did not develop AKI at day three, among those with normal renal function at the CIU admission.

Methods: Prospective observational study in consecutive mechanically ventilated patients admitted in a general intensive care. Furosemide stress test and ultrasonographical renal index were performed at the admission and clinical and laboratory data were collected before and two hours after the furosemide stress text. The urine output after the first and the second hours was recorded.

Results: Forty patients were enrolled, 19 of whom had AKI at admission. The renal index was significantly higher in patients with AKI (0.77±0.07 vs 0.72±0.08, p=0.027); patients with AKI had a significantly lower urine output after the furosemide stress test (400 [340; 1400] vs.1525 [400; 2550] ml; p=0.013). The plasma concentrations of sodium, potassium and chloride were not different before and after the furosemide stress test in patients with and without AKI, whereas in patients with AKI, the total urine output of sodium, potassium and chloride were significantly lower compared to patients without AKI. Similar results were found in patients without AKI at admission and who developed AKI at day three as compared to those who did not develop AKI.

Conclusions: The response to the furosemide stress test and the renal index could be used as additional tools to evaluate the kidney function in critically ill patients.
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http://dx.doi.org/10.23736/S0375-9393.21.14942-9DOI Listing
February 2021

Complexity and unanswered questions in the pathophysiology of COVID-19 ARDS.

Intensive Care Med 2021 Feb 1. Epub 2021 Feb 1.

Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany.

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http://dx.doi.org/10.1007/s00134-021-06353-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849962PMC
February 2021

The Many Faces of Covid-19 at a Glance: A University Hospital Multidisciplinary Account From Milan, Italy.

Front Public Health 2020;8:575029. Epub 2021 Jan 8.

Respiratory Medicine, Department of Health Sciences, San Paolo University Hospital, Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo, University of Milan Medical School, Milan, Italy.

In March 2020, northern Italy became the second country worldwide most affected by Covid-19 and the death toll overtook that in China. Hospital staff soon realized that Covid-19 was far more severe than expected from the few data available at that time. The Covid-19 pandemic forced hospitals to adjust to rapidly changing circumstances. We report our experience in a general teaching hospital in Milan, the capital of Lombardy, the most affected area in Italy. First, we briefly describe Lombardy's regional Covid-19-related health organizational changes as well as general hospital reorganization. We also provide a multidisciplinary report of the main clinical, radiological and pathological Covid-19 findings we observed in our patients.
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http://dx.doi.org/10.3389/fpubh.2020.575029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7820812PMC
February 2021

Aspirin in COVID-19 related ARDS: an old, low-cost therapy with a strong rationale.

Anesth Analg 2021 Jan 18. Epub 2021 Jan 18.

SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italia.

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http://dx.doi.org/10.1213/ANE.0000000000005408DOI Listing
January 2021

COVID-19 and ARDS: the baby lung size matters.

Intensive Care Med 2021 01 4;47(1):133-134. Epub 2020 Dec 4.

Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy.

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http://dx.doi.org/10.1007/s00134-020-06324-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716792PMC
January 2021

Pathophysiology of COVID-19-associated acute respiratory distress syndrome.

Lancet Respir Med 2021 01 13;9(1):e1. Epub 2020 Nov 13.

Pulmonary and Critical Care Medicine, Regions Hospital and University of Minnesota, St Paul, MN, USA.

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http://dx.doi.org/10.1016/S2213-2600(20)30505-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837039PMC
January 2021

Decreased serum level of sphingosine-1-phosphate: a novel predictor of clinical severity in COVID-19.

EMBO Mol Med 2021 01 9;13(1):e13424. Epub 2020 Dec 9.

Department of Medical Biotechnology and Translational Medicine, LITA-Segrate, Università degli Studi di Milano, Milan, Italy.

The severity of coronavirus disease 2019 (COVID-19) is a crucial problem in patient treatment and outcome. The aim of this study is to evaluate circulating level of sphingosine-1-phosphate (S1P) along with severity markers, in COVID-19 patients. One hundred eleven COVID-19 patients and forty-seven healthy subjects were included. The severity of COVID-19 was found significantly associated with anemia, lymphocytopenia, and significant increase of neutrophil-to-lymphocyte ratio, ferritin, fibrinogen, aminotransferases, lactate dehydrogenase (LDH), C-reactive protein (CRP), and D-dimer. Serum S1P level was inversely associated with COVID-19 severity, being significantly correlated with CRP, LDH, ferritin, and D-dimer. The decrease in S1P was strongly associated with the number of erythrocytes, the major source of plasma S1P, and both apolipoprotein M and albumin, the major transporters of blood S1P. Not last, S1P was found to be a relevant predictor of admission to an intensive care unit, and patient's outcome. Circulating S1P emerged as negative biomarker of severity/mortality of COVID-19 patients. Restoring abnormal S1P levels to a normal range may have the potential to be a therapeutic target in patients with COVID-19.
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http://dx.doi.org/10.15252/emmm.202013424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744841PMC
January 2021

Forecasting the burden of COVID-19 hospitalized patients during the SARS-CoV-2 second wave in Lombardy, Italy.

Panminerva Med 2021 03 13;63(1):86-87. Epub 2020 Nov 13.

Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.

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http://dx.doi.org/10.23736/S0031-0808.20.04212-3DOI Listing
March 2021

Fluid administration and monitoring in ARDS: which management?

Intensive Care Med 2020 Dec 9;46(12):2252-2264. Epub 2020 Nov 9.

SC Anestesia e Rianimazione, Ospedale San Paolo, Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.

Modalities of fluid management in patients sustaining the acute respiratory distress syndrome (ARDS) are challenging and controversial. Optimal fluid management should provide adequate oxygen delivery to the body, while avoiding inadvertent increase in lung edema which further impairs gas exchange. In ARDS patients, positive fluid balance has been associated with prolonged mechanical ventilation, longer ICU and hospital stay, and higher mortality. Accordingly, a restrictive strategy has been compared to a more liberal approach in randomized controlled trials conducted in various clinical settings. Restrictive strategies included fluid restriction guided by the monitoring of extravascular lung water, pulmonary capillary wedge or central venous pressure, and furosemide targeted to diuresis and/or albumin replacement in hypoproteinemic patients. Overall, restrictive strategies improved oxygenation significantly and reduced duration of mechanical ventilation, but had no significant effect on mortality. Fluid management may require different approaches depending on the time course of ARDS (i.e., early vs. late period). The effects of fluid strategy management according to ARDS phenotypes remain to be evaluated. Since ARDS is frequently associated with sepsis-induced acute circulatory failure, the prediction of fluid responsiveness is crucial in these patients to avoid hemodynamically inefficient-hence respiratory detrimental-fluid administration. Specific hemodynamic indices of fluid responsiveness or mini-fluid challenges should be preferably used. Since the positive airway pressure contributes to positive fluid balance in ventilated ARDS patients, it should be kept as low as possible. As soon as the hemodynamic status is stabilized, correction of cumulated fluid retention may rely on diuretics administration or renal replacement therapy.
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http://dx.doi.org/10.1007/s00134-020-06310-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652045PMC
December 2020

Lateral position during severe mono-lateral pneumonia: an experimental study.

Sci Rep 2020 11 9;10(1):19372. Epub 2020 Nov 9.

Department of Pulmonology, Hospital Clínic of Barcelona, Barcelona, Spain.

Patients with mono-lateral pneumonia and severe respiratory failure can be positioned in lateral decubitus, with the healthy lung dependent, to improve ventilation-perfusion coupling. Oxygenation response to this manoeuvre is heterogeneous and derecruitment of dependent lung has not been elucidated. Nine pigs (32.2 ± 1.2 kg) were sedated and mechanically ventilated. Mono-lateral right-sided pneumonia was induced with intrabronchial challenge of Pseudomonas aeruginosa. After 24 h, lungs were recruited and the animals were randomly positioned on right or left side. After 3 h of lateral positioning, the animals were placed supine; another recruitment manoeuvre was performed, and the effects of contralateral decubitus were assessed. Primary outcome was lung ultrasound score (LUS) of the dependent lung after 3-h lateral positioning. LUS of the left non-infected lung worsened while positioned in left-lateral position (from 1.33 ± 1.73 at baseline to 6.78 ± 4.49; p = 0.005). LUS of the right-infected lung improved when placed upward (9.22 ± 2.73 to 6.67 ± 3.24; p = 0.09), but worsened in right-lateral position (7.78 ± 2.86 to 13.33 ± 3.08; p < 0.001). PaO/FiO improved in the left-lateral position (p = 0.005). In an animal model of right-lung pneumonia, left-lateral decubitus improved oxygenation, but collapsed the healthy lung. Right-lateral orientation further collapsed the diseased lung. Our data raise potential clinical concerns for the use of lateral position in mono-lateral pneumonia.
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http://dx.doi.org/10.1038/s41598-020-76216-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653044PMC
November 2020

How to ventilate obese patients in the ICU.

Intensive Care Med 2020 12 23;46(12):2423-2435. Epub 2020 Oct 23.

Research Unit: PhyMedExp, INSERM U-1046, CNRS, Anesthesia and Critical Care Department (DAR-B), Saint Eloi, University of Montpellier, 34295, Montpellier, cedex 5, France.

Obesity is an important risk factor for major complications, morbidity and mortality related to intubation procedures and ventilation in the intensive care unit (ICU). The fall in functional residual capacity promotes airway closure and atelectasis formation. This narrative review presents the impact of obesity on the respiratory system and the key points to optimize airway management, noninvasive and invasive mechanical ventilation in ICU patients with obesity. Non-invasive strategies should first optimize body position with reverse Trendelenburg position or sitting position. Noninvasive ventilation (NIV) is considered as the first-line therapy in patients with obesity having a postoperative acute respiratory failure. Positive pressure pre-oxygenation before the intubation procedure is the method of reference. The use of videolaryngoscopy has to be considered by adequately trained intensivists, especially in patients with several risk factors. Regarding mechanical ventilation in patients with and without acute respiratory distress syndrome (ARDS), low tidal volume (6 ml/kg of predicted body weight) and moderate to high positive end-expiratory pressure (PEEP), with careful recruitment maneuver in selected patients, are advised. Prone positioning is a therapeutic choice in severe ARDS patients with obesity. Prophylactic NIV should be considered after extubation to prevent re-intubation. If obesity increases mortality and risk of ICU admission in the overall population, the impact of obesity on ICU mortality is less clear and several confounding factors have to be taken into account regarding the "obesity ICU paradox".
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http://dx.doi.org/10.1007/s00134-020-06286-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7582031PMC
December 2020

Physiological and quantitative CT-scan characterization of COVID-19 and typical ARDS: a matched cohort study.

Intensive Care Med 2020 12 21;46(12):2187-2196. Epub 2020 Oct 21.

Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Robert-Koch Straße 40, Göttingen, Germany.

Purpose: To investigate whether COVID-19-ARDS differs from all-cause ARDS.

Methods: Thirty-two consecutive, mechanically ventilated COVID-19-ARDS patients were compared to two historical ARDS sub-populations 1:1 matched for PaO/FiO or for compliance of the respiratory system. Gas exchange, hemodynamics and respiratory mechanics were recorded at 5 and 15 cmHO PEEP. CT scan variables were measured at 5 cmHO PEEP.

Results: Anthropometric characteristics were similar in COVID-19-ARDS, PaO/FiO-matched-ARDS and Compliance-matched-ARDS. The PaO/FiO-matched-ARDS and COVID-19-ARDS populations (both with PaO/FiO 106 ± 59 mmHg) had different respiratory system compliances (Crs) (39 ± 11 vs 49.9 ± 15.4 ml/cmHO, p = 0.03). The Compliance-matched-ARDS and COVID-19-ARDS had similar Crs (50.1 ± 15.7 and 49.9 ± 15.4 ml/cmHO, respectively) but significantly lower PaO/FiO for the same Crs (160 ± 62 vs 106.5 ± 59.6 mmHg, p < 0.001). The three populations had similar lung weights but COVID-19-ARDS had significantly higher lung gas volume (PaO/FiO-matched-ARDS 930 ± 644 ml, COVID-19-ARDS 1670 ± 791 ml and Compliance-matched-ARDS 1301 ± 627 ml, p < 0.05). The venous admixture was significantly related to the non-aerated tissue in PaO/FiO-matched-ARDS and Compliance-matched-ARDS (p < 0.001) but unrelated in COVID-19-ARDS (p = 0.75), suggesting that hypoxemia was not only due to the extent of non-aerated tissue. Increasing PEEP from 5 to 15 cmHO improved oxygenation in all groups. However, while lung mechanics and dead space improved in PaO/FiO-matched-ARDS, suggesting recruitment as primary mechanism, they remained unmodified or worsened in COVID-19-ARDS and Compliance-matched-ARDS, suggesting lower recruitment potential and/or blood flow redistribution.

Conclusions: COVID-19-ARDS is a subset of ARDS characterized overall by higher compliance and lung gas volume for a given PaO/FiO, at least when considered within the timeframe of our study.
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http://dx.doi.org/10.1007/s00134-020-06281-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577365PMC
December 2020

Urine Electrolytes in the Intensive Care Unit: From Pathophysiology to Clinical Practice.

Anesth Analg 2020 11;131(5):1456-1470

From the Struttura Complessa (SC) Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy.

Assessment of urine concentrations of sodium, chloride, and potassium is a widely available, rapid, and low-cost diagnostic option for the management of critically ill patients. Urine electrolytes have long been suggested in the diagnostic workup of hypovolemia, kidney injury, and acid-base and electrolyte disturbances. However, due to the wide range of normal reference values and challenges in interpretation, their use is controversial. To clarify their potential role in managing critical patients, we reviewed existing evidence on the use of urine electrolytes for diagnostic and therapeutic evaluation and assessment in critical illness. This review will describe the normal physiology of water and electrolyte excretion, summarize the use of urine electrolytes in hypovolemia, acute kidney injury, acid-base, and electrolyte disorders, and suggest some practical flowcharts for the potential use of urine electrolytes in daily critical care practice.
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http://dx.doi.org/10.1213/ANE.0000000000004994DOI Listing
November 2020

COVID-19: scientific reasoning, pragmatism and emotional bias.

Ann Intensive Care 2020 Oct 12;10(1):134. Epub 2020 Oct 12.

Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, and Division of Asthma, Allergy and Lung Biology, King's College London, London, UK.

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http://dx.doi.org/10.1186/s13613-020-00756-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549341PMC
October 2020

Hysteresis and Lung Recruitment in Acute Respiratory Distress Syndrome Patients: A CT Scan Study.

Crit Care Med 2020 Oct;48(10):1494-1502

SC Anestesia e Rianimazione, Ospedale San Paolo, Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.

Objectives: Hysteresis of the respiratory system pressure-volume curve is related to alveolar surface forces, lung stress relaxation, and tidal reexpansion/collapse. Hysteresis has been suggested as a means of assessing lung recruitment. The objective of this study was to determine the relationship between hysteresis, mechanical characteristics of the respiratory system, and lung recruitment assessed by a CT scan in mechanically ventilated acute respiratory distress syndrome patients.

Design: Prospective observational study.

Setting: General ICU of a university hospital.

Patients: Twenty-five consecutive sedated and paralyzed patients with acute respiratory distress syndrome (age 64 ± 15 yr, body mass index 26 ± 6 kg/m, PaO2/FIO2 147 ± 42, and positive end-expiratory pressure 9.3 ± 1.4 cm H2O) were enrolled.

Interventions: A low-flow inflation and deflation pressure-volume curve (5-45 cm H2O) and a sustained inflation recruitment maneuver (45 cm H2O for 30 s) were performed. A lung CT scan was performed during breath-holding pressure at 5 cm H2O and during the recruitment maneuver at 45 cm H2O.

Measurements And Main Results: Lung recruitment was computed as the difference in noninflated tissue and in gas volume measured at 5 and at 45 cm H2O. Hysteresis was calculated as the ratio of the area enclosed by the pressure-volume curve and expressed as the hysteresis ratio. Hysteresis was correlated with respiratory system compliance computed at 5 cm H2O and the lung gas volume entering the lung during inflation of the pressure-volume curve (R = 0.749, p < 0.001 and R = 0.851, p < 0.001). The hysteresis ratio was related to both lung tissue and gas recruitment (R = 0.266, p = 0.008, R = 0.357, p = 0.002, respectively). Receiver operating characteristic analysis showed that the optimal cutoff value to predict lung tissue recruitment for the hysteresis ratio was 28% (area under the receiver operating characteristic curve, 0.80; 95% CI, 0.62-0.98), with sensitivity and specificity of 0.75 and 0.77, respectively.

Conclusions: Hysteresis of the respiratory system computed by low-flow pressure-volume curve is related to the anatomical lung characteristics and has an acceptable accuracy to predict lung recruitment.
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http://dx.doi.org/10.1097/CCM.0000000000004518DOI Listing
October 2020

Ultrasonographic assessment of parasternal intercostal muscles during mechanical ventilation.

Ann Intensive Care 2020 Sep 7;10(1):120. Epub 2020 Sep 7.

SC Anestesia e Rianimazione, Ospedale San Paolo-Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.

Although mechanical ventilation is a lifesaving treatment, abundant evidence indicates that its prolonged use (1 week or more) promotes respiratory muscle weakness due to both contractile dysfunction and atrophy. Along with the diaphragm, the intercostal muscles are one of the most important groups of respiratory muscles. In recent years, muscular ultrasound has become a useful bedside tool for the clinician to identify patients with respiratory muscle dysfunction related to critical illness and/or invasive mechanical ventilation. Images obtained over the course of illness can document changes in muscle dimension and can be used to estimate changes in function. Recent evidence suggests the clinical usefulness of ultrasound imaging in the assessment of intercostal muscle function. In this narrative review, we summarize the current literature on ultrasound imaging of the parasternal intercostal muscles as used to assess the extent of muscle activation and muscle weakness and its potential impact during discontinuation of mechanical ventilation. In addition, we proposed a practical flowchart based on recent evidence and experience of our group that can be applied during the weaning phase. This approach integrates multiple predictive parameters of weaning success with respiratory muscle ultrasound.
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http://dx.doi.org/10.1186/s13613-020-00735-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475948PMC
September 2020

Oesophageal manometry and gas exchange in patients with COVID-19 acute respiratory distress syndrome.

Br J Anaesth 2020 11 7;125(5):e437-e438. Epub 2020 Aug 7.

Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.bja.2020.07.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413091PMC
November 2020

Hazardous mismatch between pulmonary pathogens and antibiotic treatments in COVID-19 patients.

Br J Anaesth 2020 10 28;125(4):e380-e382. Epub 2020 Jul 28.

Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.bja.2020.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386466PMC
October 2020

Chest physiotherapy improves lung aeration in hypersecretive critically ill patients: a pilot randomized physiological study.

Crit Care 2020 08 3;24(1):479. Epub 2020 Aug 3.

Department of Anesthesia and Intensive Care, Azienda Ospedaliera-Università di Padova, Padua, Italy.

Background: Besides airway suctioning, patients undergoing invasive mechanical ventilation (iMV) benefit of different combinations of chest physiotherapy techniques, to improve mucus removal. To date, little is known about the clearance effects of oscillating devices on patients with acute respiratory failure undergoing iMV. This study aimed to assess (1) the effects of high-frequency chest wall oscillation (HFCWO) on lung aeration and ventilation distribution, as assessed by electrical impedance tomography (EIT), and (2) the effect of the association of HFCWO with recruitment manoeuvres (RM).

Methods: Sixty critically ill patients, 30 classified as normosecretive and 30 as hypersecretive, who received ≥ 48 h of iMV, underwent HFCWO; patients from both subgroups were randomized to receive RM or not, according to two separated randomization sequences. We therefore obtained four arms of 15 patients each. After baseline record (T0), HFCWO was applied for 10 min. At the end of the treatment (T1) or after 1 (T2) and 3 h (T3), EIT data were recorded. At the beginning of each step, closed tracheobronchial suctioning was performed. In the RM subgroup, tracheobronchial suctioning was followed by application of 30 cmHO to the patient's airway for 30 s. At each step, we assessed the change in end-expiratory lung impedance (ΔEELI) and in tidal impedance variation (ΔTIV), and the center of gravity (COG) through EIT. We also analysed arterial blood gases (ABGs).

Results: ΔTIV and COG did not differ between normosecretive and hypersecretive patients. Compared to T0, ΔEELI significantly increased in hypersecretive patients at T2 and T3, irrespective of the RM; on the contrary, no differences were observed in normosecretive patients. No differences of ABGs were recorded.

Conclusions: In hypersecretive patients, HFCWO significantly improved aeration of the dorsal lung region, without affecting ABGs. The application of RM did not provide any further improvements.

Trial Registration: Prospectively registered at the Australian New Zealand Clinical Trial Registry ( www.anzctr.org.au ; number of registration: ACTRN12615001257550; date of registration: 17th November 2015).
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http://dx.doi.org/10.1186/s13054-020-03198-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7396943PMC
August 2020

Body mass index and acute respiratory distress severity in patients with and without SARS-CoV-2 infection.

Br J Anaesth 2020 10 19;125(4):e376-e377. Epub 2020 Jul 19.

Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.

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http://dx.doi.org/10.1016/j.bja.2020.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368887PMC
October 2020

Is blood glucose or obesity responsible for the bad prognosis of COVID-19 in obesity - diabetes?

Diabetes Res Clin Pract 2020 09 27;167:108342. Epub 2020 Jul 27.

Università degli Studi di Milano, Dipartimento di Scienze della Salute, Milan, Italy; Endocrinologia e Malattie Metaboliche, Università degli Studi di Milano Dipartimento di Scienze della Salute, Milan, Italy; Medicina, Diabetologia e Malattie Metaboliche, ASST Santi Paolo e Carlo, Ospedale San Paolo e San Carlo, Milan, Italy.

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http://dx.doi.org/10.1016/j.diabres.2020.108342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384403PMC
September 2020

Bedside calculation of mechanical power during volume- and pressure-controlled mechanical ventilation.

Crit Care 2020 07 11;24(1):417. Epub 2020 Jul 11.

Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany.

Background: Mechanical power (MP) is the energy delivered to the respiratory system over time during mechanical ventilation. Our aim was to compare the currently available methods to calculate MP during volume- and pressure-controlled ventilation, comparing different equations with the geometric reference method, to understand whether the easier to use surrogate formulas were suitable for the everyday clinical practice. This would warrant a more widespread use of mechanical power to promote lung protection.

Methods: Forty respiratory failure patients, sedated and paralyzed for clinical reasons, were ventilated in volume-controlled ventilation, at two inspiratory flows (30 and 60 L/min), and pressure-controlled ventilation with a similar tidal volume. Mechanical power was computed both with the geometric method, as the area between the inspiratory limb of the airway pressure and the volume, and with two algebraic methods, a comprehensive and a surrogate formula.

Results: The bias between the MP computed by the geometric method and by the comprehensive algebraic method during volume-controlled ventilation was respectively 0.053 (0.77, - 0.81) J/min and - 0.4 (0.70, - 1.50) J/min at low and high flows (r = 0.96 and 0.97, p < 0.01). The MP measured and computed by the two methods were highly correlated (r = 0.95 and 0.94, p < 0.01) with a bias of - 0.0074 (0.91, - 0.93) and - 1.0 (0.45, - 2.52) J/min at high-low flows. During pressure-controlled ventilation, the bias between the MP measured and the one calculated with the comprehensive and simplified methods was correlated (r = 0.81, 0.94, p < 0.01) with mean differences of - 0.001 (2.05, - 2.05) and - 0.81 (2.11, - 0.48) J/min.

Conclusions: Both for volume-controlled and pressure-controlled ventilation, the surrogate formulas approximate the reference method well enough to warrant their use in the everyday clinical practice. Given that these formulas require nothing more than the variables already displayed by the intensive care ventilator, a more widespread use of mechanical power should be encouraged to promote lung protection against ventilator-induced lung injury.
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http://dx.doi.org/10.1186/s13054-020-03116-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351639PMC
July 2020

Spontaneous breathing, transpulmonary pressure and mathematical trickery.

Ann Intensive Care 2020 Jul 8;10(1):88. Epub 2020 Jul 8.

Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, and Centre of Human Applied Physiological Sciences, King's College London, London, UK.

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http://dx.doi.org/10.1186/s13613-020-00708-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7341701PMC
July 2020

The assessment of esophageal pressure using different devices: a validation study.

Minerva Anestesiol 2020 Oct 12;86(10):1047-1056. Epub 2020 Jun 12.

Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.

Background: Although esophageal pressure measurement could help clinicians to improve the ventilatory management of acute respiratory distress syndrome (ARDS) patients, it has been mainly used in clinical research. Aim of this study was to compare the measurements of end-expiratory esophageal pressure, end-expiratory transpulmonary pressure and lung stress by three systems: a dedicated manual device, taken as gold standard, a new automatic system (Optivent) and a bedside equipment, consisting of a mechanical ventilator and a hemodynamic monitor.

Methods: In sedated and paralyzed mechanically ventilated ARDS patients the esophageal pressure was measured at three PEEP levels in random fashion (baseline level, 50% higher and 50% lower).

Results: Forty patients were enrolled (BMI 25 [23-28] kg/m2, PaO2/FiO2 187 [137-223] and PEEP 9±3 cmH2O). The mean esophageal pressure measured during an expiratory pause by the dedicated system, the bedside system and Optivent were 10.0±4.2, 10±4 and 9.9±4.0 cmH2O, respectively. The respective bias and limits of agreement between the dedicated system and Optivent and between the dedicated system and the bedside system were as follows: end-expiratory esophageal pressure, 0.2 cmH2O, (-0.4 to 0.9) and -0.1 cmH2O (-1.9 to 1.7); end-expiratory transpulmonary pressure, -0.6 cmH2O (-1.7 to 0.4) and -0.4 cmH2O, (-2.2 to 1.5); lung stress -0.9 cmH2O (-3.0 to 1.1) and -1.5 cmH2O (-4.4 to 1.4).

Conclusions: Both Optivent and the bedside system showed clinically acceptability if compared to the gold standard device. The possibility to apply one of these systems could allow a wider use of esophageal pressure in clinical practice.
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http://dx.doi.org/10.23736/S0375-9393.20.14458-4DOI Listing
October 2020

From phenotypes to black holes… and back.

Intensive Care Med 2020 07 5;46(7):1498-1499. Epub 2020 Jun 5.

Department of Anesthesiology and Intensive Care, Medical University of Göttingen, Robert-Koch Straße 40, 37075, Göttingen, Germany.

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http://dx.doi.org/10.1007/s00134-020-06124-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272587PMC
July 2020

Effect of mechanical power on intensive care mortality in ARDS patients.

Crit Care 2020 05 24;24(1):246. Epub 2020 May 24.

Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.

Background: In ARDS patients, mechanical ventilation should minimize ventilator-induced lung injury. The mechanical power which is the energy per unit time released to the respiratory system according to the applied tidal volume, PEEP, respiratory rate, and flow should reflect the ventilator-induced lung injury. However, similar levels of mechanical power applied in different lung sizes could be associated to different effects. The aim of this study was to assess the role both of the mechanical power and of the transpulmonary mechanical power, normalized to predicted body weight, respiratory system compliance, lung volume, and amount of aerated tissue on intensive care mortality.

Methods: Retrospective analysis of ARDS patients previously enrolled in seven published studies. All patients were sedated, paralyzed, and mechanically ventilated. After 20 min from a recruitment maneuver, partitioned respiratory mechanics measurements and blood gas analyses were performed with a PEEP of 5 cmHO while the remaining setting was maintained unchanged from the baseline. A whole lung CT scan at 5 cmHO of PEEP was performed to estimate the lung gas volume and the amount of well-inflated tissue. Univariate and multivariable Poisson regression models with robust standard error were used to calculate risk ratios and 95% confidence intervals of ICU mortality.

Results: Two hundred twenty-two ARDS patients were included; 88 (40%) died in ICU. Mechanical power was not different between survivors and non-survivors 14.97 [11.51-18.44] vs. 15.46 [12.33-21.45] J/min and did not affect intensive care mortality. The multivariable robust regression models showed that the mechanical power normalized to well-inflated tissue (RR 2.69 [95% CI 1.10-6.56], p = 0.029) and the mechanical power normalized to respiratory system compliance (RR 1.79 [95% CI 1.16-2.76], p = 0.008) were independently associated with intensive care mortality after adjusting for age, SAPS II, and ARDS severity. Also, transpulmonary mechanical power normalized to respiratory system compliance and to well-inflated tissue significantly increased intensive care mortality (RR 1.74 [1.11-2.70], p = 0.015; RR 3.01 [1.15-7.91], p = 0.025).

Conclusions: In our ARDS population, there is not a causal relationship between the mechanical power itself and mortality, while mechanical power normalized to the compliance or to the amount of well-aerated tissue is independently associated to the intensive care mortality. Further studies are needed to confirm this data.
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http://dx.doi.org/10.1186/s13054-020-02963-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245621PMC
May 2020

First ultrastructural autoptic findings of SARS -Cov-2 in olfactory pathways and brainstem.

Minerva Anestesiol 2020 06 13;86(6):678-679. Epub 2020 May 13.

Department of Health Sciences, University of Milan, Milan, Italy.

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http://dx.doi.org/10.23736/S0375-9393.20.14772-2DOI Listing
June 2020