Publications by authors named "Jean-Michel Arnal"

37 Publications

Collective wisdom in a pandemic.

Minerva Anestesiol 2020 Nov;86(11):1132-1134

Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.23736/S0375-9393.20.15238-6DOI Listing
November 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

In COPD, Nocturnal Noninvasive Ventilation Reduces the FIO2 Delivered Compared With Long-Term Oxygen Therapy at the Same Flow.

Respir Care 2020 Dec 21;65(12):1897-1903. Epub 2020 Jul 21.

Department of Anesthesiology and Intensive Care, Military Hospital, Hôpital d'Instruction des Armées Sainte-Anne, France.

Background: Nocturnal noninvasive ventilation is recommended for patients with hypercapnic COPD. Long-term oxygen therapy improves survival in patients with hypoxemic disease. However, leaks during noninvasive ventilation are likely to reduce the fraction of inspired oxygen.

Objectives: To compare nocturnal inspired O fractions during noninvasive ventilation with daytime pharyngeal inspired O fractions during nasal cannula oxygen therapy (with the same O flow) in patients with COPD at home (ie, real-life conditions).

Methods: This single-center prospective observational study included 14 subjects with COPD who received long-term O therapy. We analyzed pharyngeal inspired O fractions in the evening, with a nasopharyngeal probe (sidestream gas analyzer). The O flow was measured with a precision flow meter, at the usual flow. Then, the same O flow was implemented for noninvasive ventilation with a study's home ventilator. The all-night noninvasive ventilation parameters were delivered in pressure mode with a single-limb leaking circuit. Daytime and nighttime inspired O fractions were compared.

Results: The mean ± SD daytime pharyngeal inspired O fraction, measured with normobaric basal O flow, 0.308 ± 0.026%, was significantly higher than the mean ± SD nighttime inspired O fraction, measured during noninvasive ventilation (0.251 ± 0.011; < .001).

Conclusions: The nighttime inspired O fraction decreased with a modern noninvasive ventilation pattern, pressure target, and intentional leaks. This partial lack of O therapy is likely to be harmful. It might explain the poor results in all but 2 randomized controlled trials on long-term noninvasive ventilation in COPD. (ClinicalTrials.gov registration NCT02599246.).
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http://dx.doi.org/10.4187/respcare.07570DOI Listing
December 2020

Airway and transpulmonary driving pressures and mechanical powers selected by INTELLiVENT-ASV in passive, mechanically ventilated ICU patients.

Heart Lung 2020 Jul - Aug;49(4):427-434. Epub 2019 Nov 14.

Service de Réanimation Polyvalente, Hôpital Sainte Musse, 54 Avenue Henri Sainte Claire Deville, 83056 Toulon, France.

Background: Driving pressure (ΔP) and mechanical power (MP) are predictors of the risk of ventilation- induced lung injuries (VILI) in mechanically ventilated patients. INTELLiVENT-ASV® is a closed-loop ventilation mode that automatically adjusts respiratory rate and tidal volume, according to the patient's respiratory mechanics.

Objectives: This prospective observational study investigated ΔP and MP (and also transpulmonary ΔP (ΔP) and MP (MP) for a subgroup of patients) delivered by INTELLiVENT-ASV.

Methods: Adult patients admitted to the ICU were included if they were sedated and met the criteria for a single lung condition (normal lungs, COPD, or ARDS). INTELLiVENT-ASV was used with default target settings. If PEEP was above 16 cmH2O, the recruitment strategy used transpulmonary pressure as a reference, and ΔP and MP were computed. Measurements were made once for each patient.

Results: Of the 255 patients included, 98 patients were classified as normal-lungs, 28 as COPD, and 129 as ARDS patients. The median ΔP was 8 (7 - 10), 10 (8 - 12), and 9 (8 - 11) cmH2O for normal-lungs, COPD, and ARDS patients, respectively. The median MP was 9.1 (4.9 - 13.5), 11.8 (8.6 - 16.5), and 8.8 (5.6 - 13.8) J/min for normal-lungs, COPD, and ARDS patients, respectively. For the 19 patients managed with transpulmonary pressure ΔP was 6 (4 - 7) cmH2O and MP was 3.6 (3.1 - 4.4) J/min.

Conclusions: In this short term observation study, INTELLiVENT-ASV selected ΔP and MP considered in safe ranges for lung protection. In a subgroup of ARDS patients, the combination of a recruitment strategy and INTELLiVENT-ASV resulted in an apparently safe ΔP and MP.
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http://dx.doi.org/10.1016/j.hrtlng.2019.11.001DOI Listing
December 2020

Setting up home noninvasive ventilation.

Chron Respir Dis 2019 Jan-Dec;16:1479973119844090

1 Service de Réanimation Polyvalente, Hôpital Sainte Musse, Toulon, France.

Home noninvasive ventilation (NIV) is widely used to correct nocturnal alveolar hypoventilation in patients with chronic respiratory failure of various etiologies. The most commonly used ventilation mode is pressure support with a backup respiratory rate. This mode requires six main settings, as well as some additional settings that should be adjusted according to the individual patient. This review details the effect of each setting, how the settings should be adjusted according to each patient, and the risks if they are not adjusted correctly. The examples described here are based on real patient cases and bench simulations. Optimizing the settings for home NIV may improve the quality and tolerance of the treatment.
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http://dx.doi.org/10.1177/1479973119844090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6558539PMC
August 2020

Paying attention to patient self-inflicted lung injury.

Minerva Anestesiol 2019 09 3;85(9):940-942. Epub 2019 May 3.

Department of Medicine, Lerner College of Medicine and Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.

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http://dx.doi.org/10.23736/S0375-9393.19.13778-9DOI Listing
September 2019

X-linked myotubular myopathy: A prospective international natural history study.

Neurology 2019 04 22;92(16):e1852-e1867. Epub 2019 Mar 22.

From I-Motion (M.A., C.L., T.G., E.G., V.C., L.S.), Institute of Myology, Paris, France; Paediatric Neurology and Neuromuscular Center (U.S., A.G.), University of Essen, Germany; Unit of Neuromuscular and Neurodegenerative Disorders (A. D'Amico), Department of Neurosciences, Bambino Gesu Children's Research Hospital IRCCS, Rome, Italy; Division of Neurology and Program for Genetics and Genome Biology (J.J.D.), Hospital for Sick Children, Toronto, Canada; Boston Children's Hospital (B.T.D.), MA; Centre de Référence Neuromusculaire (A. Daron), CHR La Citadelle, Liège, Belgium; UCI Pediatrica (A.H.), Hospital Puerta del Mar, Cadiz, Spain; Centre de Référence Maladies Neuromusculaires Adulte (C.d.L.), Hôpital de la Croix-Rousse, Hospices Civils de Lyon; Service de Réanimation Polyvalente (J.-M.A.), Hôpital Sainte Musse, Toulon; Centre de Référence des Maladies Neuromusculaires d'Ile de France-Nord et Est (M.M.), Hôpital Armand Trousseau, Paris; Service de Neuropédiatrie Hôpital Roger Salengro (J.-M.C.), CHRU, Lille; Service de Rééducation Pédiatrique "L'Escale" (C.V., S.F.), Hôpital Mère Enfant, CHU-Lyon, France; CeRCa (R.B.), Hôpital Pierre-Zobda-Quitman, CHU de Martinique, Fort-de-France, Martinique; Laboratoire Diagnostic Génétique (V.B.), Nouvel Hôpital Civil, Strasbourg; Genethon (A.B.-B.), UMR S951 Inserm, Univ Evry, Université Paris Saclay, Evry; Neuromuscular Investigation Center (J.-Y.H.), Institute of Myology, Paris, France; and Valerion Therapeutics (H.L.), Concord, MA.

Objectives: Because X-linked myotubular myopathy (XLMTM) is a rare neuromuscular disease caused by mutations in the gene with a large phenotypic heterogeneity, to ensure clinical trial readiness, it was mandatory to better quantify disease burden and determine best outcome measures.

Methods: We designed an international prospective and longitudinal natural history study in patients with XLMTM and assessed muscle strength and motor and respiratory functions over the first year of follow-up. The humoral immunity against adeno-associated virus serotype 8 was also monitored.

Results: Forty-five male patients aged 3.5 months to 56.8 years were enrolled between May 2014 and May 2017. Thirteen patients had a mild phenotype (no ventilation support), 7 had an intermediate phenotype (ventilation support less than 12 hours a day), and 25 had a severe phenotype (ventilation support 12 or more hours a day). Most strength and motor function assessments could be performed even in very weak patients. Motor Function Measure 32 total score, grip and pinch strengths, and forced vital capacity, forced expiratory volume in the first second of exhalation, and peak cough flow measures discriminated the 3 groups of patients. Disease history revealed motor milestone loss in several patients. Longitudinal data on 37 patients showed that the Motor Function Measure 32 total score significantly decreased by 2%. Of the 38 patients evaluated, anti-adeno-associated virus type 8 neutralizing activity was detected in 26% with 2 patients having an inhibitory titer >1:10.

Conclusions: Our data confirm that XLMTM is slowly progressive for male survivors regardless of their phenotype and provide outcome validation and natural history data that can support clinical development in this population.

Clinicaltrialsgov Identifier: NCT02057705.
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http://dx.doi.org/10.1212/WNL.0000000000007319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6550499PMC
April 2019

Noninvasive ventilation: education and training. A narrative analysis and an international consensus document.

Adv Respir Med 2019 4;87(1):36-45. Epub 2019 Mar 4.

Intensive Care Unit. Hospital Morales Meseguer Murcia, Murcia, 30008, Spain.

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries.
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http://dx.doi.org/10.5603/ARM.a2019.0006DOI Listing
February 2020

Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures.

Crit Care 2018 09 23;22(1):236. Epub 2018 Sep 23.

PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France.

Background: Patients liberated from invasive mechanical ventilation are at risk of extubation failure, including inability to breathe without a tracheal tube (airway failure) or without mechanical ventilation (non-airway failure). We sought to identify respective risk factors for airway failure and non-airway failure following extubation.

Methods: The primary endpoint of this prospective, observational, multicenter study in 26 intensive care units was extubation failure, defined as need for reintubation within 48 h following extubation. A multinomial logistic regression model was used to identify risk factors for airway failure and non-airway failure.

Results: Between 1 December 2013 and 1 May 2015, 1514 patients undergoing extubation were enrolled. The extubation-failure rate was 10.4% (157/1514), including 70/157 (45%) airway failures, 78/157 (50%) non-airway failures, and 9/157 (5%) mixed airway and non-airway failures. By multivariable analysis, risk factors for extubation failure were either common to airway failure and non-airway failure: intubation for coma (OR 4.979 (2.797-8.864), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.003, respectively, intubation for acute respiratory failure (OR 3.395 (1.877-6.138), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.007, respectively, absence of strong cough (OR 1.876 (1.047-3.362), P = 0.03 and OR 3.240 (1.786-5.879), P = 0.0001, respectively, or specific to each specific mechanism: female gender (OR 2.024 (1.187-3.450), P = 0.01), length of ventilation > 8 days (OR 1.956 (1.087-3.518), P = 0.025), copious secretions (OR 4.066 (2.268-7.292), P < 0.0001) were specific to airway failure, whereas non-obese status (OR 2.153 (1.052-4.408), P = 0.036) and sequential organ failure assessment (SOFA) score ≥ 8 (OR 1.848 (1.100-3.105), P = 0.02) were specific to non-airway failure. Both airway failure and non-airway failure were associated with ICU mortality (20% and 22%, respectively, as compared to 6% in patients with extubation success, P < 0.0001).

Conclusions: Specific risk factors have been identified, allowing us to distinguish between risk of airway failure and non-airway failure. The two conditions will be managed differently, both for prevention and curative strategies.

Trial Registration: ClinicalTrials.gov, NCT 02450669 . Registered on 21 May 2015.
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http://dx.doi.org/10.1186/s13054-018-2150-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151191PMC
September 2018

COMET: a multicomponent home-based disease-management programme routine care in severe COPD.

Eur Respir J 2018 01 11;51(1). Epub 2018 Jan 11.

FRCP Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montréal, QC, Canada

The COPD Patient Management European Trial (COMET) investigated the efficacy and safety of a home-based COPD disease management intervention for severe COPD patients.The study was an international open-design clinical trial in COPD patients (forced expiratory volume in 1 s <50% of predicted value) randomised 1:1 to the disease management intervention or to the usual management practices at the study centre. The disease management intervention included a self-management programme, home telemonitoring, care coordination and medical management. The primary end-point was the number of unplanned all-cause hospitalisation days in the intention-to-treat (ITT) population. Secondary end-points included acute care hospitalisation days, BODE (body mass index, airflow obstruction, dyspnoea and exercise) index and exacerbations. Safety end-points included adverse events and deaths.For the 157 (disease management) and 162 (usual management) patients eligible for ITT analyses, all-cause hospitalisation days per year (mean±sd) were 17.4±35.4 and 22.6±41.8, respectively (mean difference -5.3, 95% CI -13.7 to -3.1; p=0.16). The disease management group had fewer per-protocol acute care hospitalisation days per year (p=0.047), a lower BODE index (p=0.01) and a lower mortality rate (1.9% 14.2%; p<0.001), with no difference in exacerbation frequency. Patient profiles and hospitalisation practices varied substantially across countries.The COMET disease management intervention did not significantly reduce unplanned all-cause hospitalisation days, but reduced acute care hospitalisation days and mortality in severe COPD patients.
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http://dx.doi.org/10.1183/13993003.01612-2017DOI Listing
January 2018

Parameters for Simulation of Adult Subjects During Mechanical Ventilation.

Respir Care 2018 Feb 17;63(2):158-168. Epub 2017 Oct 17.

Department of Medicine, Lerner College of Medicine and Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Simulation studies are often used to examine ventilator performance. However, there are no standards for selecting simulation parameters. This study collected data in passively-ventilated adult human subjects and summarized the results as a set of parameters that can be used for simulation studies of intubated, passive, adult subjects with normal lungs, COPD, or ARDS.

Methods: Consecutive adult patients admitted to the ICU were included if they were deeply sedated and mechanically ventilated for <48 h without any spontaneous breathing activity. Subjects were classified as having normal lungs, COPD, or ARDS. Respiratory mechanics variables were collected once per subject. Static compliance was calculated as the ratio between tidal volume and driving pressure. Inspiratory resistance was measured by the least-squares fitting method. The expiratory time constant was estimated by the tidal volume/flow ratio.

Results: Of the 359 subjects included, 138 were classified as having normal lungs, 181 as ARDS, and 40 as COPD. Median (interquartile range) static compliance was significantly lower in ARDS subjects as compared with normal lung and COPD subjects (39 [32-50] mL/cm HO vs 54 [44-64] and 59 [43-75] mL/cm HO, respectively, < .001). Inspiratory resistance was significantly higher in COPD subjects as compared with normal lung and ARDS subjects (22 [16-33] cm HO/L/s vs 13 [10-15] and 12 [9-14] cm HO/L/s, respectively, < .001). The expiratory time constant was significantly different for each lung condition (0.60 [0.51-0.71], 1.07 [0.68-2.14], and 0.46 [0.40-0.55] s for normal lung, COPD, and ARDS subjects, respectively, < .001). In the subgroup of subjects with ARDS, there were no significant differences in respiratory mechanics variables among mild, moderate, and severe ARDS.

Conclusions: This study provides educators, researchers, and manufacturers with a standard set of practical parameters for simulating the respiratory system's mechanical properties in passive conditions.
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http://dx.doi.org/10.4187/respcare.05775DOI Listing
February 2018

Closed loop ventilation mode in Intensive Care Unit: a randomized controlled clinical trial comparing the numbers of manual ventilator setting changes.

Minerva Anestesiol 2018 01 5;84(1):58-67. Epub 2017 Jul 5.

Multipurpose Intensive Care Service, Sainte Musse Hospital, Toulon, France.

Background: There is an equipoise regarding closed-loop ventilation modes and the ability to reduce workload for providers. On one hand some settings are managed by the ventilator but on another hand the automatic mode introduces new settings for the user.

Methods: This randomized controlled trial compared the number of manual ventilator setting changes between a full closed loop ventilation and oxygenation mode (INTELLiVENT-ASV®) and conventional ventilation modes (volume assist control and pressure support) in Intensive Care Unit (ICU) patients. The secondary endpoints were to compare the number of arterial blood gas analysis, the sedation dose and the user acceptance. Sixty subjects with an expected duration of mechanical ventilation of at least 48 hours were randomized to be ventilated using INTELLiVENT-ASV® or conventional modes with a protocolized weaning. All manual ventilator setting changes were recorded continuously from inclusion to successful extubation or death. Arterial blood gases were performed upon decision of the clinician in charge. User acceptance score was assessed for nurses and physicians once daily using a Likert Scale.

Results: The number of manual ventilator setting changes per 24 h-period per subject was lower in INTELLiVENT-ASV® as compared to conventional ventilation group (5 [4-7] versus 10 [7-17]) manuals settings per subject per day [P<0.001]). The number of arterial blood gas analysis and the sedation doses were not significantly different between the groups. Nurses and physicians reported that INTELLiVENT-ASV® was significantly easier to use as compared to conventional ventilation (P<0.001 for nurses and P<0.01 for physicians).

Conclusions: For mechanically ventilated ICU patients, INTELLiVENT-ASV® significantly reduces the number of manual ventilator setting changes with the same number of arterial blood gas analysis and sedation dose, and is easier to use for the caregivers as compared to conventional ventilation modes.
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http://dx.doi.org/10.23736/S0375-9393.17.11963-2DOI Listing
January 2018

Extracorporeal CO2 removal in the ICU: an effective treatment awaiting proper indications.

Minerva Anestesiol 2017 08 14;83(8):784-786. Epub 2017 Jun 14.

Department of Reanimation, Sainte Musse Hospital, Toulon, France.

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http://dx.doi.org/10.23736/S0375-9393.17.12135-8DOI Listing
August 2017

Practical Insight to Monitor Home NIV in COPD Patients.

COPD 2017 Aug 24;14(4):401-410. Epub 2017 Mar 24.

c AP-HP, Respiratory Physiology Department , Cochin Hospital, René Descartes University , Paris , France.

Home noninvasive ventilation (NIV) is used in COPD patients with concomitant chronic hypercapnic respiratory failure in order to correct nocturnal hypoventilation and improve sleep quality, quality of life, and survival. Monitoring of home NIV is needed to assess the effectiveness of ventilation and adherence to therapy, resolve potential adverse effects, reinforce patient knowledge, provide maintenance of the equipment, and readjust the ventilator settings according to the changing condition of the patient. Clinical monitoring is very informative. Anamnesis focuses on the improvement of nocturnal hypoventilation symptoms, sleep quality, and side effects of NIV. Side effects are major cause of intolerance. Screening side effects leads to modification of interface, gas humidification, or ventilator settings. Home care providers maintain ventilator and interface and educate patients for correct use. However, patient's education should be supervised by specialized clinicians. Blood gas measurement shows a significant decrease in PaCO when NIV is efficient. Analysis of ventilator data is very useful to assess daily use, unintentional leaks, upper airway obstruction, and patient ventilator synchrony. Nocturnal oximetry and capnography are additional monitoring tools to assess the impact of NIV on gas exchanges. In the near future, telemonitoring will reinforce and change the organization of home NIV for COPD patients.
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http://dx.doi.org/10.1080/15412555.2017.1298583DOI Listing
August 2017

A Multicenter Randomized Trial Assessing the Efficacy of Helium/Oxygen in Severe Exacerbations of Chronic Obstructive Pulmonary Disease.

Am J Respir Crit Care Med 2017 04;195(7):871-880

9 Institut national de la santé et de la recherche médicale, UMR 955, Université Paris Est, Créteil, France.

Rationale: During noninvasive ventilation (NIV) for chronic obstructive pulmonary disease (COPD) exacerbations, helium/oxygen (heliox) reduces the work of breathing and hypercapnia more than air/O, but its impact on clinical outcomes remains unknown.

Objectives: To determine whether continuous administration of heliox for 72 hours, during and in-between NIV sessions, was superior to air/O in reducing NIV failure (25-15%) in severe hypercapnic COPD exacerbations.

Methods: This was a prospective, randomized, open-label trial in 16 intensive care units (ICUs) and 6 countries. Inclusion criteria were COPD exacerbations with Pa ≥ 45 mm Hg, pH ≤ 7.35, and at least one of the following: respiratory rate ≥ 25/min, Pa ≤ 50 mm Hg, and oxygen saturation (arterial [Sa] or measured by pulse oximetry [Sp]) ≤ 90%. A 6-month follow-up was performed.

Measurements And Main Results: The primary endpoint was NIV failure (intubation or death without intubation in the ICU). The secondary endpoints were physiological parameters, duration of ventilation, duration of ICU and hospital stay, 6-month recurrence, and rehospitalization rates. The trial was stopped prematurely (445 randomized patients) because of a low global failure rate (NIV failure: air/O 14.5% [n = 32]; heliox 14.7% [n = 33]; P = 0.97, and time to NIV failure: heliox group 93 hours [n = 33], air/O group 52 hours [n = 32]; P = 0.12). Respiratory rate, pH, Pa, and encephalopathy score improved significantly faster with heliox. ICU stay was comparable between the groups. In patients intubated after NIV failed, patients on heliox had a shorter ventilation duration (7.4 ± 7.6 d vs. 13.6 ± 12.6 d; P = 0.02) and a shorter ICU stay (15.8 ± 10.9 d vs. 26.7 ± 21.0 d; P = 0.01). No difference was observed in ICU and 6-month mortality.

Conclusions: Heliox improves respiratory acidosis, encephalopathy, and the respiratory rate more quickly than air/O but does not prevent NIV failure. Overall, the rate of NIV failure was low. Clinical trial registered with www.clinicaltrials.gov (NCT 01155310).
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http://dx.doi.org/10.1164/rccm.201601-0083OCDOI Listing
April 2017

Is the ventilator switching from inspiration to expiration at the right time? Look at waveforms!

Intensive Care Med 2016 May 21;42(5):914-915. Epub 2015 Dec 21.

Anesthesia and Intensive Care, Emergency Department, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.

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http://dx.doi.org/10.1007/s00134-015-4174-6DOI Listing
May 2016

Dynamics of end expiratory lung volume after changing positive end-expiratory pressure in acute respiratory distress syndrome patients.

Crit Care 2015 Sep 18;19:340. Epub 2015 Sep 18.

Service de réanimation polyvalente, Hôpital Sainte Musse, 54 Avenue Henri Sainte Claire Deville, 83056, Toulon, France.

Introduction: Lung recruitment maneuvers followed by an individually titrated positive end-expiratory pressure (PEEP) are the key components of the open lung ventilation strategy in acute respiratory distress syndrome (ARDS). The staircase recruitment maneuver is a step-by-step increase in PEEP followed by a decremental PEEP trial. The duration of each step is usually 2 minutes without physiologic rationale.

Methods: In this prospective study, we measured the dynamic end-expiratory lung volume changes (ΔEELV) during an increase and decrease in PEEP to determine the optimal duration for each step. PEEP was progressively increased from 5 to 40 cmH2O and then decreased from 40 to 5 cmH2O in steps of 5 cmH2O every 2.5 minutes. The dynamic of ΔEELV was measured by direct spirometry as the difference between inspiratory and expiratory tidal volumes over 2.5 minutes following each increase and decrease in PEEP. ΔEELV was separated between the expected increased volume, calculated as the product of the respiratory system compliance by the change in PEEP, and the additional volume.

Results: Twenty-six early onset moderate or severe ARDS patients were included. Data are expressed as median [25th-75th quartiles]. During the increase in PEEP, the expected increased volume was achieved within 2[2-2] breaths. During the decrease in PEEP, the expected decreased volume was achieved within 1 [1-1] breath, and 95 % of the additional decreased volume was achieved within 8 [2-15] breaths. Completion of volume changes in 99 % of both increase and decrease in PEEP events required 29 breaths.

Conclusions: In early ARDS, most of the ΔEELV occurs within the first minute, and change is completed within 2 minutes, following an increase or decrease in PEEP.
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http://dx.doi.org/10.1186/s13054-015-1044-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4574463PMC
September 2015

Transpulmonary pressure cannot be determined without esophageal pressure in ARDS patients.

Minerva Anestesiol 2016 Jan 20;82(1):121-2. Epub 2015 May 20.

Service de Réanimation Polyvalente, Hôpital Sainte Musse, Toulon, France -

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January 2016

Efficiency and safety of a noninvasive therapeutic hypothermia protocol in cardiac arrest.

Eur J Emerg Med 2015 Feb;22(1):29-34

aIntensive Care Unit, Timone University Hospital, Aix-Marseille University, Marseille bIntensive Care Unit, Sainte Musse Hospital, Toulon, France.

Objectives: Therapeutic hypothermia (TH) is part of the treatment strategy for comatose survivors of cardiac arrest (CA). The aim of our study was to evaluate the efficiency and the safety of a noninvasive and affordable cooling procedure applied to all types of CA in an ICU.

Study Design: This was a retrospective, observational, monocenter study.

Patients And Methods: In all patients remaining unconscious after CA, irrespective of their initial cardiac rhythm, TH was induced with a rapid intravenous infusion of 30 ml/kg ice-cold (4°C) saline fluid associated with external surface cooling involving ice packs and wet sheets. The body temperature was maintained between 32 and 34°C during 24 h using external surface cooling only. The patients were then passively rewarmed.

Results: Of 200 eligible patients, 145 were treated by TH; 104 patients completed the 24-h TH treatment. The primary cause of noninclusion or secondary exclusion was severe hemodynamic impairment. From induction, the median time to reach the target temperature was 167 min (47-300 min). During the protocol, 24 patients did not remain within the targeted temperature range. Adverse events included hypokalemia (44%), severe arrhythmia (13.8%), bleeding (4.8%), and seizure (1.4%). All patients presented hyperglycemia. The oxygen partial pressure to oxygen fractional concentration (PaO2/FiO2) ratio remained constant after initiation and throughout the procedure, even in patients with poor systolic function.

Conclusion: This noninvasive TH procedure seems efficient and safe in all patients remaining comatose after CA. Thanks to its simplicity, it could allow prehospital cooling to reach the target temperature more rapidly.
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February 2015

Feasibility study on full closed-loop control ventilation (IntelliVent-ASV™) in ICU patients with acute respiratory failure: a prospective observational comparative study.

Crit Care 2013 Sep 11;17(5):R196. Epub 2013 Sep 11.

Introduction: IntelliVent-ASV™ is a full closed-loop ventilation mode that automatically adjusts ventilation and oxygenation parameters in both passive and active patients. This feasibility study compared oxygenation and ventilation settings automatically selected by IntelliVent-ASV™ among three predefined lung conditions (normal lung, acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD)) in active and passive patients. The feasibility of IntelliVent-ASV™ use was assessed based on the number of safety events, the need to switch to conventional mode for any medical reason, and sensor failure.

Method: This prospective observational comparative study included 100 consecutive patients who were invasively ventilated for less than 24 hours at the time of inclusion with an expected duration of ventilation of more than 12 hours. Patients were ventilated using IntelliVent-ASV™ from inclusion to extubation. Settings, automatically selected by the ventilator, delivered ventilation, respiratory mechanics, and gas exchanges were recorded once a day.

Results: Regarding feasibility, all patients were ventilated using IntelliVent-ASV™ (392 days in total). No safety issues occurred and there was never a need to switch to an alternative ventilation mode. The fully automated ventilation was used for 95% of the total ventilation time. IntelliVent-ASV™ selected different settings according to lung condition in passive and active patients. In passive patients, tidal volume (VT), predicted body weight (PBW) was significantly different between normal lung (n = 45), ARDS (n = 16) and COPD patients (n = 19) (8.1 (7.3 to 8.9) mL/kg; 7.5 (6.9 to 7.9) mL/kg; 9.9 (8.3 to 11.1) mL/kg, respectively; P 0.05). In passive ARDS patients, FiO2 and positive end-expiratory pressure (PEEP) were statistically higher than passive normal lung (35 (33 to 47)% versus 30 (30 to 31)% and 11 (8 to 13) cmH2O versus 5 (5 to 6) cmH2O, respectively; P< 0.05).

Conclusions: IntelliVent-ASV™ was safely used in unselected ventilated ICU patients with different lung conditions. Automatically selected oxygenation and ventilation settings were different according to the lung condition, especially in passive patients.

Trial Registration: ClinicalTrials.gov: NCT01489085.
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http://dx.doi.org/10.1186/cc12890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056360PMC
September 2013

Prospective randomized crossover study of a new closed-loop control system versus pressure support during weaning from mechanical ventilation.

Anesthesiology 2013 Sep;119(3):631-41

Intensive Care Unit, Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier, France.

Background: Intellivent is a new full closed-loop controlled ventilation that automatically adjusts both ventilation and oxygenation parameters. The authors compared gas exchange and breathing pattern variability of Intellivent and pressure support ventilation (PSV).

Methods: In a prospective, randomized, single-blind design crossover study, 14 patients were ventilated during the weaning phase, with Intellivent or PSV, for two periods of 24 h in a randomized order. Arterial blood gases were obtained after 1, 8, 16, and 24 h with each mode. Ventilatory parameters were recorded continuously in a breath-by-breath basis during the two study periods. The primary endpoint was oxygenation, estimated by the calculation of the difference between the PaO2/FIO2 ratio obtained after 24 h of ventilation and the PaO2/FIO2 ratio obtained at baseline in each mode. The variability in the ventilatory parameters was also evaluated by the coefficient of variation (SD to mean ratio).

Results: There were no adverse events or safety issues requiring premature interruption of both modes. The PaO2/FIO2 (mean ± SD) ratio improved significantly from 245 ± 75 at baseline to 294 ± 123 (P = 0.03) after 24 h of Intellivent. The coefficient of variation of inspiratory pressure and positive end-expiratory pressure (median [interquartile range]) were significantly higher with Intellivent, 16 [11-21] and 15 [7-23]%, compared with 6 [5-7] and 7 [5-10]% in PSV. Inspiratory pressure, positive end-expiratory pressure, and FIO2 changes were adjusted significantly more often with Intellivent compared with PSV.

Conclusions: Compared with PSV, Intellivent during a 24-h period improved the PaO2/FIO2 ratio in parallel with more variability in the ventilatory support and more changes in ventilation settings.
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September 2013

Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.

Am J Respir Crit Care Med 2013 Apr;187(8):832-9

Intensive Care and Anesthesiology Department, University of Montpellier Saint Eloi Hospital, Montpellier, France.

Rationale: Difficult intubation in the intensive care unit (ICU) is a challenging issue.

Objectives: To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications.

Methods: Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations.

Measurements And Main Results: In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the β parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001).

Conclusions: Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU. Clinical trial registered with www.clinicaltrials.gov (NCT 01532063).
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http://dx.doi.org/10.1164/rccm.201210-1851OCDOI Listing
April 2013

Does admission during morning rounds increase the mortality of patients in the medical ICU?

Chest 2012 Nov;142(5):1179-1184

Aix-Marseille Université, Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes CNRS-UMR 6236, Marseille, France; Assistance Publique Hopitaux de Marseille, Hôpital Nord, Réanimation, Marseille, France.

Background: Early optimization of treatment is crucial when admitting patients to the ICU and could depend on the organization of the medical team. The aim of this retrospective observational study was to determine whether admissions during morning rounds are independently associated with hospital mortality in a medical ICU.

Methods: The 3,540 patients admitted from May 2000 to April 2010 to the medical ICU of Sainte Marguerite Hospital in Marseille, France, were divided into two groups based on the time of admission.The non-morning rounds group was admitted between 1:00 PM and 7:59 AM , and the morningrounds group was admitted between 8:00 AM and 12:59 PM . Hospital mortality (crude and adjusted)was compared between the two groups.

Results: The 583 patients (16.5%) admitted during morning rounds were older and sicker upon admission compared with those patients admitted during non-morning rounds. The crude hospital mortality was 35.2% (95% CI , 31.4-39.1) in the group of patients admitted during morning rounds and 28.0% (95% CI, 26.4-29.7) in the other group ( P < .001). An admission during morning rounds was not independently associated with hospital death (adjusted hazard ratio, 1.10; 95% CI,0.94-1.28; P 5=.24).

Conclusions: Being admitted to the medical ICU during morning rounds is not associated with a poorer outcome than afternoon and night admissions. The conditions of the patients admitted during morning rounds were more severe, which underlines the importance of the ICU team’s availability during this time. Further studies are needed to evaluate if the presence of a specific medical team overnight in the wards would be able to improve patients’ outcome by preventing delayed ICU admission.
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http://dx.doi.org/10.1378/chest.11-2680DOI Listing
November 2012

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy.

Crit Care 2012 Dec 12;16(2):R65. Epub 2012 Dec 12.

Service de Réanimation des Détresses Respiratoires et Infections Sévères, Assistance Publique Hôpitaux de Marseille, URMITE CNRS-UMR 6236, Aix-Marseille Univ, Marseille 13015, France.

Introduction: Ventilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated by using a strictly standardized lung-protective strategy.

Methods: This prospective epidemiologic study was done in all the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis.

Results: Ninety-eight (28.9%) patients had at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared with 74 (30.7%) of the 241 patients without VAP (P = 0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition, and the use of a subglottic secretion-drainage device were protective.

Conclusions: In patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment.
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http://dx.doi.org/10.1186/cc11312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681394PMC
December 2012

Safety and efficacy of a fully closed-loop control ventilation (IntelliVent-ASV®) in sedated ICU patients with acute respiratory failure: a prospective randomized crossover study.

Intensive Care Med 2012 May 30;38(5):781-7. Epub 2012 Mar 30.

Intensive Care Unit, Hôpital Font Pré, 1208 avenue du colonel Picot, 83100, Toulon, France.

Purpose: IntelliVent-ASV(®) is a development of adaptive support ventilation (ASV) that automatically adjusts ventilation and oxygenation parameters. This study assessed the safety and efficacy of IntelliVent-ASV(®) in sedated intensive care unit (ICU) patients with acute respiratory failure.

Methods: This prospective randomized crossover comparative study was conducted in a 12-bed ICU in a general hospital. Two periods of 2 h of ventilation in randomly applied ASV or IntelliVent-ASV(®) were compared in 50 sedated, passively ventilated patients. Tidal volume (V(T)), respiratory rate (RR), inspiratory pressure (P(INSP)), SpO(2) and E(T)CO(2) were continuously monitored and recorded breath by breath. Mean values over the 2-h period were calculated. Respiratory mechanics, plateau pressure (P(PLAT)) and blood gas exchanges were measured at the end of each period.

Results: There was no safety issue requiring premature interruption of IntelliVent-ASV(®). Minute ventilation (MV) and V(T) decreased from 7.6 (6.5-9.5) to 6.8 (6.0-8.0) L/min (p < 0.001) and from 8.3 (7.8-9.0) to 8.1 (7.7-8.6) mL/kg PBW (p = 0.003) during IntelliVent-ASV(®) as compared to ASV. P(PLAT) and FiO(2) decreased from 24 (20-29) to 20 (19-25) cmH(2)O (p = 0.005) and from 40 (30-50) to 30 (30-39) % (p < 0.001) during IntelliVent-ASV(®) as compared to ASV. RR, P(INSP), and PEEP decreased as well during IntelliVent-ASV(®) as compared to ASV. Respiratory mechanics, pH, PaO(2) and PaO(2)/FiO(2) ratio were not different but PaCO(2) was slightly higher during IntelliVent-ASV(®) as compared to ASV.

Conclusions: In passive patients with acute respiratory failure, IntelliVent-ASV(®) was safe and able to ventilate patients with less pressure, volume and FiO(2) while producing the same results in terms of oxygenation.
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May 2012

Optimal duration of a sustained inflation recruitment maneuver in ARDS patients.

Intensive Care Med 2011 Oct 20;37(10):1588-94. Epub 2011 Aug 20.

Service de Réanimation Polyvalente, Hôpital Font Pré, 1208 Avenue du Colonel Picot, 83100 Toulon, France.

Purpose: To measure the dynamics of recruitment and the hemodynamic status during a sustained inflation recruitment maneuver (RM) in order to determine the optimal duration of RM in acute respiratory distress syndrome (ARDS) patients.

Methods: This prospective study was conducted in a 12-bed intensive care unit (ICU) in a general hospital. A 40 cmH(2)O sustained inflation RM maintained for 30 s was performed in 50 sedated ventilated patients within the first 24 h of meeting ARDS criteria. Invasive arterial pressures, heart rate, and SpO(2) were measured at 10-s intervals during the RM. The volume increase during the RM was measured by integration of the flow required to maintain the pressure at 40 cmH(2)O, which provides an estimation of the volume recruited during the RM. Raw data were corrected for gas consumption and fitted with an exponential curve in order to determine an individual time constant for the volume increase.

Results: The average volume increase and time constant were 210 ± 198 mL and 2.3 ± 1.3 s, respectively. Heart rate, diastolic arterial pressure, and SpO(2) did not change during or after the RM. Systolic and mean arterial pressures were maintained at 10 s, decreased significantly at 20 and 30 s during the RM, and recovered to the pre-RM value 30 s after the end of the RM (ANOVA, p < 0.01).

Conclusions: In early-onset ARDS patients, most of the recruitment occurs during the first 10 s of a sustained inflation RM. However, hemodynamic impairment is significant after the tenth second of RM.
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October 2011

Neuromuscular blockers in early acute respiratory distress syndrome.

N Engl J Med 2010 Sep;363(12):1107-16

Assistance Publique-Hôpitaux de Marseille Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, Centre National de la Recherche Scientifique-Unité Mixte de Recherche 6236, Université de la Méditerranée Aix-Marseille II, Marseille, France.

Background: In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS.

Methods: In this multicenter, double-blind trial, 340 patients presenting to the intensive care unit (ICU) with an onset of severe ARDS within the previous 48 hours were randomly assigned to receive, for 48 hours, either cisatracurium besylate (178 patients) or placebo (162 patients). Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FIO2) of less than 150, with a positive end-expiratory pressure of 5 cm or more of water and a tidal volume of 6 to 8 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died either before hospital discharge or within 90 days after study enrollment (i.e., the 90-day in-hospital mortality rate), adjusted for predefined covariates and baseline differences between groups with the use of a Cox model.

Results: The hazard ratio for death at 90 days in the cisatracurium group, as compared with the placebo group, was 0.68 (95% confidence interval [CI], 0.48 to 0.98; P=0.04), after adjustment for both the baseline PaO2:FIO2 and plateau pressure and the Simplified Acute Physiology II score. The crude 90-day mortality was 31.6% (95% CI, 25.2 to 38.8) in the cisatracurium group and 40.7% (95% CI, 33.5 to 48.4) in the placebo group (P=0.08). Mortality at 28 days was 23.7% (95% CI, 18.1 to 30.5) with cisatracurium and 33.3% (95% CI, 26.5 to 40.9) with placebo (P=0.05). The rate of ICU-acquired paresis did not differ significantly between the two groups.

Conclusions: In patients with severe ARDS, early administration of a neuromuscular blocking agent improved the adjusted 90-day survival and increased the time off the ventilator without increasing muscle weakness. (Funded by Assistance Publique-Hôpitaux de Marseille and the Programme Hospitalier de Recherche Clinique Régional 2004-26 of the French Ministry of Health; ClinicalTrials.gov number, NCT00299650.)
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September 2010

Recruitability of the lung estimated by the pressure volume curve hysteresis in ARDS patients.

Intensive Care Med 2008 Nov 25;34(11):2019-25. Epub 2008 Jun 25.

Service de réanimation polyvalente, Hôpital Font Pré, Toulon, France.

Objective: To assess the hysteresis of the pressure-volume curve (PV curve) as to estimate, easily and at the bedside, the recruitability of the lung in ARDS patients.

Design: Prospective study.

Setting: Twelve medico-surgical ICU beds of a general hospital.

Patients: Twenty-six patients within the first 24 h from meeting ARDS criteria.

Intervention: A Quasi-static inflation and deflation PV curve from 0 to 40 cmH(2)O and a 40 cmH(2)O recruitment maneuver (RM) maintained for 10 s were successively done with an interval of 30 min in between. RECORDINGS AND CALCULATION: Hysteresis of the PV curve (H(PV)) was calculated as the ratio of the area enclosed by the pressure volume loop divided by the predicted body weight (PBW). The volume increase during the RM (V(RM)) was measured by integration of the flow required to maintain the pressure at 40 cmH(2)O and divided by PBW, as an estimation of the volume recruited during the RM.

Results: A positive linear correlation was found between H(PV) and V(RM) (r = 0.81, P < 0.0001).

Conclusions: The results suggest using the hysteresis of the PV curve to assess the recruitability of the lung.
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http://dx.doi.org/10.1007/s00134-008-1167-8DOI Listing
November 2008

Automatic selection of breathing pattern using adaptive support ventilation.

Intensive Care Med 2008 Jan 11;34(1):75-81. Epub 2007 Sep 11.

Hôpital Font Pré, Service de réanimation polyvalente, 1208 avenue du colonel Picot, 83100 Toulon, France.

Objective: In a cohort of mechanically ventilated patients to compare the automatic tidal volume (VT)-respiratory rate (RR) combination generated by adaptive support ventilation (ASV) for various lung conditions.

Design And Setting: Prospective observational cohort study in the 11-bed medicosurgical ICU of a general hospital.

Patients: 243 patients receiving 1327 days of invasive ventilation on ASV.

Measurements: Daily collection of ventilator settings, breathing pattern, arterial blood gases, and underlying clinical respiratory conditions categorized as: normal lungs, ALI/ARDS, COPD, chest wall stiffness, or acute respiratory failure.

Results: Overall the respiratory mechanics differed significantly with the underlying conditions. In passive patients ASV delivered different VT-RR combinations based on the underlying condition, providing higher VT and lower RR in COPD than in ALI/ARDS: 9.3ml/kg (8.2-10.8) predicted body weight (PBW) and 13 breaths/min (11-16) vs. 7.6ml/kg (6.7-8.8) PBW and 18 breaths/min (16-22). In patients actively triggering the ventilator the VT-RR combinations did not differ between COPD, ALI/ARDS, and normal lungs.

Conclusions: ASV selects different VT-RR combinations based on respiratory mechanics in passive, mechanically ventilated patients.
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http://dx.doi.org/10.1007/s00134-007-0847-0DOI Listing
January 2008

High-frequency oscillatory ventilation following prone positioning prevents a further impairment in oxygenation.

Crit Care Med 2007 Jan;35(1):106-11

Service de Réanimation Médicale, Hôpital Sainte-Marguerite, Université de la Méditerranée, Marseille, France.

Objective: The improvement in oxygenation with prone positioning is not persistent when patients with acute respiratory distress syndrome (ARDS) are turned supine. High-frequency oscillatory ventilation (HFOV) aims to maintain an open lung volume by the application of a constant mean airway pressure. The aim of this study was to show that HFOV is able to prevent the impairment in oxygenation when ARDS patients are turned back from the prone to the supine position.

Design: Prospective, comparative randomized study.

Setting: A medical intensive care unit.

Patients: Forty-three ARDS patients with a Pao2/Fio2 ratio <150 at positive end-expiratory pressure > or =5 cm H2O.

Interventions: After an optimization period, the patients were assigned to one of three groups: a) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by a 12-hr period of conventional lung-protective mechanical ventilation in the supine position (CV(prone)-CV(supine)); b) conventional lung-protective mechanical ventilation in the supine position (12 hrs) followed by HFOV in the supine position (12 hrs) (CV(supine)-HFOV(supine)); or c) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by HFOV in the supine position (CV(prone)-HFOV(supine) group).

Measurements And Main Results: Pao2/Fio2 ratio was higher at the end of the study period in the CV(prone)-HFOV(supine) group than in the CV(prone)-CV(supine) group (p < .02). Venous admixture at the end of the study period was lower in the CV(prone)-HFOV(supine) group than in the two other groups.

Conclusions: HFOV maintained the improvement in oxygenation related to prone positioning when ARDS patients were returned to the supine position.
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http://dx.doi.org/10.1097/01.CCM.0000251128.60336.FEDOI Listing
January 2007