Aggressive alveolar recruitment in ARDS: More shadows than lights

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The mentioned drugs are not stated according to order of priority. It is advisable to base the choice of drug taking into account the characteristics of the patient and the possible side effects. Dexmedetomidine is recommended in sequential sedation (when we wish to switch from deep sedation to mild sedation), for the treatment of alcohol or pharmacological privation (including benzodiazepines), in patients subjected to extracorporeal membrane oxygenation (ECMO), and in situations of hyperactive delirium. Ketamine should be considered in patients with poor control of pain, status asthmaticus, in individuals subjected to ECMO or in hemodynamically unstable patients. In selected patients, inhalatory anesthetics may be regarded as a first choice, even over benzodiazepines, for maintaining RASS ≤ −4, and can also be used in patients with status asthmaticus or epilepticus. Although typical antipsychotics (haloperidol) and atypical antipsychotics (quetiapine and olanzapine) have not been shown to shorten the duration of delirium, MV or stay in IC, they can be used to control symptoms such as agitation, anxiety or hallucinations. Valproic acid can be used in the case of symptoms refractory to antipsychotic agents. In this regard, we can administer 1500 mg/day divided into 3–4 doses, that may be preceded by a loading dose of 28 mg/kg. CAM-ICU: Confusion Assessment Method for the ICU." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Alcántara Carmona, M. García Sánchez" "autores" => array:2 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Alcántara Carmona" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "García Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572721000746?idApp=WMIE" "url" => "/21735727/0000004500000007/v1_202109230629/S2173572721000746/v1_202109230629/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173572720300813" "issn" => "21735727" "doi" => "10.1016/j.medine.2020.04.002" "estado" => "S300" "fechaPublicacion" => "2021-10-01" "aid" => "1428" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Med Intensiva. 2021;45:421-30" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Effect of half-molar sodium lactate infusion on biochemical parameters in critically ill patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "421" "paginaFinal" => "430" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efecto de la infusión de lactato de sodio 0,5 molar sobre el medio interno de pacientes críticos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1074 "Ancho" => 1208 "Tamanyo" => 54118 ] ] "descripcion" => array:1 [ "en" => "Changes in plasma lactate at preinfusion (T0), 30min after infusion (T1) and 60min after infusion (T2) reported with the median, IQR and maximum and minimum value. Friedman test." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Aramendi, A. Stolovas, S. Mendaña, A. Barindelli, W. Manzanares, A. Biestro" "autores" => array:6 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Aramendi" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Stolovas" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Mendaña" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Barindelli" ] 4 => array:2 [ "nombre" => "W." "apellidos" => "Manzanares" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Biestro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569119302803" "doi" => "10.1016/j.medin.2019.11.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569119302803?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572720300813?idApp=WMIE" "url" => "/21735727/0000004500000007/v1_202109230629/S2173572720300813/v1_202109230629/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Special article" "titulo" => "Aggressive alveolar recruitment in ARDS: More shadows than lights" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "431" "paginaFinal" => "436" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. 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"apellidos" => "Mancebo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Universidad Autónoma de Querétaro, Hospital H+ Querétaro, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Universitario Vall d'Hebron, Departamento de Cuidados Intensivos, Politraumáticos y Gran Quemado, Unidad de Investigación de Neurocirugía y Neurotraumatología, Universidad Autónoma de Barcelona" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital H+ Querétaro, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Centro de prevención y Rehabilitación de Enfermedades Pulmonares, Hospital Universitario UANL, Monterrey México, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Hospital H+ Querétaro, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Medical and Surgical Research Unit, Instituto de Investigación Sanitaria Puerta de Hierro Majadahonda, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servei Medicina Intensiva, Parc Taulí Hospital Universitario, Instituto de Investigación e Innovación Parc Taulí, Universidad Autónoma de Barcelona, Sabadell, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servei Medicina Intensiva, Hospital Sant Pau, Barcelona" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reclutamiento alveolar agresivo en el SDRA: más sombras que luces" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1491 "Ancho" => 1520 "Tamanyo" => 196828 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Multicompartment system of intraabdominal, intrathoracic and intracranial pressure interaction. The increase in IAP and TTP (RM) with low Cs, and its repercussion upon the intrapulmonary pressures, result in an ascending LCR flow during inspiration and difficult JVR, with the consequent increase in ICP. On the other hand, the increase in PEEP (RM), according to volemia status, may result in a decrease in cardiac preload and an increase in right ventricle afterload. Abbreviations: Cs: pulmonary compliance, TTP: transthoracic pressure, ΔP: driving pressure, PL: transpulmonary pressure, IAP: intraabdominal pressure, PEEP: positive end-expiratory pressure, CSF: cerebrospinal fluid, JVR: jugular venous return, CPP: cerebral perfusion pressure, ICP: intracranial pressure, RM: recruitment maneuver." ] ] ] "textoCompleto" => "Definition of recruitmentNo universally accepted definition from either the anatomical/morphological perspective or the functional viewpoint has been established for alveolar recruitment in patients with acute respiratory distress syndrome (ARDS).<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> This is due to the methodology used for the analysis and quantification of alveolar recruitment. The commonly accepted definition of recruitment is based on the pulmonary tomographic evaluation of gas penetration into previously unventilated areas of the lungs – including or not the penetration of gas into poorly ventilated zones.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> This evaluation is made in accordance with the modification of the radiological density range within the lungs. When using methods based on pulmonary mechanics or the dilution of inert gases, recruitment takes into account both the gas that has penetrated into previously unventilated zones and the gas that has penetrated into partially ventilated zones.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a>Types of recruitment maneuversAn alveolar recruitment maneuver (RM) consists of a transient increase in alveolar pressure to levels above those of protective ventilation. Alveolar recruitment during RM depends on a number of factors: the duration of the maneuver, the existence of recruitable lung tissue, the balance between recruitment of collapsed areas and overdistension of ventilated areas, the hemodynamic response during the maneuver (which largely determine its tolerance) and the positive end-expiratory pressure (PEEP) required after RM. This PEEP level after RM is usually adjusted according to the increase in pulmonary compliance or a sustained increase in oxygenation.<a class="elsevierStyleCrossRefs" href="#bib0030">6–9</a> Many alveolar recruitment procedures have been described, of which two are the most widely used<a class="elsevierStyleCrossRefs" href="#bib0030">6,10,11</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Application of CPAP between 30–40 cmH2O during a period of 30–40 s.</li><li class="elsevierStyleListItem" id="lsti0010">-Pressure control ventilation and the elevation of PEEP to limits of 30–40 cmH2O with peak pressures no higher than 50–60 cmH2O.</li></ul>Maneuvers with sustained CPAP produce more marked reductions of cardiac output and arterial pressure than pressure control ventilation recruitment maneuvering – probably because the latter affords a limited and intermittent peak inspiratory pressure within the airway, which allows venous return, in contrast to the constant pressure of maneuvering with CPAP.<a class="elsevierStyleCrossRefs" href="#bib0030">6,12</a> To date, no studies have compared the incidence of barotrauma or the impact upon mortality according to the type of recruitment maneuver used.The degree of hemodynamic impairment produced by RM is largely dependent upon the volemia level at the time of the maneuver. Experimental studies have shown that the hemodynamic effects of RM can be enhanced by hypovolemia – the main underlying mechanism being the drop in venous return and ventricular filling. Asystolia may result in extreme cases. In normovolemic situations, the increase in right ventricle afterload due to the elevation of intrathoracic pressure is the main cause of lowered cardiac output.<a class="elsevierStyleCrossRefs" href="#bib0060">12–15</a>Estimation of recruitmentImaging and lung mechanical studies show that alveolar recruitment takes place from the start of insufflation to the end of the latter.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Thus, a fundamental characteristic of recruitment is that it occurs during inspiration. In this regard, positive end-expiratory pressure (PEEP) per se does not give rise to recruitment, but rather avoids derecruitment and expiratory alveolar collapse.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>Consequently, the magnitude of recruitment will depend on the end-inspiratory pressure, and for the same PEEP levels, the recruitment observed in patients with acute lung injury and ventilated with low circulating volumes (6 ml/kg) is less than that observed at higher circulating volumes (10 ml/kg).<a class="elsevierStyleCrossRef" href="#bib0085">17</a> However, when patients are ventilated with an airway plateau pressure of about 30 cmH2O, the combination of elevated PEEP with low circulating volume generates greater recruitment than the combination of high circulating volume and lower PEEP. These findings evidence the importance of avoiding derecruitment following any alveolar recruitment maneuver.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Different methods have been developed to assess the degree of alveolar recruitment. Some of them are based on the plotting of volume and pressure curves, where the PEEP level is modified and an estimation is made of the gain between the increase or decrease in total expired gas volume between two PEEP points. On constructing these two points, any modification of the PEEP level will result in an increase or decrease in expired gas volume: if the latter is greater than expected (determined by compliance and the pressure gradient), recruitment will have taken place.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a> This principle is also applicable to the gas dilution methods, where evaluation is made of the concentration of inert gases (usually helium or nitrogen), with calculation at different PEEP levels of the greater or lesser dilution of the gas – corresponding to greater or lesser lung volume.<a class="elsevierStyleCrossRefs" href="#bib0020">4,6</a>Thoracic computed tomography is the imaging technique traditionally used to estimate alveolar recruitment, and may be regarded as the gold standard in this regard. The technique analyzes the radiological densities of the lung tissue from the images obtained. Density is expressed in Hounsfield units (HU), and ranges from +100 to −1000. Thus, and depending on the authors,<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> unventilated zones are considered to present between +100 and −100 HU, poorly ventilated zones between −100 and −500 HU, well ventilated zones between −500 and −900 HU, and hyperinsufflated zones between −900 and −1000 HU. Based on the respective densities, calculation is made of the volume of gas in each of the zones and the changes induced by PEEP and/or the circulating volume, thus providing an estimation of recruitment.More recently, the estimation of alveolar recruitment has been made on a point-of-care and noninvasive basis using imaging techniques simpler than thoracic computed tomography. These techniques include lung ultrasound and electrical impedance tomography.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> In expert hands, different lung ultrasound indices have shown good correlation to alveolar recruitment estimated from thoracic computed tomography.<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> Lastly, electrical impedance tomography allows us to estimate not only alveolar recruitment but also the hyperinsufflation induced by ventilation. Accordingly, it may be a useful tool for individualizing the ventilatory parameters.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a>Oxygenation is the most widely used method for evaluating the response to alveolar recruitment. The simplest methods for assessing the response to recruitment with oxygenation are those used in the ART study and in the ALVEOLI trial. In the ART study, the criterion for determining the response to recruitment was a change in the PaO2/FiO2 ratio of >50 mmHg, and the method used was the gradual increase in PEEP level with an inspiratory pressure of 15 cmH2O.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In the ALVEOLI study, the criterion for determining the response to alveolar recruitment was an increase of between 5–9% in SaO2 following CPAP 40 cmH2O during 40 s.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Recruitment maneuvering in neurocritical patientsLung–brain interaction is one of the main challenges in the management of neurocritical patients, where it has been shown that hypoventilation and hypoxemia increase cerebral blood flow, resulting in an increased risk of brain edema and intracranial hypertension. Acute respiratory distress syndrome has been associated to high morbidity-mortality in neurocritical patients; alveolar RM is therefore of considerable interest in the management of these individuals.<a class="elsevierStyleCrossRefs" href="#bib0130">26–28</a>The benefits of protective ventilation have been well established, in the same way as the benefits of measures such as prone decubitus. Recruitment maneuvers and the use of high PEEP levels have been prescribed to improve oxygenation in patients with refractory acute respiratory failure. However, due to the increase in intrathoracic pressure and the consequent decrease in venous return, these measures may cause deleterious effects such as an increase in intracranial pressure (ICP) and a decrease in cerebral perfusion pressure (CPP).<a class="elsevierStyleCrossRefs" href="#bib0135">27,29,30</a><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> describes the different interactions between intracranial, intraabdominal and intrathoracic pressure.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Recruitment maneuvering in neurocritical patients is subject to controversy.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> Wolf et al.,<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Pulitano et al.,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> and McGuire et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> documented the safety of high PEEP in patients with brain damage, showing that the ICP increments secondary to an increase in PEEP were not clinically significant. Nermer et al.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> likewise documented the safety of RM based on the increase in inspiratory levels over PEEP levels of 15 cmH2O, with the aim of improving oxygenation; their study evidenced no significant changes in ICP or CPP. Borsellino et al.,<a class="elsevierStyleCrossRef" href="#bib0145">29</a> in a systematic review, observed great variability among the published studies, and concluded that there are no scientific reasons for not performing RM in patients with acute brain damage, provided brain perfusion and hemodynamics can be monitored. Lastly, the association between the variations in PEEP and their effect upon ICP is related to the respiratory system mechanics.<a class="elsevierStyleCrossRefs" href="#bib0130">26,35</a>In sum, RM based on an increase in inspiratory pressure in neurocritical patients has been shown to improve oxygenation. However, due to the risk of secondary brain damage, such measures should only be adopted under strict monitoring of brain perfusion and hemodynamics – placing priority on the safety of the patient neurological condition, and individualizing each case.Scientific evidenceThe use of RM in patients with ARDS remains subject to controversy. The latest randomized studies on the utilization of RM have unanimously demonstrated an increase in oxygenation, though without improvements in terms of mortality<a class="elsevierStyleCrossRefs" href="#bib0040">8,36–38</a> or with an increase in mortality in the group subjected to the optimization of PEEP following alveolar RM.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> It is therefore considered that RM should not be used on a generalized basis in patients with ARDS.<a class="elsevierStyleCrossRefs" href="#bib0010">2,39,40</a> Recently, Papazian et al.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> personalized mechanical ventilation (MV) in ARDS according to the radiological morphology of lung damage. The patients randomized to the control group received a tidal volume (TV) of 6 ml/kg and a PEEP level according to a FiO2/PEEP table, and were placed in early prone decubitus, while the personalized group was treated according to the morphology of the lung injury. The patients with focal lung injury received a TV of 8 ml/kg and PEEP between 5–9 cmH2O, and were placed in early prone decubitus. The patients with diffuse lesions received a TV of 6 ml/kg, PEEP to reach an end-inspiratory pressure of 30 cmH2O, and RM. There were no differences in mortality between the control group and the personalized treatment group, though 21% of the patients were wrongly classified due to incorrect identification of the lung injury as being either focal or diffuse. A relevant finding of this study was greater survival in the correctly classified personalized treatment cases and greater mortality in the wrongly classified personalized treatment cases. The study published by Constantin et al.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> evidences the difficult of providing individualized MV in patients with ARDS. Recruitment maneuvering applied to patients with focal ARDS may prove deleterious, since it can induce overpressure phenomena and deformation in aerated lung zones, redistribution of pulmonary circulation towards unventilated zones with an increase in pulmonary shunting, and elevation of the pulmonary vascular resistances and right ventricle afterload – all these phenomena being known to be able to increase the damage already established by ARDS itself.<a class="elsevierStyleCrossRefs" href="#bib0035">7,12,15,42</a>ConclusionsInvasive ventilatory support in ARDS should be based on the evidence of a protective TV with early prone decubitus, and on the individualization of PEEP and other adjuvant treatments according to the etiology of ARDS and the morphology of the lung injury.<a class="elsevierStyleCrossRefs" href="#bib0195">39,40</a> Alveolar RM has been used as a rescue strategy in situations of refractory hypoxemia, and its application requires good knowledge of respiratory pathophysiology and precise assessment of the impact of these maneuvers upon organs at a distance from the lungs – particularly the cardiovascular system. In sum, RM is a risky intervention when not performed on an individualized basis, and when the response to maneuvering is not adequately monitored.Financial supportThe present study has received partial funding from CIBER Enfermedades Respiratorias (ISCiii, Madrid, Spain).Contribution of the authorsAll the authors of the VentiBarna group have contributed to the prior discussions on the orientation of the manuscript and its drafting.Conflicts of interestThe authors of the VentiBarna Group declare that they have no personal or financial conflicts of interest in relation to the present study." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1576160" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1420337" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1576159" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1420338" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Definition of recruitment" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Types of recruitment maneuvers" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Estimation of recruitment" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Recruitment maneuvering in neurocritical patients" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Scientific evidence" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Financial support" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Contribution of the authors" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-08" "fechaAceptado" => "2020-03-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1420337" "palabras" => array:4 [ 0 => "Alveolar recruitment" 1 => "Mechanical ventilation" 2 => "Acute respiratory distress syndrome" 3 => "Lung damage" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1420338" "palabras" => array:4 [ 0 => "Reclutamiento Alveolar" 1 => "Ventilación mecánica" 2 => "Síndrome de Distrés Respiratorio Agudo" 3 => "Daño Pulmonar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Alveolar recruitment in acute respiratory distress syndrome (ARDS) is defined as the penetration of gas into previously unventilated areas or poorly ventilated areas. Alveolar recruitment during recruitment maneuvering (RM) depends on the duration of the maneuver, the recruitable lung tissue, and the balance between the recruitment of collapsed areas and over-insufflation of the ventilated areas. Alveolar recruitment is estimated using computed tomography of the lung and, at the patient bedside, through assessment of the recruited volume using pressure-volume curves and assessing lung morphology with pulmonary ultrasound and/or impedance tomography. The scientific evidence on RM in patients with ARDS remains subject to controversy. Randomized studies on ARDS have shown no benefit or have even reflected an increase in mortality. The routine use of RM is therefore not recommended." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Reclutamiento alveolar en el síndrome de distrés respiratorio agudo (SDRA) se define como la entrada de gas en zonas previamente no ventiladas o en zonas pobremente ventiladas. El reclutamiento alveolar durante una maniobra de reclutamiento (MR) dependerá de la duración de la maniobra, del tejido pulmonar reclutable, del balance entre reclutamiento de áreas colapsadas y sobredistensión de las áreas ventiladas. La estimación del reclutamiento alveolar se realiza con la tomografía computarizada de tórax y, a pie de cama, con la construcción de curvas de volumen y presión, la ecografía pulmonar y la tomografía por impedancia. La evidencia científica nos indica que la utilización de las MR en pacientes con SDRA sigue sujeta a controversia. Estudios aleatorizados del SDRA o bien no han demostrado beneficio o bien han revelado un incremento de la mortalidad y, por ello, no se recomienda su uso rutinario." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Lomeli M, Dominguez Cenzano L, Torres L, Chavarría U, Poblano M, Tendillo F, et al. Reclutamiento alveolar agresivo en el SDRA: más sombras que luces. Med Intensiva. 2021;45:431–436." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1491 "Ancho" => 1520 "Tamanyo" => 196828 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Multicompartment system of intraabdominal, intrathoracic and intracranial pressure interaction. The increase in IAP and TTP (RM) with low Cs, and its repercussion upon the intrapulmonary pressures, result in an ascending LCR flow during inspiration and difficult JVR, with the consequent increase in ICP. On the other hand, the increase in PEEP (RM), according to volemia status, may result in a decrease in cardiac preload and an increase in right ventricle afterload. Abbreviations: Cs: pulmonary compliance, TTP: transthoracic pressure, ΔP: driving pressure, PL: transpulmonary pressure, IAP: intraabdominal pressure, PEEP: positive end-expiratory pressure, CSF: cerebrospinal fluid, JVR: jugular venous return, CPP: cerebral perfusion pressure, ICP: intracranial pressure, RM: recruitment maneuver." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The "baby lung" became an adult" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Gattinoni" 1 => "J.J. Marini" 2 => "A. Pesenti" 3 => "M. Quintel" 4 => "J. Mancebo" 5 => "L. 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Special article

Aggressive alveolar recruitment in ARDS: More shadows than lights

Reclutamiento alveolar agresivo en el SDRA: más sombras que luces

M. Lomelia, L. Dominguez Cenzanob, L. Torresc, U. Chavarríad, M. Poblanoe, F. Tendillof, L. Blanchg,

Corresponding author

lblanch@tauli.cat

Corresponding author.

, J. Manceboh

a Universidad Autónoma de Querétaro, Hospital H+ Querétaro, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica

b Hospital Universitario Vall d'Hebron, Departamento de Cuidados Intensivos, Politraumáticos y Gran Quemado, Unidad de Investigación de Neurocirugía y Neurotraumatología, Universidad Autónoma de Barcelona

c Hospital H+ Querétaro, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica

d Centro de prevención y Rehabilitación de Enfermedades Pulmonares, Hospital Universitario UANL, Monterrey México, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica

e Hospital H+ Querétaro, Grupo Ventilación Mecánica México, Colegio Mexicano de Medicina Crítica

f Medical and Surgical Research Unit, Instituto de Investigación Sanitaria Puerta de Hierro Majadahonda, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid

g Servei Medicina Intensiva, Parc Taulí Hospital Universitario, Instituto de Investigación e Innovación Parc Taulí, Universidad Autónoma de Barcelona, Sabadell, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid

h Servei Medicina Intensiva, Hospital Sant Pau, Barcelona

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When using methods based on pulmonary mechanics or the dilution of inert gases&#44; recruitment takes into account both the gas that has penetrated into previously unventilated zones and the gas that has penetrated into partially ventilated zones&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Types of recruitment maneuvers</span><p id="par0010" class="elsevierStylePara elsevierViewall">An alveolar recruitment maneuver &#40;RM&#41; consists of a transient increase in alveolar pressure to levels above those of protective ventilation&#46; Alveolar recruitment during RM depends on a number of factors&#58; the duration of the maneuver&#44; the existence of recruitable lung tissue&#44; the balance between recruitment of collapsed areas and overdistension of ventilated areas&#44; the hemodynamic response during the maneuver &#40;which largely determine its tolerance&#41; and the positive end-expiratory pressure &#40;PEEP&#41; required after RM&#46; This PEEP level after RM is usually adjusted according to the increase in pulmonary compliance or a sustained increase in oxygenation&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;9</span></a> Many alveolar recruitment procedures have been described&#44; of which two are the most widely used<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;10&#44;11</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Application of CPAP between 30&#8211;40&#160;cmH<span class="elsevierStyleInf">2</span>O during a period of 30&#8211;40&#160;s&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">Pressure control ventilation and the elevation of PEEP to limits of 30&#8211;40&#160;cmH<span class="elsevierStyleInf">2</span>O with peak pressures no higher than 50&#8211;60&#160;cmH<span class="elsevierStyleInf">2</span>O&#46;</p></li></ul></p><p id="par0025" class="elsevierStylePara elsevierViewall">Maneuvers with sustained CPAP produce more marked reductions of cardiac output and arterial pressure than pressure control ventilation recruitment maneuvering &#8211; probably because the latter affords a limited and intermittent peak inspiratory pressure within the airway&#44; which allows venous return&#44; in contrast to the constant pressure of maneuvering with CPAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;12</span></a> To date&#44; no studies have compared the incidence of barotrauma or the impact upon mortality according to the type of recruitment maneuver used&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The degree of hemodynamic impairment produced by RM is largely dependent upon the volemia level at the time of the maneuver&#46; Experimental studies have shown that the hemodynamic effects of RM can be enhanced by hypovolemia &#8211; the main underlying mechanism being the drop in venous return and ventricular filling&#46; Asystolia may result in extreme cases&#46; In normovolemic situations&#44; the increase in right ventricle afterload due to the elevation of intrathoracic pressure is the main cause of lowered cardiac output&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Estimation of recruitment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Imaging and lung mechanical studies show that alveolar recruitment takes place from the start of insufflation to the end of the latter&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Thus&#44; a fundamental characteristic of recruitment is that it occurs during inspiration&#46; In this regard&#44; positive end-expiratory pressure &#40;PEEP&#41; <span class="elsevierStyleItalic">per se</span> does not give rise to recruitment&#44; but rather avoids derecruitment and expiratory alveolar collapse&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Consequently&#44; the magnitude of recruitment will depend on the end-inspiratory pressure&#44; and for the same PEEP levels&#44; the recruitment observed in patients with acute lung injury and ventilated with low circulating volumes &#40;6&#160;ml&#47;kg&#41; is less than that observed at higher circulating volumes &#40;10&#160;ml&#47;kg&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However&#44; when patients are ventilated with an airway plateau pressure of about 30&#160;cmH<span class="elsevierStyleInf">2</span>O&#44; the combination of elevated PEEP with low circulating volume generates greater recruitment than the combination of high circulating volume and lower PEEP&#46; These findings evidence the importance of avoiding derecruitment following any alveolar recruitment maneuver&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Different methods have been developed to assess the degree of alveolar recruitment&#46; Some of them are based on the plotting of volume and pressure curves&#44; where the PEEP level is modified and an estimation is made of the gain between the increase or decrease in total expired gas volume between two PEEP points&#46; On constructing these two points&#44; any modification of the PEEP level will result in an increase or decrease in expired gas volume&#58; if the latter is greater than expected &#40;determined by compliance and the pressure gradient&#41;&#44; recruitment will have taken place&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> This principle is also applicable to the gas dilution methods&#44; where evaluation is made of the concentration of inert gases &#40;usually helium or nitrogen&#41;&#44; with calculation at different PEEP levels of the greater or lesser dilution of the gas &#8211; corresponding to greater or lesser lung volume&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Thoracic computed tomography is the imaging technique traditionally used to estimate alveolar recruitment&#44; and may be regarded as the gold standard in this regard&#46; The technique analyzes the radiological densities of the lung tissue from the images obtained&#46; Density is expressed in Hounsfield units &#40;HU&#41;&#44; and ranges from &#43;100 to &#8722;1000&#46; Thus&#44; and depending on the authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> unventilated zones are considered to present between &#43;100 and &#8722;100 HU&#44; poorly ventilated zones between &#8722;100 and &#8722;500 HU&#44; well ventilated zones between &#8722;500 and &#8722;900 HU&#44; and hyperinsufflated zones between &#8722;900 and &#8722;1000 HU&#46; Based on the respective densities&#44; calculation is made of the volume of gas in each of the zones and the changes induced by PEEP and&#47;or the circulating volume&#44; thus providing an estimation of recruitment&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">More recently&#44; the estimation of alveolar recruitment has been made on a point-of-care and noninvasive basis using imaging techniques simpler than thoracic computed tomography&#46; These techniques include lung ultrasound and electrical impedance tomography&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> In expert hands&#44; different lung ultrasound indices have shown good correlation to alveolar recruitment estimated from thoracic computed tomography&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> Lastly&#44; electrical impedance tomography allows us to estimate not only alveolar recruitment but also the hyperinsufflation induced by ventilation&#46; Accordingly&#44; it may be a useful tool for individualizing the ventilatory parameters&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Oxygenation is the most widely used method for evaluating the response to alveolar recruitment&#46; The simplest methods for assessing the response to recruitment with oxygenation are those used in the ART study and in the ALVEOLI trial&#46; In the ART study&#44; the criterion for determining the response to recruitment was a change in the PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> ratio of &#62;50&#160;mmHg&#44; and the method used was the gradual increase in PEEP level with an inspiratory pressure of 15&#160;cmH<span class="elsevierStyleInf">2</span>O&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In the ALVEOLI study&#44; the criterion for determining the response to alveolar recruitment was an increase of between 5&#8211;9&#37; in SaO<span class="elsevierStyleInf">2</span> following CPAP 40&#160;cmH<span class="elsevierStyleInf">2</span>O during 40&#160;s&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recruitment maneuvering in neurocritical patients</span><p id="par0065" class="elsevierStylePara elsevierViewall">Lung&#8211;brain interaction is one of the main challenges in the management of neurocritical patients&#44; where it has been shown that hypoventilation and hypoxemia increase cerebral blood flow&#44; resulting in an increased risk of brain edema and intracranial hypertension&#46; Acute respiratory distress syndrome has been associated to high morbidity-mortality in neurocritical patients&#59; alveolar RM is therefore of considerable interest in the management of these individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#8211;28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The benefits of protective ventilation have been well established&#44; in the same way as the benefits of measures such as prone decubitus&#46; Recruitment maneuvers and the use of high PEEP levels have been prescribed to improve oxygenation in patients with refractory acute respiratory failure&#46; However&#44; due to the increase in intrathoracic pressure and the consequent decrease in venous return&#44; these measures may cause deleterious effects such as an increase in intracranial pressure &#40;ICP&#41; and a decrease in cerebral perfusion pressure &#40;CPP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;29&#44;30</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> describes the different interactions between intracranial&#44; intraabdominal and intrathoracic pressure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Recruitment maneuvering in neurocritical patients is subject to controversy&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Wolf et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Pulitano et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> and McGuire et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> documented the safety of high PEEP in patients with brain damage&#44; showing that the ICP increments secondary to an increase in PEEP were not clinically significant&#46; Nermer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> likewise documented the safety of RM based on the increase in inspiratory levels over PEEP levels of 15&#160;cmH<span class="elsevierStyleInf">2</span>O&#44; with the aim of improving oxygenation&#59; their study evidenced no significant changes in ICP or CPP&#46; Borsellino et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> in a systematic review&#44; observed great variability among the published studies&#44; and concluded that there are no scientific reasons for not performing RM in patients with acute brain damage&#44; provided brain perfusion and hemodynamics can be monitored&#46; Lastly&#44; the association between the variations in PEEP and their effect upon ICP is related to the respiratory system mechanics&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;35</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In sum&#44; RM based on an increase in inspiratory pressure in neurocritical patients has been shown to improve oxygenation&#46; However&#44; due to the risk of secondary brain damage&#44; such measures should only be adopted under strict monitoring of brain perfusion and hemodynamics &#8211; placing priority on the safety of the patient neurological condition&#44; and individualizing each case&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Scientific evidence</span><p id="par0085" class="elsevierStylePara elsevierViewall">The use of RM in patients with ARDS remains subject to controversy&#46; The latest randomized studies on the utilization of RM have unanimously demonstrated an increase in oxygenation&#44; though without improvements in terms of mortality<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;36&#8211;38</span></a> or with an increase in mortality in the group subjected to the optimization of PEEP following alveolar RM&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It is therefore considered that RM should not be used on a generalized basis in patients with ARDS&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;39&#44;40</span></a> Recently&#44; Papazian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> personalized mechanical ventilation &#40;MV&#41; in ARDS according to the radiological morphology of lung damage&#46; The patients randomized to the control group received a tidal volume &#40;TV&#41; of 6&#160;ml&#47;kg and a PEEP level according to a FiO2&#47;PEEP table&#44; and were placed in early prone decubitus&#44; while the personalized group was treated according to the morphology of the lung injury&#46; The patients with focal lung injury received a TV of 8&#160;ml&#47;kg and PEEP between 5&#8211;9&#160;cmH<span class="elsevierStyleInf">2</span>O&#44; and were placed in early prone decubitus&#46; The patients with diffuse lesions received a TV of 6&#160;ml&#47;kg&#44; PEEP to reach an end-inspiratory pressure of 30&#160;cmH<span class="elsevierStyleInf">2</span>O&#44; and RM&#46; There were no differences in mortality between the control group and the personalized treatment group&#44; though 21&#37; of the patients were wrongly classified due to incorrect identification of the lung injury as being either focal or diffuse&#46; A relevant finding of this study was greater survival in the correctly classified personalized treatment cases and greater mortality in the wrongly classified personalized treatment cases&#46; The study published by Constantin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> evidences the difficult of providing individualized MV in patients with ARDS&#46; Recruitment maneuvering applied to patients with focal ARDS may prove deleterious&#44; since it can induce overpressure phenomena and deformation in aerated lung zones&#44; redistribution of pulmonary circulation towards unventilated zones with an increase in pulmonary shunting&#44; and elevation of the pulmonary vascular resistances and right ventricle afterload &#8211; all these phenomena being known to be able to increase the damage already established by ARDS itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;12&#44;15&#44;42</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Invasive ventilatory support in ARDS should be based on the evidence of a protective TV with early prone decubitus&#44; and on the individualization of PEEP and other adjuvant treatments according to the etiology of ARDS and the morphology of the lung injury&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a> Alveolar RM has been used as a rescue strategy in situations of refractory hypoxemia&#44; and its application requires good knowledge of respiratory pathophysiology and precise assessment of the impact of these maneuvers upon organs at a distance from the lungs &#8211; particularly the cardiovascular system&#46; In sum&#44; RM is a risky intervention when not performed on an individualized basis&#44; and when the response to maneuvering is not adequately monitored&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Financial support</span><p id="par0095" class="elsevierStylePara elsevierViewall">The present study has received partial funding from <span class="elsevierStyleGrantSponsor" id="gs0005"><span class="elsevierStyleItalic">CIBER Enfermedades Respiratorias</span></span> &#40;ISCiii&#44; Madrid&#44; Spain&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Contribution of the authors</span><p id="par0100" class="elsevierStylePara elsevierViewall">All the authors of the VentiBarna group have contributed to the prior discussions on the orientation of the manuscript and its drafting&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors of the VentiBarna Group declare that they have no personal or financial conflicts of interest in relation to the present study&#46;</p></span></span>"
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          "titulo" => "Definition of recruitment"
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          "identificador" => "sec0010"
          "titulo" => "Types of recruitment maneuvers"
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          "titulo" => "Estimation of recruitment"
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          "titulo" => "Recruitment maneuvering in neurocritical patients"
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    "fechaRecibido" => "2020-03-08"
    "fechaAceptado" => "2020-03-18"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Alveolar recruitment"
            1 => "Mechanical ventilation"
            2 => "Acute respiratory distress syndrome"
            3 => "Lung damage"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Reclutamiento Alveolar"
            1 => "Ventilaci&#243;n mec&#225;nica"
            2 => "S&#237;ndrome de Distr&#233;s Respiratorio Agudo"
            3 => "Da&#241;o Pulmonar"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Alveolar recruitment in acute respiratory distress syndrome &#40;ARDS&#41; is defined as the penetration of gas into previously unventilated areas or poorly ventilated areas&#46; Alveolar recruitment during recruitment maneuvering &#40;RM&#41; depends on the duration of the maneuver&#44; the recruitable lung tissue&#44; and the balance between the recruitment of collapsed areas and over-insufflation of the ventilated areas&#46; Alveolar recruitment is estimated using computed tomography of the lung and&#44; at the patient bedside&#44; through assessment of the recruited volume using pressure-volume curves and assessing lung morphology with pulmonary ultrasound and&#47;or impedance tomography&#46; The scientific evidence on RM in patients with ARDS remains subject to controversy&#46; Randomized studies on ARDS have shown no benefit or have even reflected an increase in mortality&#46; The routine use of RM is therefore not recommended&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Reclutamiento alveolar en el s&#237;ndrome de distr&#233;s respiratorio agudo &#40;SDRA&#41; se define como la entrada de gas en zonas previamente no ventiladas o en zonas pobremente ventiladas&#46; El reclutamiento alveolar durante una maniobra de reclutamiento &#40;MR&#41; depender&#225; de la duraci&#243;n de la maniobra&#44; del tejido pulmonar reclutable&#44; del balance entre reclutamiento de &#225;reas colapsadas y sobredistensi&#243;n de las &#225;reas ventiladas&#46; La estimaci&#243;n del reclutamiento alveolar se realiza con la tomograf&#237;a computarizada de t&#243;rax y&#44; a pie de cama&#44; con la construcci&#243;n de curvas de volumen y presi&#243;n&#44; la ecograf&#237;a pulmonar y la tomograf&#237;a por impedancia&#46; La evidencia cient&#237;fica nos indica que la utilizaci&#243;n de las MR en pacientes con SDRA sigue sujeta a controversia&#46; Estudios aleatorizados del SDRA o bien no han demostrado beneficio o bien han revelado un incremento de la mortalidad y&#44; por ello&#44; no se recomienda su uso rutinario&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lomeli M&#44; Dominguez Cenzano L&#44; Torres L&#44; Chavarr&#237;a U&#44; Poblano M&#44; Tendillo F&#44; et al&#46; Reclutamiento alveolar agresivo en el SDRA&#58; m&#225;s sombras que luces&#46; Med Intensiva&#46; 2021&#59;45&#58;431&#8211;436&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multicompartment system of intraabdominal&#44; intrathoracic and intracranial pressure interaction&#46; The increase in IAP and TTP &#40;RM&#41; with low Cs&#44; and its repercussion upon the intrapulmonary pressures&#44; result in an ascending LCR flow during inspiration and difficult JVR&#44; with the consequent increase in ICP&#46; On the other hand&#44; the increase in PEEP &#40;RM&#41;&#44; according to volemia status&#44; may result in a decrease in cardiac preload and an increase in right ventricle afterload&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; Cs&#58; pulmonary compliance&#44; TTP&#58; transthoracic pressure&#44; &#916;P&#58; driving pressure&#44; PL&#58; transpulmonary pressure&#44; IAP&#58; intraabdominal pressure&#44; PEEP&#58; positive end-expiratory pressure&#44; CSF&#58; cerebrospinal fluid&#44; JVR&#58; jugular venous return&#44; CPP&#58; cerebral perfusion pressure&#44; ICP&#58; intracranial pressure&#44; RM&#58; recruitment maneuver&#46;</p>"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2021.06.003

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Year/Month	Html	Pdf	Total

2024 October	29	35	64
2024 September	49	46	95
2024 August	67	69	136
2024 July	43	40	83
2024 June	51	61	112
2024 May	42	45	87
2024 April	58	53	111
2024 March	58	39	97
2024 February	50	46	96
2024 January	43	35	78
2023 December	36	43	79
2023 November	54	58	112
2023 October	25	45	70
2023 September	35	38	73
2023 August	24	26	50
2023 July	31	33	64
2023 June	35	28	63
2023 May	45	45	90
2023 April	42	21	63
2023 March	81	37	118
2023 February	49	30	79
2023 January	30	47	77
2022 December	77	70	147
2022 November	55	57	112
2022 October	87	61	148
2022 September	47	51	98
2022 August	37	25	62
2022 July	45	52	97
2022 June	47	43	90
2022 May	44	42	86
2022 April	44	44	88
2022 March	58	66	124
2022 February	52	42	94
2022 January	72	47	119
2021 December	0	2	2
2021 October	2	0	2
2021 August	4	2	6

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