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  1. Article ; Online: Setting positive end-expiratory pressure: using the pressure-volume curve.

    Mojoli, Francesco / Pozzi, Marco / Arisi, Eric

    Current opinion in critical care

    2023  Volume 30, Issue 1, Page(s) 35–42

    Abstract: Purpose of review: To discuss the role of pressure-volume curve (PV curve) in exploring elastic properties of the respiratory system and setting mechanical ventilator to reduce ventilator-induced lung injury.: Recent findings: Nowadays, quasi-static ... ...

    Abstract Purpose of review: To discuss the role of pressure-volume curve (PV curve) in exploring elastic properties of the respiratory system and setting mechanical ventilator to reduce ventilator-induced lung injury.
    Recent findings: Nowadays, quasi-static PV curves and loops can be easily obtained and analyzed at the bedside without disconnection of the patient from the ventilator. It is shown that this tool can provide useful information to optimize ventilator setting. For example, PV curves can assess for patient's individual potential for lung recruitability and also evaluate the risk for lung injury of the ongoing mechanical ventilation setting.
    Summary: In conclusion, PV curve is an easily available bedside tool: its correct interpretation can be extremely valuable to enlighten potential for lung recruitability and select a high or low positive end-expiratory pressure (PEEP) strategy. Furthermore, recent studies have shown that PV curve can play a significant role in PEEP and driving pressure fine tuning: clinical studies are needed to prove whether this technique will improve outcome.
    MeSH term(s) Humans ; Positive-Pressure Respiration/methods ; Respiration, Artificial/adverse effects ; Respiration, Artificial/methods ; Lung ; Ventilator-Induced Lung Injury/prevention & control ; Ventilators, Mechanical
    Language English
    Publishing date 2023-12-06
    Publishing country United States
    Document type Review ; Journal Article
    ZDB-ID 1235629-3
    ISSN 1531-7072 ; 1070-5295
    ISSN (online) 1531-7072
    ISSN 1070-5295
    DOI 10.1097/MCC.0000000000001127
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  2. Article ; Online: Tidal lung hysteresis to interpret PEEP-induced changes in compliance in ARDS patients.

    Mojoli, Francesco / Pozzi, Marco / Arisi, Eric / Mongodi, Silvia / Orlando, Anita / Maggio, Giuseppe / Capra Marzani, Federico / Brochard, Laurent

    Critical care (London, England)

    2023  Volume 27, Issue 1, Page(s) 233

    Abstract: Background: In ARDS, the PEEP level associated with the best respiratory system compliance is often selected; however, intra-tidal recruitment can increase compliance, falsely suggesting improvement in baseline mechanics. Tidal lung hysteresis increases ...

    Abstract Background: In ARDS, the PEEP level associated with the best respiratory system compliance is often selected; however, intra-tidal recruitment can increase compliance, falsely suggesting improvement in baseline mechanics. Tidal lung hysteresis increases with intra-tidal recruitment and can help interpreting changes in compliance. This study aims to assess tidal recruitment in ARDS patients and to test a combined approach, based on tidal hysteresis and compliance, to interpret decremental PEEP trials.
    Methods: A decremental PEEP trial was performed in 38 COVID-19 moderate to severe ARDS patients. At each step, we performed a low-flow inflation-deflation manoeuvre between PEEP and a constant plateau pressure, to measure tidal hysteresis and compliance.
    Results: According to changes of tidal hysteresis, three typical patterns were observed: 10 (26%) patients showed consistently high tidal-recruitment, 12 (32%) consistently low tidal-recruitment and 16 (42%) displayed a biphasic pattern moving from low to high tidal-recruitment below a certain PEEP. Compliance increased after 82% of PEEP step decreases and this was associated to a large increase of tidal hysteresis in 44% of cases. Agreement between best compliance and combined approaches was accordingly poor (K = 0.024). The combined approach suggested to increase PEEP in high tidal-recruiters, mainly to keep PEEP constant in biphasic pattern and to decrease PEEP in low tidal-recruiters. PEEP based on the combined approach was associated with lower tidal hysteresis (92.7 ± 20.9 vs. 204.7 ± 110.0 mL; p < 0.001) and lower dissipated energy per breath (0.1 ± 0.1 vs. 0.4 ± 0.2 J; p < 0.001) compared to the best compliance approach. Tidal hysteresis ≥ 100 mL was highly predictive of tidal recruitment at next PEEP step reduction (AUC 0.97; p < 0.001).
    Conclusions: Assessment of tidal hysteresis improves the interpretation of decremental PEEP trials and may help limiting tidal recruitment and energy dissipated into the respiratory system during mechanical ventilation of ARDS patients.
    MeSH term(s) Humans ; COVID-19 ; Body Fluids ; Patients ; Respiratory Distress Syndrome/therapy ; Lung
    Language English
    Publishing date 2023-06-13
    Publishing country England
    Document type Journal Article
    ZDB-ID 2041406-7
    ISSN 1466-609X ; 1364-8535
    ISSN (online) 1466-609X
    ISSN 1364-8535
    DOI 10.1186/s13054-023-04506-6
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    Zs.A 5517: Show issues Location:
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  3. Article ; Online: Waveforms-guided cycling-off during pressure support ventilation improves both inspiratory and expiratory patient-ventilator synchronisation.

    Mojoli, Francesco / Orlando, Anita / Bianchi, Isabella Maria / Puce, Roberta / Arisi, Eric / Salve, Giulia / Maggio, Giuseppe / Mongodi, Silvia / Pozzi, Marco

    Anaesthesia, critical care & pain medicine

    2022  Volume 41, Issue 6, Page(s) 101153

    Abstract: Objective: To test the performance of a software able to control mechanical ventilator cycling-off by means of automatic, real-time analysis of ventilator waveforms during pressure support ventilation.: Design: Prospective randomised crossover study.! ...

    Abstract Objective: To test the performance of a software able to control mechanical ventilator cycling-off by means of automatic, real-time analysis of ventilator waveforms during pressure support ventilation.
    Design: Prospective randomised crossover study.
    Setting: University Intensive Care Unit.
    Patients: Fifteen difficult-to-wean patients under pressure support ventilation.
    Interventions: Patients were ventilated using a G5 ventilator (Hamilton Medical, Bonaduz, Switzerland) with three different cycling-off settings: standard (expiratory trigger sensitivity set at 25% of peak inspiratory flow), optimised by an expert clinician and automated; the last two settings were tested at baseline pressure support and after a 50% increase in pressure support.
    Measurements and main results: Ventilator waveforms were recorded and analysed by four physicians experts in waveforms analysis. Major and minor asynchronies were detected and total asynchrony time computed. Automation compared to standard setting reduced cycling delay from 407 ms [257-567] to 59 ms [22-111] and ineffective efforts from 12.5% [3.4-46.4] to 2.8% [1.9-4.6]) at baseline support (p < 0.001); expert optimisation performed similarly. At high support both cycling delay and ineffective efforts increased, mainly in the case of expert setting, with the need of reoptimisation of expiratory trigger sensitivity. At baseline support, asynchrony time decreased from 39.9% [27.4-58.7] with standard setting to 32% [22.3-39.4] with expert optimisation (p < 0.01) and to 24.4% [19.6-32.5] with automation (p < 0.001). Both at baseline and at high support, asynchrony time was lower with automation than with expert setting.
    Conclusions: Cycling-off guided by automated real-time waveforms analysis seems a reliable solution to improve synchronisation in difficult-to-wean patients under pressure support ventilation.
    MeSH term(s) Humans ; Positive-Pressure Respiration ; Prospective Studies ; Respiration ; Respiration, Artificial ; Ventilators, Mechanical ; Cross-Over Studies
    Language English
    Publishing date 2022-09-06
    Publishing country France
    Document type Randomized Controlled Trial ; Journal Article
    ISSN 2352-5568
    ISSN (online) 2352-5568
    DOI 10.1016/j.accpm.2022.101153
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  4. Article ; Online: Timing of inspiratory muscle activity detected from airway pressure and flow during pressure support ventilation: the waveform method.

    Mojoli, Francesco / Pozzi, Marco / Orlando, Anita / Bianchi, Isabella M / Arisi, Eric / Iotti, Giorgio A / Braschi, Antonio / Brochard, Laurent

    Critical care (London, England)

    2022  Volume 26, Issue 1, Page(s) 32

    Abstract: Background: Whether respiratory efforts and their timing can be reliably detected during pressure support ventilation using standard ventilator waveforms is unclear. This would give the opportunity to assess and improve patient-ventilator interaction ... ...

    Abstract Background: Whether respiratory efforts and their timing can be reliably detected during pressure support ventilation using standard ventilator waveforms is unclear. This would give the opportunity to assess and improve patient-ventilator interaction without the need of special equipment.
    Methods: In 16 patients under invasive pressure support ventilation, flow and pressure waveforms were obtained from proximal sensors and analyzed by three trained physicians and one resident to assess patient's spontaneous activity. A systematic method (the waveform method) based on explicit rules was adopted. Esophageal pressure tracings were analyzed independently and used as reference. Breaths were classified as assisted or auto-triggered, double-triggered or ineffective. For assisted breaths, trigger delay, early and late cycling (minor asynchronies) were diagnosed. The percentage of breaths with major asynchronies (asynchrony index) and total asynchrony time were computed.
    Results: Out of 4426 analyzed breaths, 94.1% (70.4-99.4) were assisted, 0.0% (0.0-0.2) auto-triggered and 5.8% (0.4-29.6) ineffective. Asynchrony index was 5.9% (0.6-29.6). Total asynchrony time represented 22.4% (16.3-30.1) of recording time and was mainly due to minor asynchronies. Applying the waveform method resulted in an inter-operator agreement of 0.99 (0.98-0.99); 99.5% of efforts were detected on waveforms and agreement with the reference in detecting major asynchronies was 0.99 (0.98-0.99). Timing of respiratory efforts was accurately detected on waveforms: AUC for trigger delay, cycling delay and early cycling was 0.865 (0.853-0.876), 0.903 (0.892-0.914) and 0.983 (0.970-0.991), respectively.
    Conclusions: Ventilator waveforms can be used alone to reliably assess patient's spontaneous activity and patient-ventilator interaction provided that a systematic method is adopted.
    MeSH term(s) Humans ; Muscles ; Positive-Pressure Respiration ; Respiration ; Respiration, Artificial ; Ventilators, Mechanical
    Language English
    Publishing date 2022-01-30
    Publishing country England
    Document type Journal Article
    ZDB-ID 2041406-7
    ISSN 1466-609X ; 1364-8535
    ISSN (online) 1466-609X
    ISSN 1364-8535
    DOI 10.1186/s13054-022-03895-4
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  5. Article: Technical aspects of bedside respiratory monitoring of transpulmonary pressure.

    Mojoli, Francesco / Torriglia, Francesca / Orlando, Anita / Bianchi, Isabella / Arisi, Eric / Pozzi, Marco

    Annals of translational medicine

    2018  Volume 6, Issue 19, Page(s) 377

    Abstract: Transpulmonary pressure, that is the difference between airway pressure (Paw) and pleural pressure, is considered one of the most important parameters to know in order to set a safe mechanical ventilation in acute respiratory distress syndrome (ARDS) ... ...

    Abstract Transpulmonary pressure, that is the difference between airway pressure (Paw) and pleural pressure, is considered one of the most important parameters to know in order to set a safe mechanical ventilation in acute respiratory distress syndrome (ARDS) patients but also in critically ill obese patients, in abdominal pathologies or in pathologies affecting the chest wall itself. Transpulmonary pressure should rely on the assessment of intrathoracic pleural pressure. Esophageal pressure (Pes) is considered the best surrogate of pleural pressure in critically ill patients, but concerns about its reliability exist. The aim of this article is to describe the technique of Pes measurement in mechanically ventilated patients: the catheter insertion, the proper balloon placement and filling, the validation test and specific procedures to remove the main artifacts will be discussed.
    Language English
    Publishing date 2018-11-06
    Publishing country China
    Document type Journal Article ; Review
    ZDB-ID 2893931-1
    ISSN 2305-5847 ; 2305-5839
    ISSN (online) 2305-5847
    ISSN 2305-5839
    DOI 10.21037/atm.2018.08.37
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  6. Article ; Online: Our recommendations for acute management of COVID-19.

    Mojoli, Francesco / Mongodi, Silvia / Orlando, Anita / Arisi, Eric / Pozzi, Marco / Civardi, Luca / Tavazzi, Guido / Baldanti, Fausto / Bruno, Raffaele / Iotti, Giorgio Antonio

    Critical care (London, England)

    2020  Volume 24, Issue 1, Page(s) 207

    MeSH term(s) Antiviral Agents/therapeutic use ; Betacoronavirus ; Clinical Laboratory Techniques ; Coronavirus Infections/complications ; Coronavirus Infections/diagnosis ; Coronavirus Infections/drug therapy ; Coronavirus Infections/therapy ; Humans ; Italy ; Lung/diagnostic imaging ; Pandemics ; Pneumonia, Viral/complications ; Pneumonia, Viral/diagnosis ; Pneumonia, Viral/therapy ; Practice Guidelines as Topic ; Severe Acute Respiratory Syndrome/etiology ; Severe Acute Respiratory Syndrome/therapy ; Ultrasonography
    Chemical Substances Antiviral Agents
    Keywords covid19
    Language English
    Publishing date 2020-05-08
    Publishing country England
    Document type Editorial
    ZDB-ID 2051256-9
    ISSN 1466-609X ; 1364-8535
    ISSN (online) 1466-609X
    ISSN 1364-8535
    DOI 10.1186/s13054-020-02930-6
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  7. Article ; Online: Mechanical Ventilation Guided by Uncalibrated Esophageal Pressure May Be Potentially Harmful.

    Cammarota, Gianmaria / Lauro, Gianluigi / Santangelo, Erminio / Sguazzotti, Ilaria / Perucca, Raffaella / Verdina, Federico / Boniolo, Ester / Tarquini, Riccardo / Bignami, Elena / Mongodi, Silvia / Arisi, Eric / Orlando, Anita / Della Corte, Francesco / Vaschetto, Rosanna / Mojoli, Francesco

    Anesthesiology

    2020  Volume 133, Issue 1, Page(s) 145–153

    Abstract: Background: Esophageal balloon calibration was proposed in acute respiratory failure patients to improve esophageal pressure assessment. In a clinical setting characterized by a high variability of abdominal load and intrathoracic pressure (i.e., pelvic ...

    Abstract Background: Esophageal balloon calibration was proposed in acute respiratory failure patients to improve esophageal pressure assessment. In a clinical setting characterized by a high variability of abdominal load and intrathoracic pressure (i.e., pelvic robotic surgery), the authors hypothesized that esophageal balloon calibration could improve esophageal pressure measurements. Accordingly, the authors assessed the impact of esophageal balloon calibration compared to conventional uncalibrated approach during pelvic robotic surgery.
    Methods: In 30 adult patients, scheduled for elective pelvic robotic surgery, calibrated end-expiratory and end-inspiratory esophageal pressure, and the associated respiratory variations were obtained at baseline, after pneumoperitoneum-Trendelenburg application, and with positive end-expiratory pressure (PEEP) administration and compared to uncalibrated values measured at 4-ml filling volume, as per manufacturer recommendation. Data are expressed as median and [25th, 75th percentile].
    Results: Ninety calibrations were successfully performed. Chest wall elastance worsened with pneumoperitoneum-Trendelenburg and PEEP (19.0 [15.5, 24.6] and 16.7 [11.4, 21.7] cm H2O/l) compared to baseline (8.8 [6.3, 9.8] cm H2O/l; P < 0.0001 for both comparisons). End-expiratory and end-inspiratory calibrated esophageal pressure progressively increased from baseline (3.7 [2.2, 6.0] and 7.7 [5.9, 10.2] cm H2O) to pneumoperitoneum-Trendelenburg (6.2 [3.8, 10.2] and 16.1 [13.1, 20.6] cm H2O; P = 0.014 and P < 0.001) and PEEP (8.8 [7.7, 15.6] and 18.9 [16.3, 22.0] cm H2O; P < 0.0001 vs. baseline for both comparison; P < 0.001 and P = 0.002 vs. pneumoperitoneum-Trendelenburg) and, at each study step, they were persistently lower than uncalibrated esophageal pressure (P < 0.0001 for all comparisons). Overall, difference among uncalibrated and calibrated esophageal pressure was 5.1 [3.8, 8.4] cm H2O at end-expiration and 3.8 [3.0, 6.3] cm H2O at end-inspiration. Uncalibrated esophageal pressure swing was always lower than calibrated one (P < 0.0001 for all comparisons) with a difference of -1.0 [-1.8, -0.4] cm H2O.
    Conclusions: In a clinical setting with variable chest wall mechanics, uncalibrated measurements substantially overestimated absolute values and underestimated respiratory variations of esophageal pressure. Calibration could substantially improve mechanical ventilation guided by esophageal pressure.
    MeSH term(s) Aged ; Algorithms ; Balloon Occlusion ; Calibration ; Chest Wall Oscillation ; Elasticity ; Esophagus/physiology ; Female ; Head-Down Tilt ; Humans ; Male ; Middle Aged ; Pelvis/surgery ; Pneumoperitoneum, Artificial ; Positive-Pressure Respiration ; Pressure ; Respiration, Artificial/adverse effects ; Respiration, Artificial/methods ; Respiratory Function Tests ; Robotic Surgical Procedures/methods
    Language English
    Publishing date 2020-04-26
    Publishing country United States
    Document type Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't
    ZDB-ID 269-0
    ISSN 1528-1175 ; 0003-3022
    ISSN (online) 1528-1175
    ISSN 0003-3022
    DOI 10.1097/ALN.0000000000003327
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  8. Article ; Online: Lung Ultrasound in Patients with Acute Respiratory Failure Reduces Conventional Imaging and Health Care Provider Exposure to COVID-19.

    Mongodi, Silvia / Orlando, Anita / Arisi, Eric / Tavazzi, Guido / Santangelo, Erminio / Caneva, Luca / Pozzi, Marco / Pariani, Eleonora / Bettini, Giada / Maggio, Giuseppe / Perlini, Stefano / Preda, Lorenzo / Iotti, Giorgio Antonio / Mojoli, Francesco

    Ultrasound in medicine & biology

    2020  Volume 46, Issue 8, Page(s) 2090–2093

    Abstract: Lung ultrasound gained a leading position in the last year as an imaging technique for the assessment and management of patients with acute respiratory failure. In coronavirus disease 2019 (COVID-19), its role may be of further importance because it is ... ...

    Abstract Lung ultrasound gained a leading position in the last year as an imaging technique for the assessment and management of patients with acute respiratory failure. In coronavirus disease 2019 (COVID-19), its role may be of further importance because it is performed bedside and may limit chest X-ray and the need for transport to radiology for computed tomography (CT) scan. Since February 21, we progressively turned into a coronavirus-dedicated intensive care unit and applied an ultrasound-based approach to avoid traditional imaging and limit contamination as much as possible. We performed a complete daily examination with lung ultrasound score computation and systematic search of complications (pneumothorax, ventilator-associated pneumonia); on-duty physicians were free to perform CT or chest X-ray when deemed indicated. We compared conventional imaging exams performed in the first 4 wk of the COVID-19 epidemic with those in the same time frame in 2019: there were 84 patients in 2020 and 112 in 2019; 64 and 22 (76.2% vs. 19.6%, p < 0.001) had acute respiratory failure, respectively, of which 55 (85.9%) were COVID-19 in 2020. When COVID-19 patients in 2020 were compared with acute respiratory failure patients in 2019, the median number of chest X-rays was 1.0 (1.0-2.0) versus 3.0 (1.0-4.0) (p = 0.0098); 2 patients 2 (3.6%) versus 7 patients (31.8%) had undergone at least one thoracic CT scan (p = 0.001). A self-imposed ultrasound-based approach reduces the number of chest X-rays and thoracic CT scans in COVID-19 patients compared with patients with standard acute respiratory failure, thus reducing the number of health care providers exposed to possible contamination and sparing personal protective equipment.
    MeSH term(s) Aged ; Betacoronavirus ; COVID-19 ; Coronavirus Infections/diagnostic imaging ; Female ; Humans ; Lung/diagnostic imaging ; Male ; Middle Aged ; Occupational Exposure/prevention & control ; Pandemics ; Pneumonia, Viral/diagnostic imaging ; Respiratory Insufficiency/diagnostic imaging ; SARS-CoV-2 ; Ultrasonography/methods
    Keywords covid19
    Language English
    Publishing date 2020-05-06
    Publishing country England
    Document type Journal Article
    ZDB-ID 186150-5
    ISSN 1879-291X ; 0301-5629
    ISSN (online) 1879-291X
    ISSN 0301-5629
    DOI 10.1016/j.ultrasmedbio.2020.04.033
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  9. Article: Our recommendations for acute management of COVID-19

    Mojoli, Francesco / Mongodi, Silvia / Orlando, Anita / Arisi, Eric / Pozzi, Marco / Civardi, Luca / Tavazzi, Guido / Baldanti, Fausto / Bruno, Raffaele / Iotti, Giorgio Antonio

    Crit Care

    Keywords covid19
    Publisher WHO
    Document type Article
    Note WHO #Covidence: #209507
    Database COVID19

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  10. Article: Lung Ultrasound in Patients with Acute Respiratory Failure Reduces Conventional Imaging and Health Care Provider Exposure to COVID-19

    Mongodi, Silvia / Orlando, Anita / Arisi, Eric / Tavazzi, Guido / Santangelo, Erminio / Caneva, Luca / Pozzi, Marco / Pariani, Eleonora / Bettini, Giada / Maggio, Giuseppe / Perlini, Stefano / Preda, Lorenzo / Iotti, Giorgio Antonio / Mojoli, Francesco

    Ultrasound Med Biol

    Abstract: Lung ultrasound gained a leading position in the last year as an imaging technique for the assessment and management of patients with acute respiratory failure. In coronavirus disease 2019 (COVID-19), its role may be of further importance because it is ... ...

    Abstract Lung ultrasound gained a leading position in the last year as an imaging technique for the assessment and management of patients with acute respiratory failure. In coronavirus disease 2019 (COVID-19), its role may be of further importance because it is performed bedside and may limit chest X-ray and the need for transport to radiology for computed tomography (CT) scan. Since February 21, we progressively turned into a coronavirus-dedicated intensive care unit and applied an ultrasound-based approach to avoid traditional imaging and limit contamination as much as possible. We performed a complete daily examination with lung ultrasound score computation and systematic search of complications (pneumothorax, ventilator-associated pneumonia); on-duty physicians were free to perform CT or chest X-ray when deemed indicated. We compared conventional imaging exams performed in the first 4 wk of the COVID-19 epidemic with those in the same time frame in 2019: there were 84 patients in 2020 and 112 in 2019; 64 and 22 (76.2% vs. 19.6%, p < 0.001) had acute respiratory failure, respectively, of which 55 (85.9%) were COVID-19 in 2020. When COVID-19 patients in 2020 were compared with acute respiratory failure patients in 2019, the median number of chest X-rays was 1.0 (1.0-2.0) versus 3.0 (1.0-4.0) (p = 0.0098); 2 patients 2 (3.6%) versus 7 patients (31.8%) had undergone at least one thoracic CT scan (p = 0.001). A self-imposed ultrasound-based approach reduces the number of chest X-rays and thoracic CT scans in COVID-19 patients compared with patients with standard acute respiratory failure, thus reducing the number of health care providers exposed to possible contamination and sparing personal protective equipment.
    Keywords covid19
    Publisher WHO
    Document type Article
    Note WHO #Covidence: #186451
    Database COVID19

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