A new mode of mechanical ventilation: positive + negative synchronized ventilation
Keywords:
PNSV, iron-lung, cuirass, ponchowrap, alveolar pressure, transpulmonary pressure, negative pressureAbstract
Often, in supporting patients suffering from severe respiratory diseases with mechanical ventilation, obstacles are encountered due to pulmonary and/or thoracic alterations, reductions in the ventilable lung parenchyma, increases in airway resistance, alterations in thoraco-pulmonary compliance, advanced age of the subjects. All this involves difficulties in finding the right ventilation parameters and an adequate driving pressure to guarantee sufficient ventilation. Therefrom, new mechanical ventilation techniques were sought that could help overcome the aforementioned obstacles. A new mode of mechanical ventilation is being presented, i.e., a Positive + Negative Synchronized Ventilation (PNSV), characterized by the association and integration of two pulmonary ventilators; one acting inside the chest with positive pressures and one externally with negative pressure. The peculiarity of this combination is the complete synchronization, which takes place with specific electronic modifications. The PNSV can be applied both in a completely non-invasive and invasive way and, therefore, be used both in acute care wards and in ICU. The most relevant effect found, due to the compensation of opposing pressures acting on the chest, is that, during the entire inspiratory act created by the ventilators, the pressure at the alveolar level is equal to zero even if adding together the two ventilators’ pressures; thus, the transpulmonary pressure is doubled. The application of this pressure for 1 hour on elderly patients suffering from severe acute respiratory failure, resulted in a significant improvement in blood gas analytical and clinical parameters without any side effects. An increased pulmonary recruitment, including posterior lung areas, and a reduction in spontaneous ventilatory rate have also been demonstrated with PNSV. This also paves the way to the search for the best ventilatory treatment in critically ill or ARDS patients. The compensation of intrathoracic pressures should also lead, although not yet proven, to an improvement in venous return, systolic and cardiac output. In the analysis of the study in which this method was applied, the total transpulmonary pressure delivered was the sum of the individual pressures applied by the two ventilators. However, this does not exclude the possibility of reducing the pressures of the two machines to modulate a lower but balanced total transpulmonary pressure within the chest.
References
Carpagnano GE, Sabato R, Lacedonia D, Di Gioia R, Saliani R, Vincenzi U, et al. New non-invasive ventilator strategy applied to COPD patients in acute ventilator failure. Pulm Pharmacol Ther 2017;46:64-8.
Garay SM, Turino GM, Goldring RM. Sustained reversal of chronic hypercapnia in patients with alveolar hypoventilation syndromes. Long-term maintenance with noninvasive nocturnal mechanical ventilation. Am J Med 1981;70:269-74.
Corrado A, Gorini M. Negative-pressure ventilation: is there still a role? Eur Respir J 2002;20:187-97.
Splaingard ML, Frates RC Jr., Jefferson LS, Rosen CL, Harrison GM. home negative pressure ventilation: Report of 20 years of experience in patients with neuromuscular disease. Arch Phys Med Rehabil 1985;66:239-42.
Corrado A, Gorini M, Villella G, De Paola E. Negative pressure ventilation in the treatment of acute respiratory failure: an old noninvasive technique reconsidered. Eur Respir J 1996;9:1531-44.
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.
Corrado A, Gorini M, De Paola E, Bruscoli G, Tozzi D, Augustynen A. et al. Iron lung treatment of acute on chronic respiratory failure: 16 yrs of experience. Monaldi Arch Chest Dis1994;49:552-5.
Corrado A, Gorini M, Villella G, Augustynen A, Tozzi D, De Paola E. Negative pressure ventilation in COPD patients with acute on chronic respiratory failure. Monaldi Arch Chest Dis 1997;52:60-3.
Corrado A, Vianello A. Noninvasive mechanical ventilation for the treatment of acute respiratory failure in neuromuscular diseases. Eur Respir J 2000;16:542s.
Cvetnic WG, Waffarn F, Martin JM. Continuous nega-tive pressure and intermittent mandatory ventilation in the management of pulmonary interstitial emphysema: A preliminary study. J Perinatol 1989;9:26–32.
Sills JH, Cvetnic WG, Pietz J. Continuous negative pressure in the treatment of infants with pulmonary hypertension and respiratory failure. J Perinatol 1989;9:43–8.
Samuels MP, Southall DP. Negative extrathoracic pres-sure in treatment of respiratory failure in infants and young children. Br Med J 1989;299:1253–7.
Huang HY, Chou PC, Joa WC, Chen LF, Sheng TF, Lin HC et al. Pulmonary rehabilitation coupled with negative pres-sure ventilation decreases decline in lung function, hospitalizations, and medical cost in COPD. A 5-year study. Medicine (Baltimore) 2016;95:41.
Vitacca M, Natalini G, Cavaliere S, Clini E, Foccoli P, Candiani A et al. Breathing pattern and arterial blood gases during Nd-YAG laser photoresection of endobronchial lesions under general anesthesia: use of negative pressure ventilation: a preliminary study. Chest 1997;112:1466-73.
Petrella F, Borri A, Casiraghi M, Cavaliere S, Donghi S, Galetta D, et al. Operative rigid bronchoscopy: indications, basic techniques and results. Multimed Man Cardiothorac Surg 2014;2014: mmu006.
Corrado A, De Paola E, Gorini M, Messori A, Bruscoli G, Nutini S, et al. Intermittent negative pressure ventilation in the treatment of hypoxic hypercapnic coma in chronic respiratory insufficiency. Thorax 1996;51:1077-82.
Gorini M, Villella G, Ginanni R, Augustynen A, Tozzi D, Corrado A. Effect of assist negative pressure ventilation by microprocessor based iron lung on breathing effort. Thorax 2002;57:258-62.
Levy RD, Cosio MG, Gibbons L, Macklem PT, Martin JG. Induction of sleep apnoea with negative pressure ventilation in patients with chronic obstructive lung disease. Thorax 1992;47:612-5.
Mukherjee S, Patel SR, Kales SN, Ayas NT, Strohl KP, Gozal D, et al. An Official American Thoracic Society Statement: The importance of healthy sleep. Recommendations and future priorities. Am J Respir Crit Care Med 2015;191:1450-8.
Walia HK, Thompson NR, Pascoe M, Faisal M, Douglas E, Moul DE, et al. Effect of positive airway pressure therapy on drowsy driving in a large clinic-based obstructive sleep apnea cohort. J Clin Sleep Med 2019;15:1613-20.
Zhou L, Chen P, Peng Y, Ouyang R. Role of oxidative stress in the neurocognitive dysfunction of obstructive sleep apnea syndrome. Oxid Med Cell Longev 2016;2016:9626831.
Todea D, Herescu A. Modern and multidimensional approach of sleep apnea as a public health problem. Clujul Med 2013;86:10-5.
Nielsen Jeschke K, Bonnesen B, Hansen EF, Jensen JS, Lapperre TS, Weinreich UM, et al. Guideline for the management of COVID-19 patients during hospital admission in a nonintensive care setting. Eur Clin Respir J 2020;7:1761677.
Pagano A, Porta G, Bosso G, Allegorico E, Serra C, Dello Vicario F et al. Non-invasive CPAP in mild and moderate ARDS secondary to SARS-CoV-2. Respir Physiol Neurobiol 2020;280:103489.
Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50:1602426.
Van Der Leest S, Duiverman M. High-intensity non-invasive ventilation in stable hypercapnic COPD: Evidence of efficacy and practical advice. Respirology 2019;24:318-28.
Duiverman ML, Vonk JM, Bladder G, van Melle JP, Nieuwenhuis J, Hazenberg A et al. Home initiation of chronic non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure: a randomised controlled trial. Thorax 2020;75:244-52.
Clini E, Sturani C, Rossi A, Viaggiz S, Corrado A, Donner CF, et al. The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients Eur Respir J 2002;20:529-38.
Toussaint M, Chatwin M, Soudon P. Mechanical ventilation in Duchenne patients with chronic respiratory insufficiency: clinical implications of 20 years published experience. Chron Respir Dis 2007;4:167-77.
Langer M, Mosconi P, Cigada M, Mandelli M. Long-term respiratory support and risk of pneumonia in critically ill patients. Am Rev Respir Dis 1989;140:302-5.
Anzueto A, Frutos–Vivar F, Esteban A, Alìa I, Brochard L, Stewart T, et al. Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med 2004;30:612-9.
Ioannidis G, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Lampaki S et al. Barotrauma and pneumothorax. J Thorac Dis 2015;7:S38-43.
Carron M, Freo U, BaHammam AS, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth 2013;110:896-914.
Maruccia M, Ruggieri M, Onesti MG. Facial skin breakdown in patients with non-invasive ventilation devices: report of two cases and indications for treatment and prevention. Int Wound J 2015;12:451-5.
Antonelli M, Conti G, Pelosi P, Gregoretti C, Pennisi MA, Costa R, et al. New treatment of acute hypoxemic respiratory failure: noninvasive pressure support ventilation delivered by helmet - a pilot controlled trial. Crit Care Med 2002;30:602-8.
Schettino GP, Tucci MR, Sousa R, Valente Barbas CS, Passos Amato MB, Carvalho CR. Mask mechanics and leak dynamics during noninvasive pressure support ventilation: a bench study. Intensive Care Med 2001;27:1887-91.
Gay PC. Complications of noninvasive ventilation in acute care. Respir Care 2009;54:246-57.
Schnhofer B, Sortor-Leger S. Equipment needs for noninvasive mechanical ventilation. Eur Respir J 2002;20:1029-36.
Hasan D, Satalin J, van der Zee P, Kollisch-Singule M, Blankman P, Shono A, et al. Excessive extracellular ATP desensitizes P2Y2 and P2X4 receptors provoking surfactant impairment ending in ventilation-induced lung injury. Int J Mol Sci 2018;19:1185.
Rothen H U, Sporre B, Engberg G, Wegwnius G, Reber A, Hedenstierna G. Prevention of atelectasis during general anaesthesia. Lancet 1995;345: 387-91.
Helmerhorst H J F, Schultz M J, van der Voort P H J, de Jonge E, van Westerloo D J. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care 2015;19:284.
van der Zee P, Diederik Gommers D. Recruitment maneuvers and higher PEEP, the so-called open lung concept, in patients with ARDS. Crit Care 2019;23:73.
Marini JJ, Culver BH, Butler J. Mechanical effect of lung distention with positive pressure on cardiac function. Am Rev Respir Dis 1981;124:382-6.
Grübler MR, Wigger O, Berger D, Bloechlinger S. Basic concepts of heart-lung interactions during mechanical ventilation. Swiss Med Wkly 2017;147:w14491.
Chaturvedi RK, Zidulka AA, Goldberg P, deVarennes B, Iqbal S, Rahme E, et al. Use of negative extrathoracic pressure to improve hemodynamics after cardiac surgery. Ann Thorac Surg 2008;85:1355-60.
McBride WT, Ranaldi G, Dougherty MJ, Siciliano T, Trethowan B, Elliott P, et al. The hemodynamic and respiratory effects of continuous negative and control-mode cuirass ventilation in recently extubated cardiac surgery patients: Part 2. J Cardiothorac Vasc Anesth 2012;26873-7.
Sato Y, Saeki N, Asakura T, Aoshiba K, Kotani T. Effects of extrathoracic mechanical ventilation on pulmonary hypertension secondary to lung disease. J Anesth 2016;30:663-70.
Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A, et al. Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2014;189:149-58.
Gattinoni L, Tonetti L, Quintel M. Regional physiology of ARDS. Critical Care 2017;21:S312.
Grasso S, Stripoli T, De Michele M, Bruno F, Moschetta M, Angelelli G, et al. ARDSnet ventilatory protocol and alveolar hyperinflation. Role of positive end-expiratory pressure. Am J Respir Crit Care Med 2007;176:761-7.
McGuinness G, Zhan C, Rosenberg N, Azour L, Wickstrom M, Mason DM, et al. Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation. Radiology 2020;297:E252-62.
Pan C, Chen L, Lu C, Ahang W, Xia JA, Sklar MC, et al. Lung recruitability in COVID-19– associated acute respiratory distress syndrome: A single-center observational study. Am J Respir Crit Care Med 2020;201:1294-7.
Van der Zee P, Gommers D. Recruitment maneuvers and higher PEEP, the so-called open lung concept, in patients with ARDS. Critical Care 2019;23:73.
Raymondos K, Ahrens J, Molitoris U. Combined negative- and positive-pressure ventilation for the treatment of ARDS. Case Rep Crit Care 2015;2015:714902.
Navalesi P, Colombo D, Della Corte F. NAVA ventilation. Minerva Anestesiol 2010;76:346-52.
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