“Dissipated energy is minimized when FCV® is used”Tom Barnes
High energy dissipation is associated with ventilator induced lung injury (VILI)
More than 90% of the patients on Intensive Care Units (ICUs) suffer from inflammatory responses[i]. Clinical studies show that mechanical ventilation plays an important role in ICU mortality2, 3,: mechanical ventilation itself, even when applied for only a few hours4,5, is a source of lung injury, causing VILI6. Mechanical power (energy when measured overtime) derives from a.o. flow and pressures provided by the ventilator during inspiration. However, the passive and abrupt expiration is considerably relevant11, and potentially a key factor in inducing lung damage12. Moreover, controlling expiration has been shown to reduce lung damage in porcine ARDS15
Energy dissipation in the lungs of a patient during mechanical ventilation is increasingly accepted as one of the causes for VILI7,8. Moreover, a recent study revealed that mechanical power is associated with worse outcomes in critically ill patients receiving mechanical ventilation for more than 48 hour9. As energy dissipation can be calculated based on a.o. pressures, flow and respiratory rate, it was postulated that the ideal ventilator should monitor and display energy dissipation in order to really apply ‘safe’ ventilation10.
Energy dissipation during FCV similar to natural breathing
During laryngeal surgery using FCV ventilation, PV loops were recorded using pressure measured directly within the patient’s trachea. The energy dissipated in the patient was calculated from the hysteresis area of the PV loops. The energy dissipation was 0.17 J/L, which is even lower than values quoted in literature for spontaneous breathing (0.2-0.7 J/L).
[READ MORE, ref 14] [Plaatje Tom Barnes simulator wat nu op de home page staat]
FCV improves arterial oxygenation and stabilizes alveolar walls in porcine ARDS
Price winning study showed that in porcine ARDS three hours of FCV ventilation stabilized alveolar walls and resulted in 53% higher arterial oxygen, while using a 30% lower minute volume as compared to VCV. This research was awarded Best Abstract at Euroanaesthesia 2018 Copenhagen.
[READ MORE, ref 13]
Patient’s life saved by Evone
FCV results in lower energy dissipation in the lungs compared to general protocols for VCV and PCV13
FCV is based on the generation of a constant flow into and out of the lungs, resulting in linear increases and decreases of intratracheal pressures that are just high or low enough to facilitate mechanical breathing with efficient gas exchange. The sudden alveolar pressure drop during passive expiration with conventional ventilation is prevented. In other words, the amount of effort (energy) of the ventilator is just enough to facilitate respiration. Thereby the impact on the lung tissue by dissipated energy is kept to a minimum, enabling ventilation with markedly reduced risk of lung damage.
FCV by Evone
- FCV minimizes energy dissipation in the lungs13
- Results in lower energy dissipation as compared to general protocols for VCV and PCV13
- Evone accurately measures intratracheal pressures and inspiratory flows, resulting in high accurate calculation of energy dissipation
- Energy dissipation can be accurately measured in real time14
- FCV results in similar energy dissipation as compared to natural breathing14
- FCV has lung protective effects in porcine ARDS16
- Lord J et al. The Systemic Immune Response to Trauma: An Overview of Pathophysiology and Treatment. The Lancet 2014 ;1455-465.
- Cressoni M et al. Mechanical Power and Development of Ventilator-induced Lung Injury. Anaesthesiology 2016;124(5):1100-8
- Brower R et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8.
- Wolthuis E et al. Mechanical ventilation using non-injurious ventilation settings causes lung injury in the absence of pre-existing lung injury in healthy mice. Crit Care. 2009;13(1): R1.
- Woods S et al. Kinetic profiling of in vivo lung cellular inflammatory responses to mechanical ventilation. Am J Physiol Lung Cell Mol Physiol 2015;308:L912–L921.
- Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2014 Mar 6;370(10):980
- Gattinoni L et al. Ventilator-related causes of lung injury: the mechanical power. Intesive Care Med. 2016;42(10):1567-1575
- Protti A et al. Lung anatomy, energy load, and ventilator-induced lung injury. Intensive Care Med Exp. 2015;3(1):34
- Serpa Neto A, Deliberato R, Johnson AE, et al. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Medicine 2018. (In Press).
- Gattinoni L et al. Intensive care medicin in 2050: ventilator-induced lung injury. Intensive Care Med Published online: 22 March 2017
- Gattinoni L, Marini JJ, Collino F, et al. The future of mechanical ventilation: lessons from the present and the past. Crit Care 2017;21:183.
- Katira BH, Engelberts D, Otulakowski G, Giesinger RE, Yoshida T, Post M, Kuebler WM, Connelly KA, Kavanagh BP. Abrupt Deflation after Sustained Inflation Causes Lung Injury. Am J Respir Crit Care Med. 2018 Nov 1;198(9):1165-1176
- Barnes, D. van Asseldonk and D. Enk. Minimisation of dissipated energy in the airways during mechanical ventilation by using constant inspiratory and expiratory flows – flow controlled ventilation. Medical Hypotheses 2018 Dec;121:167-176.
- Barnes and D. Enk. Ventilation for low dissipated energy achieved using flow control during both inspiration and expiration. Trends in Anaesthesia and Critical Care 2018, in press
- Goebel U, Haberstroh J, Foerster K, Dassow C, Priebe HJ, Guttmann J, Schumann Flow-controlled expiration: a novel ventilation mode to attenuate experimental porcine lung injury. Br J Anaesth. 2014 Sep;113(3):474-83. doi: 10.1093/bja/aeu058. Epub 2014 Apr 2. PubMed PMID: 24694683
- Schmidt, C. Wenzel, S. Spassov, S. Wirth and S. Schumann. Expiratory Ventilation Assistance during mandatory ventilation in porcine ARDS improves arterial oxygenation – a randomized controlled animal study. Abstract Euroanaesthesia 2018
1 Bluth T, Teichmann R, Kiss T, Bobek I, Canet J, Cinnella G, De Baerdemaeker L, Gregoretti C, Hedenstierna G, Hemmes SN, Hiesmayr M, Hollmann MW, Jaber S, Laffey JG, Licker MJ, Markstaller K, Matot I, Müller G, Mills GH, Mulier JP, Putensen C, Rossaint R, Schmitt J, Senturk M, Serpa Neto A, Severgnini P, Sprung J, Vidal Melo MF, Wrigge H, Schultz MJ, Pelosi P, Gama de Abreu M; PROBESE investigators; PROtective VEntilation Network (PROVEnet); Clinical Trial Network of the European Society of Anaesthesiology (ESA). Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial. Trials. 2017 Apr 28;18(1):202. doi: 10.1186/s13063-017-1929-0. Erratum in: Trials. 2017 Jun 1;18(1):247. PubMed PMID: 28454590; PubMed Central PMCID: PMC5410049.
3 Amar D, Munoz D, Shi W, Zhang H, Thaler HT. A clinical prediction rule for pulmonary complications after thoracic surgery for primary lung cancer. Anesth Analg. 2010 May 1;110(5):1343-8. doi: 10.1213/ANE.0b013e3181bf5c99. Epub 2009 Oct 27. PubMed PMID: 19861366.
4 Rahmanian PB, Kröner A, Langebartels G, Özel O, Wippermann J, Wahlers T. Impact of major non-cardiac complications on outcome following cardiac surgery procedures: logistic regression analysis in a very recent patient cohort. Interact Cardiovasc Thorac Surg. 2013 Aug;17(2):319-26; discussion 326-7. doi: 10.1093/icvts/ivt149. Epub 2013 May 10. PubMed PMID: 23667066; PubMed Central PMCID: PMC3715168.
5 Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med. 1995 Dec;10(12):671-8. PubMed PMID: 8770719.
6 Smetana GW, Lawrence VA, Cornell JE; American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):581-95. Review. PubMed PMID: 16618956.
7 Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, Sabaté S, Mazo V, Briones Z, Sanchis J; ARISCAT Group. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010 Dec;113(6):1338-50. doi: 10.1097/ALN.0b013e3181fc6e0a. PubMed PMID: 21045639.
8 Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ; Participants in the VA National Surgical Quality Improvement Program. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005 Sep;242(3):326-41; discussion 341-3. PubMed PMID: 16135919; PubMed Central PMCID: PMC1357741.
9 LAS VEGAS investigators. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS – an observational study in 29 countries. Eur J Anaesthesiol. 2017 Aug;34(8):492-507. doi: 10.1097/EJA.0000000000000646. PubMed PMID: 28633157; PubMed Central PMCID: PMC5502122.
10 Mazo V, Sabaté S, Canet J, Gallart L, de Abreu MG, Belda J, Langeron O, Hoeft A, Pelosi P. Prospective external validation of a predictive score for postoperative pulmonary complications. Anesthesiology. 2014 Aug;121(2):219-31. doi: 10.1097/ALN.0000000000000334. PubMed PMID: 24901240.
11 De Gasperi Feltracco P, Ceravola E, Mazza E. Pulmonary complications in patients receiving a solid-organ transplant, Crit Care 2014; 20 (4) 411-419.
12 J. Schmidt, C. Wenzel, M. Mahn, S. Spassov, H.C. Schmitz, S. Borgmann, Z. Lin, J. Haberstroh, S. Meckel, S. Eiden, S. Wirth, H. Buerkle and S. Schumann. Improved lung recruitment and oxygenation during mandatory ventilation with a new expiratory ventilation assistance device: A controlled interventional trial in healthy pigs. Eur J Anaesthesiol. 2018 35:1-9
13 J. Schmidt, C. Wenzel, S. Spassov, S. Wirth and S. Schumann. Expiratory Ventilation Assistance during mandatory ventilation in porcine ARDS improves arterial oxygenation – a randomized controlled animal study. Abstract Euroanaesthesia 2018
Two recent publications highlight FCV as a potentially lung-protective ventilation mode by minimizing energy dissipation in the airways
A new article by Barnes, Van Asseldonk and Enk in Medical Hypotheses provides clear theoretical evidence for lower energy dissipation in the lungs by FCV as compared to VCV or PCV. They authors present a simple analysis and numerical calculations indicating that energy dissipation may be minimized by controlling the ventilation flow to be constant and continuous during both inspiration and expiration, and by ventilating at an I:E ratio close to 1:1 – that is by using FCV.
In a second publication by Barnes and Enk in Trends in Anaesthesia and Critical Care, minimized energy dissipation in the lungs by ventilating with FCV by Evone is for the first time demonstrated in a patient. The authors describe a clinical case in which during FCV ventilation, both inspiratory and expiratory flows were kept nearly constant around 12 L/min. With an I:E ratio of 1:1 this resulted in a minute volume of 6.2 L/min. Pressure-volume (PV) loops were recorded and the energy dissipated in the patient’s lungs was calculated from the hysteresis area of the PV loops. Strikingly, the energy dissipation was 0.17 J/L, which is even lower than values reported for spontaneous breathing (0.2-0.7 J/L).
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