- Research Articles
- Open access
- Published:
Impact of the transpulmonary pressure on right ventricle impairment incidence during acute respiratory distress syndrome: a pilot study in adults and children
Intensive Care Medicine Experimental volume 12, Article number: 84 (2024)
Abstract
Background
Right ventricle impairment (RVI) is common during acute respiratory distress syndrome (ARDS) in adults and children, possibly mediated by the level of transpulmonary pressure (PL). We sought to investigate the impact of the level of PL on ARDS-associated right ventricle impairment (RVI).
Methods
Adults and children (> 72 h of life) were included in this two centers prospective study if they were ventilated for a new-onset ARDS or pediatric ARDS, without spontaneous breathing and contra-indication to esophageal catheter. Serial measures of static lung, chest wall, and respiratory mechanics were coupled to critical care echocardiography (CCE) for 3 days. Mixed-effect logistic regression models tested the impact of lung stress (ΔPL) along with age, lung injury severity, and carbon dioxide partial pressure, on RVI using two definitions: acute cor pulmonale (ACP), and RV dysfunction (RVD). ACP was defined as a dilated RV with septal dyskinesia; RVD was defined as a composite criterion using tricuspid annular plane systolic excursion, S wave velocity, and fractional area change.
Results
46 patients were included (16 children, 30 adults) with 106 CCE (median of 2 CCE/patient). At day one, 19% of adults and 4/7 children > 1 year exhibited ACP, while 59% of adults and 44% of children exhibited RVD. In the entire population, ACP was present on 17/75 (23%) CCE. ACP was associated with an increased lung stress (mean ΔPL of 16.2 ± 6.6 cmH2O in ACP vs 11.3 ± 3.6 cmH2O, adjusted OR of 1.33, CI95% [1.11–1.59], p = 0.002) and being a child. RVD was present in 59/102 (58%) CCE and associated with lung stress. In children > 1 year, PEEP was significantly lower in case of ACP (9.3 [8.6; 10.0] cmH2O in ACP vs 15.0 [11.9; 16.3] cmH2O, p = 0.03).
Conclusion
Lung stress was associated with RVI in adults and children with ARDS, children being particularly susceptible to RVI.
Trial registration Clinical trials identifier: NCT0418467.
Background
Right ventricle impairment (RVI) is common during adult [1] and pediatric acute respiratory distress syndrome (ARDS) [2]. The underlying mechanisms of RVI depends on the transpulmonary pressure (PL), which increases pulmonary vascular resistances (PVR) and RV afterload when excessive [3]. PL reflects the distending pressure and stress of the lungs [4]. PL is approximated using esophageal manometry as it is calculated as the difference between the airway pressure (PAW) and the esophageal pressure (PES) used as a surrogate for pleural pressure [5]. In adults with ARDS, PL-guided strategies failed to improve patient’s outcome [6]. This may be partly explained by the lack of consideration of the impact of lung stress induced by ventilator settings on RV function. RVI has been reported to be associated with worse outcome. The risk factors for RVI include a lower PaO2/FiO2, a higher PaCO2, and a higher airway driving pressure (ΔPAW) [1]. However, no study has tested the potential impact of PL on RV function in ARDS despite a strong pathophysiological rationale [7, 8]. In particular, children may be more susceptible to RVI because of their high PVR [9], their limited cardiac response to an increase in preload, and their high ventricle interdependence [10].
In this pilot study, we sought to evaluate the impact of PL on the occurrence of ARDS-associated RVI in adults and children testing two different definitions of RVI.
Methods
This pilot physiological study was conducted in two tertiary university hospitals in France: one pediatric intensive care unit (Necker universitary hospital, Paris) and one adult intensive care unit (Ambroise Paré universitary hospital, Boulogne-Billancourt). The study was approved by an institutional review board (CPP Sud-Ouest et Outre-Mer 3-n°2019-A02814-53) and registered on the clinicaltrials database (NCT 04184674). Written informed consent from the patient or their guardians was obtained before inclusion.
Population
Patients suffering from new-onset (within 48 h following admission) ARDS [11, 12] were included if invasively ventilated. Exclusion criteria comprised: neonates ≤ 37 weeks of corrected gestational age and/or less than 72 h of age, pregnant women, contra-indication to esophageal catheter, extracorporeal membrane oxygenation, congenital heart defect affecting RV function, and lack of social coverage.
Study procedure
Patients received ventilation using cuffed endotracheal tubes connected to an ICU ventilator (V500 or Evita XL, Draeger, Netherlands, for children. Hamilton S1, USA, for adults). The ventilator settings and adjuvant therapies were left at the physician’s discretion, following guidelines for lung-protective ventilation [11, 13, 14]. Briefly, the ventilation strategies used in both units were defined to deliver a tidal volume around 6 mL/kg of predicted body weight, with a maximal airway plateau pressure at 28–30 cmH2O, and a minimal positive end-expiratory pressure (PEEP) level set at 5 cmH2O, then adapted depending on severity and respiratory mechanics. Patients could be ventilated in volumetric or barometric mode, although volume-(assist) control ventilation was prioritized in the two centers. Esophageal pressure monitoring was not considered for ventilator settings modifications. Critical care echocardiography (CCE), followed by static respiratory mechanics measurements were performed at day one, then, in case of PEEP level modification, up to 3 days.
Critical care echocardiography
CCE (transthoracic echocardiography for all, followed by transesophageal echography in adults) was performed by the same investigator along the procedure, according to a standard protocol [15]. RVI was defined as either acute cor pulmonale (ACP) or RV systolic dysfunction (RVD). The former was defined as a dilated RV (RV/left ventricle (LV) end-diastolic area ratio > 0.6) associated with a septal dyskinesia, [16] and the latter as a fractional area change (FAC) < 35%, and/or a tricuspid annular plane systolic excursion (TAPSE) < 16 mm in adults or a z-score < − 2 in children [17], and/or a S wave velocity < 10 cm/s [18]. Each CCE could be classified as ACP only, RVD only, or both ACP and RVD. All the ultrasound images and loops were stored and exported to dedicated software (Echopac™, version 201, GE Healthcare Systems, Chicago, USA). A blinded analysis was performed off-line (Echopac) by two cardiopediatricians for children, and two intensivists for adults, all having expertise in RV assessment.
Respiratory and lung mechanics
PES was measured using an esophageal balloon catheter (Marquat, France, for children; Nutrivent, Italy, for adults) inserted as recommended [19, 20], and filled with the appropriate volume of air [21, 22]. Airflow and airway pressure (PAW) were measured using a proximal calibrated pneumotachometer (Hans Rudolph, USA, for children; Hamilton, USA, for adults). All signals were displayed on the ventilator screen in adults, and recorded at 200Â Hz using an analogical/numeric acquisition system (MP150, Biopac systems, USA) run on a PC computer and displayed using dedicated software (AcqKnowledge, version 4.2, Biopac systems) in children. Tidal volume was obtained by integrating the airflow signal over time.
Gas leaks were carefully excluded before measurements. After one minute of stable breathing, the investigator performed 3 consecutive inspiratory and expiratory holds. Airway and esophageal plateau pressures were obtained at the end of the inspiratory hold, while airway and esophageal PEEP were obtained at the end of a prolonged expiratory hold (4 s in adults, 3 in children) to account for intrinsic PEEP [23]. PL was calculated online by subtracting PES from PAW. The subsequent transpulmonary driving pressure (ΔPL) and compliances of the respiratory system (CRS), lung (CL), and chest wall (CCW) were calculated and normalized on actual (children) or predicted (adults) body weight. Expiratory-PL (PL-EXP) was computed directly from the measured end-expiratory PL, while inspiratory-PL (PL-INSP) was computed using the elastance ratio method [24].
Analyses
CCE data were first described at T0 at the patient level according to the presence or not of RVI, in adults, and children. Each measure of respiratory mechanics was coupled to simultaneous CCE to assess the impact of PL on RVI using mixed-effect logistic regression models (one for ACP, one for RVD). For each model, the patient was treated as a random effect, to adjust for the correlation between repeated measures within the same patient. Based on the ACP prevalence in adults, and the physiological differences between children and adults, we anticipated RVI prevalence of 30% in the total population. Assuming the inclusion of 45 patients with at least 2 measurements, 4 variables could be included in the models. Variables of interest were selected a priori based on the physiologic rationale and the current literature evidence regarding ARDS-associated RVI, with variables exhibiting collinearity excluded. Four variables of interest were finally included: ΔPL, partial pressure of carbon dioxide (pCO2), lung injury severity, and age [1, 25, 26]. ΔPL was used as a continuous variable as a surrogate for the tidal lung stress. PCO2 was measured using arterial blood gas in adult patients, and in either arterial or venous blood gas in children. Because of the differences between pediatric and adult guidelines regarding the estimation of hypoxemia and lung injury severity, we considered the level of the arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) and the oxygenation index (OI) in children. OI was either measured or calculated from the oxygen saturation index (OSI) (using the equation OI = 0.0745 + 1.7830 * OSI [27]) in the absence of arterial blood gas. Lung-injury severity was then categorized in mild/moderate or severe ARDS following the recommended thresholds of PaO2/FiO2 (severe ARDS if PaO2/FiO2 ≤ 100) or OI (severe ARDS if OI ≥ 16) [12, 28]. This transformation of the variable allowed to minimize the number of missing data, and to achieve the greatest homogeneity in the population. Because of a highly skewed distribution and to distinguish adults and children, age was also categorized in two classes: adults (≥ 18 years old) and children (< 18 years old). Because echocardiographic assessment of RV dilation might be uncertain in infants [29], children less than 1 year old were excluded from all the analyses using the ACP definition.
Respiratory mechanics were then compared in CCE studies with or without RVI, in adults and children separately, using the t-test or Wilcoxon rank sum test depending on the variables’ normality. Continuous variables were presented as means ± standard deviations (SD) or medians and interquartile ranges (IQR) depending on the sample size and their distribution, and categorical variables as numbers and percentages. We also described the relationship between ΔPL and driving airway pressure (ΔPAW) using linear regression model. Data were analyzed using R programming software. A p value < 0.05 defined statistical significance.
Results
Population
From July 2020 to July 2022, 83 adults and 51 children were admitted in the two centers for ARDS or PARDS. Among those, 58 patients met the inclusion criteria and 46 were included (16 children, 30 adults) (Fig. 1). Patients’ characteristics are presented in Table 1. Median [IQR] age was 0.7 [0.4; 7.1] years for children, and 67 [61; 72] years for adults. The most common trigger for ARDS was pneumonia, especially due to SARS-CoV2 infection in adults (80%). The majority of the patients had severe ARDS. Mortality rate in the intensive care unit at 28 days was 13% for children and 60% for adults (Table 1).
CCE studies at day 1
There were 5 (19%) adult patients exhibiting ACP on their first CCE (T0) and 17 (59%) RVD. RV/LV end-diastolic area ratio, S wave, TAPSE, and FAC seemed affected in patients with ACP and RVD as compared to their counterpart. RV/LV end-diastolic area ratio was significantly higher in adults with either ACP or RVD as compared to those without RVI (p = 0.01), with a significant alteration of left ventricle output (lower aortic velocity time integral, p = 0.01) (Table 2).
Regarding children > 1 year of age, 7 had measurements of RV/LV end-diastolic area ratio and septal motion assessment, whose 4 had ACP. RV/LV end-diastolic area ratio, S wave, TAPSE z-score, and FAC seemed affected in children with ACP despite no statistical difference (Table 2). Seven (44%) children exhibited RVD on their first CCE. RVI did not impair LV systolic function in children (Table 3).
Among patients who benefitted from complete ultrasounds at day one, 25 had RVI with either CPA, RVF, or both (16 adults and 9 children): 9 adults (56%) and one child (11%) were deceased at day 28.
Association between lung stress and RVI
Overall, 75 CCE studies were available in patients > 1 year of age to assess ACP, with 74 being coupled to respiratory mechanics measurements. ACP was present on 17/75 (23%) CCE. Lung stress was associated with the presence of ACP (mean ΔPL of 16.2 ± 6.6 cmH2O in ACP vs 11.3 ± 3.6 cmH2O, adjusted OR of 1.33, CI95% [1.11–1.59], p = 0.002], whereas being an adult significantly decreased the risk of ACP (65% of adults in ACP vs 90%, adjusted OR of 0.09, CI95% [0.01; 0.62], p = 0.015). ARDS severity and the level of PCO2 were not associated with ACP (Table 4).
A total of 102 CCE studies were available to assess RVD, with 101 being coupled to respiratory mechanics measurements. RVD was observed in 59/102 (58%) CCE. Lung stress was associated with RVD (mean ΔPL of 13.3 ± 5.3 cmH2O in RVD vs 11.4 ± 4.2 cmH2O, adjusted OR of 1.16, CI95% [1.02–1.31], p = 0.027). Age, ARDS severity, and the level of PCO2 were not associated with RVD (Table 4).
Respiratory mechanics in adults and children with or without RVI
In CCE of adults, ACP was present in 10/62 (16%) CCE and significantly associated with both higher ΔPAW (p = 0.01) and plateau PAW (p < 0.001), and lower CRS (p = 0.01) and CL (p = 0.03), as compared to CCE without signs of ACP. ΔPL was higher in case of ACP, without statistically significant difference (Fig. 2, online Table 1). RVD was associated with higher ΔPL (p = 0.04) and plateau PAW (p = 0.04) as compared to normal CCE (online Table 1).
In CCE of children, ACP was present in 6/12 (50%) CCE and significantly associated with higher ΔPL (p = 0.002), ΔPAW (p = 0.004), and elastance ratio (EL/ERS 0.9 [0.89; 0.95] in CCE with ACP vs 0.83 [0.82–0.83], p = 0.002), and a lower normalized CL/kg (p = 0.02). PEEP was significantly lower in case of ACP (9.3 [8.6; 10.0] vs 15.0 [11.9; 16.3] cmH2O, p = 0.03) (Fig. 2, online Table 2). RVD was significantly associated with a higher tidal volume (p = 0.03) (online Table 2).
There was a strong linear relationship between ΔPL and ΔPAW in the entire population (R = 0.93, p < 0.01) (online Fig. 2).
Discussion
To our knowledge, this physiological study is the first to investigate the complex relationship between transpulmonary pressure and RVI in a heterogeneous population of adults and children undergoing controlled ventilation for ARDS. We found that: (i) the level of ΔPL as a surrogate for lung stress was associated with RVI, whatever the definition used; (ii) ACP seemed more common in children than adults; (iii) ACP was associated with lower PEEP levels in children.
Lung stress is one of the main determinants of mechanical ventilation-related injuries [30,31,32]. In clinical practice, lung stress is estimated by the plateau pressure and the driving airway pressure, which represents the best predictor of ACP [1] and mortality [25, 26] in adults with ARDS. However, the estimation of transpulmonary pressure using PES is the most precise marker of lung stress, and allows partitioning of lung and chest wall mechanics. With regard to the pathophysiology of RVI under mechanical ventilation, we used the ΔPL as a surrogate for the tidal lung stress.
In adults, our results are in line with previous studies [1, 26]. Our results relative to the association between ΔPAW and RVI is also consistent with the recent findings of Chen et al., who reported that the airway driving pressure was better associated with outcome than the driving transpulmonary pressure. Our observation may confirm that the airway driving pressure is a good indicator of ventilator-induced lung injury, but also contains some information about the patient’s severity, herein illustrated by RVI. In addition, the driving airway pressure was strongly correlated to ΔPL in our population, suggesting that there is a potential benefit to use it as an estimate for lung stress in the most severe patients when esophageal pressure is not available. We believe, however, that ΔPL represents the best physiological component to explain mechanical ventilation-related injuries, irrespective of patient severity. Partitioning lung and chest wall mechanics remains important to deliver not only a lung-protective, but also heart-protective tailored ventilation.
We cannot preclude the result we observed may be due to the overall severity in the adult population, as attested by the high mortality rate. We assume that this was due to the recruitment period during the beginning of SARS-CoV2 pandemic, with selected population of patients with SARS-CoV2 associated pneumoniae being intubated later than for usual ARDS. While ACP has been classically defined as the most severe form of RV failure, it is also crucial to detect early RV dysfunction. Our findings not only confirm the impact of high levels of lung stress on the presence of ACP, but also show that this relationship is present even in RVD, which represents a milder form of RVI.
The interpretation of respiratory mechanics measurements requires estimation of the airway occlusion pressure (AOP), which was not calculated in this study. Despite AOP being frequent in adults with ARDS, its prevalence is unknown in children because measures have not been validated. In addition, RVI may be related to either lung collapse or overinflation. AOP is always reached by inflation of the tidal volume in clinical practice. Then, closing pressure is probably more crucial to avoid lung collapse and is well-known to be much lower than the opening pressure [33]. In our study, especially in adults, PEEP was expected to avoid lung derecruitment and optimize compliance, and we did not find any intrinsic PEEP. Thus, we believe that the respiratory settings in adult patients might have limited the presence of AOP or its impact on driving pressure calculation. That being said, PEEP levels were relatively low in adults, with only 25% of them having PEEP above 7 cmH2O. We do not believe that PEEP levels would modify the relationship between lung stress and RVI, but setting a higher PEEP in patients with recruitable lungs may reduce both lung stress and RVI incidence, as we observed in our pediatric population.
Children have a more compliant chest wall and a smaller functional residual capacity, which may favor lung retraction and atelectasis. Interestingly, the PEEP level was higher in the absence of ACP and in case of lower lung stress. We may assume that in those cases, a higher PEEP level is associated with a better lung recruitment and improved lung compliance. Preliminary reports have recently showed the benefits of a PL-targeted PEEP titration on RV function in adults [34]. In this respect, setting a higher PEEP level in children with recruitable lungs may reduce PL and its subsequent afterload effect, which may preserve RV function. We also observed a higher elastance ratio in children with ACP, which may suggest a higher transmission of the airway pressure to the lung in the most severe patients, as reported in adults [35]. Larger studies are needed to investigate how the elastance ratio differs in children as compared to adults.
There is a lack of evidence regarding RVI in critically ill children outside congenital heart defects, which may be partly explained because the ultrasound assessment of the RV is challenging, especially in the PICU [18, 36]. Thanks to our multimodal ultrasound analysis using two different definitions of RVI, we provided a detailed assessment of RV function along with respiratory mechanics in this poorly described population. RV dysfunction vary from 26 to 65% of children with ARDS according to the ultrasound parameter used [2]. Similarly, we found a high prevalence of both RVD and ACP in children. ACP has been scarcely studied in critically ill children because the accuracy and reliability of echocardiography assessment of RV size and of septal flattening are poor [29, 37]. In the youngest children who often face high PVR, RV might dilate in case of chronic pulmonary hypertension without RV congestion or dysfunction [38, 39]. In this situation, RV/LV area may reflect more the RV adaptation to afterload constraint than an accurate marker of RVI. We believe that intensivists should not focus on the RV/LV area ratio only to define ACP and RVI in neonates and infants.
Our study has limitations. First, the sample size was small, especially in children, and the non-inclusion of some patients due to logistic reasons may have introduced selection bias. As a consequence, we were not able to analyze the impact of lung stress according to PEEP levels. Second, pediatric and adult cardiac ultrasounds were analyzed separately by different investigators to maximize expertise, which may have induced an interpretation bias. However, we used homogenized definitions in both populations and performed blinded analyses. Third, PES gives only an estimation of PL and its surrogates. Even if all measurements were performed as recommended, there are unique aspects regarding the type and placement of the catheter, as well as the volume of air inflated in the balloon to ensure accuracy, which are unique to children and still not validated. Finally, due to the recruitment period during the beginning of SARS-CoV2 pandemics, most adult patients had Covid-19 related ARDS, which leads to changes in vascularization likely to impact the relationship between lung stress and RVI [40].
Conclusion
This original pilot study confirmed the impact of the lung stress on RV function during ARDS in non-spontaneously breathing adults and children, with the latter being particularly susceptible to RVI. How a ventilatory strategy based on the driving airway and transpulmonary pressures could prevent the occurrence of RVI and improve outcome remains to be demonstrated in both adult and pediatric settings.
Availability of data and materials
Data are available upon reasonable request from M.Vedrenne-Cloquet.
Abbreviations
- ACP:
-
Acute cor pulmonale
- ARDS:
-
Acute respiratory distress syndrome
- AOP:
-
Airway occlusion pressure
- CCE:
-
Critical care echocardiography
- C RS :
-
Respiratory system compliance
- C L :
-
Lung compliance
- FAC:
-
Fractional area change
- ICU:
-
Intensive care unit
- PARDS:
-
Pediatric acute respiratory distress syndrome
- RV:
-
Right ventricle
- RVFWS:
-
Right ventricle free wall strain
- RVI:
-
Right ventricle impairment
- RVD:
-
Right ventricle dysfunction
- STE:
-
Speckle tracking echocardiography
- TAPSE:
-
Tricuspid annular plane systolic excursion
- P AW :
-
Airway pressure
- P ES :
-
Esophageal pressure
- PICU:
-
Pediatric intensive care unit
- P L :
-
Transpulmonary pressure
- PVR:
-
Pulmonary vascular resistances
References
Mekontso Dessap A, Boissier F, Charron C et al (2016) Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. Intensive Care Med 42:862–870. https://doi.org/10.1007/s00134-015-4141-2
Himebauch AS, Yehya N, Wang Y et al (2018) Early right ventricular systolic dysfunction and pulmonary hypertension are associated with worse outcomes in pediatric acute respiratory distress syndrome. Crit Care Med 46:e1055–e1062. https://doi.org/10.1097/CCM.0000000000003358
Vieillard-Baron A, Loubieres Y, Schmitt JM et al (1999) Cyclic changes in right ventricular output impedance during mechanical ventilation. J Appl Physiol (1985) 87:1644–1650. https://doi.org/10.1152/jappl.1999.87.5.1644
Chiumello D, Carlesso E, Brioni M, Cressoni M (2016) Airway driving pressure and lung stress in ARDS patients. Crit Care 20:276. https://doi.org/10.1186/s13054-016-1446-7
Mauri T, Yoshida T, Bellani G et al (2016) Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 42:1360–1373. https://doi.org/10.1007/s00134-016-4400-x
Beitler JR, Sarge T, Banner-Goodspeed VM et al (2019) Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure-guided strategy vs an empirical high PEEP-Fio2 strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. https://doi.org/10.1001/jama.2019.0555
Slobod D, Assanangkornchai N, Alhazza M et al (2022) Right ventricular loading by lung inflation during controlled mechanical ventilation. Am J Respir Crit Care Med 205:1311–1319. https://doi.org/10.1164/rccm.202111-2483OC
Whittenberger JL, McGREGOR M, Berglund E, Borst HG (1960) Influence of state of inflation of the lung on pulmonary vascular resistance. J Appl Physiol 15:878–882. https://doi.org/10.1152/jappl.1960.15.5.878
Bronicki RA, Penny DJ, Anas NG, Fuhrman B (2016) Cardiopulmonary interactions. Pediatr Crit Care Med 17:S182-193. https://doi.org/10.1097/PCC.0000000000000829
Burkett DA, Slorach C, Patel SS et al (2016) Impact of pulmonary hemodynamics and ventricular interdependence on left ventricular diastolic function in children with pulmonary hypertension. Circ Cardiovasc Imaging 9:e004612. https://doi.org/10.1161/CIRCIMAGING.116.004612
Khemani RG, Smith LS, Zimmerman JJ et al (2015) Pediatric acute respiratory distress syndrome: definition, incidence, and epidemiology: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 16:S23-40. https://doi.org/10.1097/PCC.0000000000000432
Definition Task Force ARDS, Ranieri VM, Rubenfeld GD et al (2012) Acute respiratory distress syndrome: the Berlin Definition. JAMA 307:2526–2533. https://doi.org/10.1001/jama.2012.5669
Papazian L, Aubron C, Brochard L et al (2019) Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 9(1):69. https://doi.org/10.1186/s13613-019-0540-9
Kneyber MCJ, de Luca D, Calderini E et al (2017) Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med 43:1764–1780. https://doi.org/10.1007/s00134-017-4920-z
Sanfilippo F, Huang S, Herpain A et al (2021) The PRICES statement: an ESICM expert consensus on methodology for conducting and reporting critical care echocardiography research studies. Intensive Care Med 47:1–13. https://doi.org/10.1007/s00134-020-06262-5
Jardin F, Dubourg O, Bourdarias JP (1997) Echocardiographic pattern of acute cor pulmonale. Chest 111:209–217. https://doi.org/10.1378/chest.111.1.209
Koestenberger M, Ravekes W, Everett AD et al (2009) Right ventricular function in infants, children and adolescents: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 640 healthy patients and calculation of z score values. J Am Soc Echocardiogr 22:715–719. https://doi.org/10.1016/j.echo.2009.03.026
Rudski LG, Lai WW, Afilalo J et al (2010) Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 23:685–713. https://doi.org/10.1016/j.echo.2010.05.010. (quiz 786–788)
Baydur A, Behrakis PK, Zin WA et al (1982) A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis 126:788–791. https://doi.org/10.1164/arrd.1982.126.5.788
Lanteri CJ, Kano S, Sly PD (1994) Validation of esophageal pressure occlusion test after paralysis. Pediatr Pulmonol 17:56–62. https://doi.org/10.1002/ppul.1950170110
Mojoli F, Iotti GA, Torriglia F et al (2016) In vivo calibration of esophageal pressure in the mechanically ventilated patient makes measurements reliable. Crit Care 20:98. https://doi.org/10.1186/s13054-016-1278-5
Hotz JC, Sodetani CT, Van Steenbergen J et al (2018) Measurements obtained from esophageal balloon catheters are affected by the esophageal balloon filling volume in children with ARDS. Respir Care 63:177–186. https://doi.org/10.4187/respcare.05685
Vieillard-Baron A, Prin S, Schmitt J-M et al (2002) Pressure-volume curves in acute respiratory distress syndrome: clinical demonstration of the influence of expiratory flow limitation on the initial slope. Am J Respir Crit Care Med 165:1107–1112. https://doi.org/10.1164/ajrccm.165.8.2106104
Gattinoni L, Giosa L, Bonifazi M et al (2019) Targeting transpulmonary pressure to prevent ventilator-induced lung injury. Expert Rev Respir Med 13:737–746. https://doi.org/10.1080/17476348.2019.1638767
Amato MBP, Meade MO, Slutsky AS et al (2015) Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 372:747–755. https://doi.org/10.1056/NEJMsa1410639
Chen L, Grieco DL, Beloncle F et al (2022) Partition of respiratory mechanics in patients with acute respiratory distress syndrome and association with outcome: a multicentre clinical study. Intensive Care Med 48:888–898. https://doi.org/10.1007/s00134-022-06724-y
Muniraman HK, Song AY, Ramanathan R et al (2019) Evaluation of oxygen saturation index compared with oxygenation index in neonates with hypoxemic respiratory failure. JAMA Netw Open 2:e191179. https://doi.org/10.1001/jamanetworkopen.2019.1179
Emeriaud G, López-Fernández YM, Iyer NP et al (2023) Executive summary of the second international guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PALICC-2). Pediatr Crit Care Med 24:143–168. https://doi.org/10.1097/PCC.0000000000003147
Smith A, Purna JR, Castaldo MP et al (2019) Accuracy and reliability of qualitative echocardiography assessment of right ventricular size and function in neonates. Echocardiography 36:1346–1352. https://doi.org/10.1111/echo.14409
Slutsky AS, Ranieri VM (2013) Ventilator-induced lung injury. N Engl J Med 369:2126–2136. https://doi.org/10.1056/NEJMra1208707
Goligher EC, Brochard LJ, Reid WD et al (2019) Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure. Lancet Respir Med 7:90–98. https://doi.org/10.1016/S2213-2600(18)30366-7
Marini JJ, Culver BH, Butler J (1981) Mechanical effect of lung distention with positive pressure on cardiac function. Am Rev Respir Dis 124:382–386. https://doi.org/10.1164/arrd.1981.124.4.382
Crotti S, Mascheroni D, Caironi P et al (2001) Recruitment and derecruitment during acute respiratory failure: a clinical study. Am J Respir Crit Care Med 164:131–140. https://doi.org/10.1164/ajrccm.164.1.2007011
Dong D, Jing C, Zong Y et al (2023) Effect of different titration methods on right heart function and prognosis in patients with acute respiratory distress syndrome. Heart Lung 61:127–135. https://doi.org/10.1016/j.hrtlng.2023.05.009
Jardin F, Genevray B, Brun-Ney D, Bourdarias JP (1985) Influence of lung and chest wall compliances on transmission of airway pressure to the pleural space in critically ill patients. Chest 88:653–658. https://doi.org/10.1378/chest.88.5.653
Vieillard-Baron A, Naeije R, Haddad F et al (2018) Diagnostic workup, etiologies and management of acute right ventricle failure: a state-of-the-art paper. Intensive Care Med 44:774–790. https://doi.org/10.1007/s00134-018-5172-2
Lai WW, Gauvreau K, Rivera ES et al (2008) Accuracy of guideline recommendations for two-dimensional quantification of the right ventricle by echocardiography. Int J Cardiovasc Imaging 24:691–698. https://doi.org/10.1007/s10554-008-9314-4
Avitabile CM, Flohr S, Mathew L et al (2023) Quantitative measures of right ventricular size and function by echocardiogram correlate with cardiac catheterization hemodynamics in congenital diaphragmatic hernia. J Pediatr 261:113564. https://doi.org/10.1016/j.jpeds.2023.113564
Madden BA, Conaway MR, Zanelli SA, McCulloch MA (2022) Screening echocardiography identifies risk factors for pulmonary hypertension at discharge in premature infants with bronchopulmonary dysplasia. Pediatr Cardiol 43:1743–1751. https://doi.org/10.1007/s00246-022-02911-2
Paternoster G, Bertini P, Innelli P et al (2021) Right ventricular dysfunction in patients with COVID-19: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 35:3319–3324. https://doi.org/10.1053/j.jvca.2021.04.008
Acknowledgements
This study was promoted by Assistance Publique-Hopitaux de Paris (AP-HP).
Funding
M.Vedrenne-Cloquet received a grant from GFRUP (Groupe Francophone de Recherche aux Urgences et Reanimation Pediatrique) for this work.
Author information
Authors and Affiliations
Contributions
MVC, AVB and BF conceived and designed the study. MVC, MP, SK, CC, SK, EP, MH acquired, analyzed, and interpreted the data. MVC performed the formal analysis and drafted the original manuscript supervised by AVB. All authors revised or provided critical revision of the article, and approved final version of this manuscript.
Corresponding author
Ethics declarations
Ethics approval and consent to participate
The study was approved by an institutional review board (CPP Sud-Ouest et Outre-Mer 3-n°2019-A02814-53) and registered on the clinicaltrials database (NCT 04184674). Written informed consent from the patient or their guardians was obtained before inclusion.
Consent for publication
Not applicable.
Competing interests
Authors have nothing to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Vedrenne-Cloquet, M., Petit, M., Khirani, S. et al. Impact of the transpulmonary pressure on right ventricle impairment incidence during acute respiratory distress syndrome: a pilot study in adults and children. ICMx 12, 84 (2024). https://doi.org/10.1186/s40635-024-00671-2
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s40635-024-00671-2