Manchula Navaratnam, Alexander R Schmidt, Michelle Kaplinski, Elizabeth De Souza, Meaghan J Beattie, Echo V Rowe, Rajesh Punn, Chandra Ramamoorthy
{"title":"改变正压通气期间潮气量对丰坦循环血流动力学的影响：随机交叉试验。","authors":"Manchula Navaratnam, Alexander R Schmidt, Michelle Kaplinski, Elizabeth De Souza, Meaghan J Beattie, Echo V Rowe, Rajesh Punn, Chandra Ramamoorthy","doi":"10.1111/pan.15096","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Primary determinants of pulmonary blood flow in the Fontan circulation are low transpulmonary gradient and pulmonary vascular resistance (PVR). Changes in intrathoracic pressure during intermittent positive pressure ventilation can influence the transpulmonary gradient, PVR, pulmonary blood flow, and cardiac output. The aim of this study was to evaluate the effect of low (5 mL/kg) versus high (10 mL/kg) tidal volume (V<sub>T</sub>) ventilation on Fontan circulation hemodynamics.</p><p><strong>Method: </strong>Postoperative patients with a Fontan circulation were enrolled in this single-center, randomized crossover trial. Patients, randomized to group 1 or 2, underwent a ventilation study sequence (baseline ventilation [7 mL/kg], then high V<sub>T</sub> [10 mL/kg] or low V<sub>T</sub> [5 mL/kg], then washout ventilation [7 mL/kg], followed by low [5 mL/kg] or high V<sub>T</sub> [10 mL/kg]) in the operating room at the end of the cardiac surgical procedure. Respiratory, hemodynamic, and transesophageal (TEE) measurements were recorded after 5 min in each ventilation condition. The primary aim of this study was to evaluate the effect of low V<sub>T</sub> ventilation (5 mL/kg) versus high V<sub>T</sub> ventilation (10 mL/kg) on transpulmonary gradient (Fontan pressure minus left atrial pressure). The secondary aim was to compare TEE measurements of pulmonary blood flow, stroke volume, and Fontan flow between low and high V<sub>T</sub> ventilation. We also compared standard hemodynamic and ventilation parameters for all ventilation conditions. Analysis was of paired data, calculating the between-treatment difference within participants across ventilation conditions.</p><p><strong>Results: </strong>Eleven patients were included in the final data analysis with a median [IQR] age of 5 [4, 11] years and weight of 16.3 [13.8, 31.6] kg. The mean (±SD) peak inspiratory pressure during low and high V<sub>T</sub> ventilation was 15.3 (±2.9) cmH<sub>2</sub>O and 22.2 (±3.7) cmH<sub>2</sub>O, respectively (difference -6.9, 95% CI -7.8, -5.9, p < 0.001). The mean airway pressure during low and high V<sub>T</sub> ventilation was 7.3 ± 0.8 and 8.7 ± 0.9 (difference -1.5, 95% CI -2.1, -0.8, p = 0.001) with a mean inspiratory time of 0.62 (±0.22) s and 1.21 (±0.55) s (difference -0.59, 95% CI -0.84, -0.34, p < 0.001), respectively. During low V<sub>T</sub> ventilation, the mean Fontan pressure was 13.3 (±1.8) mmHg compared to 12.3 (±2.5) mmHg for high V<sub>T</sub> ventilation (difference 0.8, 95% CI -0.5, 2.1, p = 0.18). The mean transpulmonary gradient was 7.0 ± 1.3 mmHg compared to 6.8 ± 1.2 mmHg during low and high V<sub>T</sub> ventilation, respectively (difference 0.2, 95% CI -0.2, 0.6, p = 0.21). We found no significant differences between low and high V<sub>T</sub> ventilation in TEE measures of pulmonary blood flow, stroke volume, and Fontan flow.</p><p><strong>Conclusions: </strong>This randomized, crossover pilot trial of Fontan patients showed that a low V<sub>T</sub> ventilation (5 mL/kg) resulted in significantly lower peak and mean airway pressure compared with a high V<sub>T</sub> ventilation (10 mL/kg). However, there were no significant changes in transpulmonary gradient, mean Fontan pressure, or TEE parameters of stroke volume, pulmonary blood flow, or Fontan flow.</p><p><strong>Clinical trials registration number: </strong>NCT04633343.</p><p><strong>Principal investigator: </strong>Manchula Navaratnam.</p><p><strong>Date of registration: </strong>November 11, 2020. Clinical Trials Registration Registry URL: https://clinicaltrials.gov/study/NCT04633343?term=Fontan%20ventilation&rank=3.</p><p><strong>Prior presentations: </strong>Congenital Cardiac Anesthesia Society Annual Meeting Top Oral Abstract Presentation.</p><p><strong>Presenter: </strong>Alexander R Schmidt, March 30th, 2023.</p>","PeriodicalId":19745,"journal":{"name":"Pediatric Anesthesia","volume":" ","pages":""},"PeriodicalIF":1.7000,"publicationDate":"2025-03-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Hemodynamic Effects of Altering Tidal Volume During Positive Pressure Ventilation in the Fontan Circulation: A Randomized Crossover Trial.\",\"authors\":\"Manchula Navaratnam, Alexander R Schmidt, Michelle Kaplinski, Elizabeth De Souza, Meaghan J Beattie, Echo V Rowe, Rajesh Punn, Chandra Ramamoorthy\",\"doi\":\"10.1111/pan.15096\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Primary determinants of pulmonary blood flow in the Fontan circulation are low transpulmonary gradient and pulmonary vascular resistance (PVR). Changes in intrathoracic pressure during intermittent positive pressure ventilation can influence the transpulmonary gradient, PVR, pulmonary blood flow, and cardiac output. The aim of this study was to evaluate the effect of low (5 mL/kg) versus high (10 mL/kg) tidal volume (V<sub>T</sub>) ventilation on Fontan circulation hemodynamics.</p><p><strong>Method: </strong>Postoperative patients with a Fontan circulation were enrolled in this single-center, randomized crossover trial. Patients, randomized to group 1 or 2, underwent a ventilation study sequence (baseline ventilation [7 mL/kg], then high V<sub>T</sub> [10 mL/kg] or low V<sub>T</sub> [5 mL/kg], then washout ventilation [7 mL/kg], followed by low [5 mL/kg] or high V<sub>T</sub> [10 mL/kg]) in the operating room at the end of the cardiac surgical procedure. Respiratory, hemodynamic, and transesophageal (TEE) measurements were recorded after 5 min in each ventilation condition. The primary aim of this study was to evaluate the effect of low V<sub>T</sub> ventilation (5 mL/kg) versus high V<sub>T</sub> ventilation (10 mL/kg) on transpulmonary gradient (Fontan pressure minus left atrial pressure). The secondary aim was to compare TEE measurements of pulmonary blood flow, stroke volume, and Fontan flow between low and high V<sub>T</sub> ventilation. We also compared standard hemodynamic and ventilation parameters for all ventilation conditions. Analysis was of paired data, calculating the between-treatment difference within participants across ventilation conditions.</p><p><strong>Results: </strong>Eleven patients were included in the final data analysis with a median [IQR] age of 5 [4, 11] years and weight of 16.3 [13.8, 31.6] kg. The mean (±SD) peak inspiratory pressure during low and high V<sub>T</sub> ventilation was 15.3 (±2.9) cmH<sub>2</sub>O and 22.2 (±3.7) cmH<sub>2</sub>O, respectively (difference -6.9, 95% CI -7.8, -5.9, p < 0.001). The mean airway pressure during low and high V<sub>T</sub> ventilation was 7.3 ± 0.8 and 8.7 ± 0.9 (difference -1.5, 95% CI -2.1, -0.8, p = 0.001) with a mean inspiratory time of 0.62 (±0.22) s and 1.21 (±0.55) s (difference -0.59, 95% CI -0.84, -0.34, p < 0.001), respectively. During low V<sub>T</sub> ventilation, the mean Fontan pressure was 13.3 (±1.8) mmHg compared to 12.3 (±2.5) mmHg for high V<sub>T</sub> ventilation (difference 0.8, 95% CI -0.5, 2.1, p = 0.18). The mean transpulmonary gradient was 7.0 ± 1.3 mmHg compared to 6.8 ± 1.2 mmHg during low and high V<sub>T</sub> ventilation, respectively (difference 0.2, 95% CI -0.2, 0.6, p = 0.21). We found no significant differences between low and high V<sub>T</sub> ventilation in TEE measures of pulmonary blood flow, stroke volume, and Fontan flow.</p><p><strong>Conclusions: </strong>This randomized, crossover pilot trial of Fontan patients showed that a low V<sub>T</sub> ventilation (5 mL/kg) resulted in significantly lower peak and mean airway pressure compared with a high V<sub>T</sub> ventilation (10 mL/kg). However, there were no significant changes in transpulmonary gradient, mean Fontan pressure, or TEE parameters of stroke volume, pulmonary blood flow, or Fontan flow.</p><p><strong>Clinical trials registration number: </strong>NCT04633343.</p><p><strong>Principal investigator: </strong>Manchula Navaratnam.</p><p><strong>Date of registration: </strong>November 11, 2020. 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引用次数: 0
摘要
背景：丰坦循环中肺血流的主要决定因素是低跨肺梯度和肺血管阻力（PVR）。间歇正压通气时胸内压的变化可影响经肺梯度、PVR、肺血流量和心输出量。本研究的目的是评估低（5 mL/kg）与高（10 mL/kg）潮气量（VT）通气对Fontan循环血流动力学的影响。方法：采用单中心、随机交叉试验，纳入术后丰坦循环患者。患者随机分为1组或2组，在心脏手术结束时在手术室接受通气研究顺序（基线通气[7 mL/kg]，然后高VT [10 mL/kg]或低VT [5 mL/kg]，然后冲洗通气[7 mL/kg]，随后低VT [5 mL/kg]或高VT [10 mL/kg]）。在每种通气条件下5分钟后记录呼吸、血流动力学和经食管（TEE）测量。本研究的主要目的是评估低室速通气（5ml /kg）与高室速通气（10ml /kg）对经肺梯度（方坦压减去左房压）的影响。第二个目的是比较低和高VT通气时肺血流量、搏量和方坦流量的TEE测量结果。我们还比较了所有通气条件下的标准血流动力学和通气参数。对配对数据进行分析，计算不同通风条件下参与者的处理间差异。结果：11例患者纳入最终数据分析，中位[IQR]年龄为5[4,11]岁，体重为16.3 [13.8,31.6]kg。低、高VT通气时平均（±SD）峰值吸气压分别为15.3（±2.9）cmH2O和22.2（±3.7）cmH2O(差异-6.9,95% CI -7.8, -5.9， p T通气分别为7.3±0.8和8.7±0.9（差异-1.5,95% CI -2.1, -0.8, p = 0.001），平均吸气时间分别为0.62（±0.22）s和1.21（±0.55）s(差异-0.59,95% CI -0.84, -0.34， p T通气；平均丰坦压为13.3（±1.8）mmHg，而高VT通气组为12.3（±2.5）mmHg（差异0.8,95% CI -0.5, 2.1, p = 0.18）。低和高VT通气时的平均肺梯度分别为7.0±1.3 mmHg和6.8±1.2 mmHg（差异0.2,95% CI -0.2, 0.6, p = 0.21）。我们发现低和高VT通气在TEE测量肺血流量、搏量和方滩流量方面没有显著差异。结论：这项针对Fontan患者的随机交叉试验表明，与高VT通气（10 mL/kg）相比，低VT通气（5 mL/kg）可显著降低峰值和平均气道压力。然而，经肺梯度、平均方坦压或TEE参数的脑卒中容量、肺血流量或方坦流量均无明显变化。临床试验注册号：NCT04633343。首席研究员：Manchula Navaratnam。报名日期：2020年11月11日。临床试验注册注册网址：https://clinicaltrials.gov/study/NCT04633343?term=Fontan%20ventilation&rank=3.Prior演讲：先天性心脏麻醉学会年度会议顶级口腔摘要演讲。主讲人：Alexander R Schmidt， 2023年3月30日。
Hemodynamic Effects of Altering Tidal Volume During Positive Pressure Ventilation in the Fontan Circulation: A Randomized Crossover Trial.
Background: Primary determinants of pulmonary blood flow in the Fontan circulation are low transpulmonary gradient and pulmonary vascular resistance (PVR). Changes in intrathoracic pressure during intermittent positive pressure ventilation can influence the transpulmonary gradient, PVR, pulmonary blood flow, and cardiac output. The aim of this study was to evaluate the effect of low (5 mL/kg) versus high (10 mL/kg) tidal volume (VT) ventilation on Fontan circulation hemodynamics.
Method: Postoperative patients with a Fontan circulation were enrolled in this single-center, randomized crossover trial. Patients, randomized to group 1 or 2, underwent a ventilation study sequence (baseline ventilation [7 mL/kg], then high VT [10 mL/kg] or low VT [5 mL/kg], then washout ventilation [7 mL/kg], followed by low [5 mL/kg] or high VT [10 mL/kg]) in the operating room at the end of the cardiac surgical procedure. Respiratory, hemodynamic, and transesophageal (TEE) measurements were recorded after 5 min in each ventilation condition. The primary aim of this study was to evaluate the effect of low VT ventilation (5 mL/kg) versus high VT ventilation (10 mL/kg) on transpulmonary gradient (Fontan pressure minus left atrial pressure). The secondary aim was to compare TEE measurements of pulmonary blood flow, stroke volume, and Fontan flow between low and high VT ventilation. We also compared standard hemodynamic and ventilation parameters for all ventilation conditions. Analysis was of paired data, calculating the between-treatment difference within participants across ventilation conditions.
Results: Eleven patients were included in the final data analysis with a median [IQR] age of 5 [4, 11] years and weight of 16.3 [13.8, 31.6] kg. The mean (±SD) peak inspiratory pressure during low and high VT ventilation was 15.3 (±2.9) cmH2O and 22.2 (±3.7) cmH2O, respectively (difference -6.9, 95% CI -7.8, -5.9, p < 0.001). The mean airway pressure during low and high VT ventilation was 7.3 ± 0.8 and 8.7 ± 0.9 (difference -1.5, 95% CI -2.1, -0.8, p = 0.001) with a mean inspiratory time of 0.62 (±0.22) s and 1.21 (±0.55) s (difference -0.59, 95% CI -0.84, -0.34, p < 0.001), respectively. During low VT ventilation, the mean Fontan pressure was 13.3 (±1.8) mmHg compared to 12.3 (±2.5) mmHg for high VT ventilation (difference 0.8, 95% CI -0.5, 2.1, p = 0.18). The mean transpulmonary gradient was 7.0 ± 1.3 mmHg compared to 6.8 ± 1.2 mmHg during low and high VT ventilation, respectively (difference 0.2, 95% CI -0.2, 0.6, p = 0.21). We found no significant differences between low and high VT ventilation in TEE measures of pulmonary blood flow, stroke volume, and Fontan flow.
Conclusions: This randomized, crossover pilot trial of Fontan patients showed that a low VT ventilation (5 mL/kg) resulted in significantly lower peak and mean airway pressure compared with a high VT ventilation (10 mL/kg). However, there were no significant changes in transpulmonary gradient, mean Fontan pressure, or TEE parameters of stroke volume, pulmonary blood flow, or Fontan flow.
Clinical trials registration number: NCT04633343.
Principal investigator: Manchula Navaratnam.
Date of registration: November 11, 2020. Clinical Trials Registration Registry URL: https://clinicaltrials.gov/study/NCT04633343?term=Fontan%20ventilation&rank=3.
Prior presentations: Congenital Cardiac Anesthesia Society Annual Meeting Top Oral Abstract Presentation.
期刊介绍：
Devoted to the dissemination of research of interest and importance to practising anesthetists everywhere, the scientific and clinical content of Pediatric Anesthesia covers a wide selection of medical disciplines in all areas relevant to paediatric anaesthesia, pain management and peri-operative medicine. The International Editorial Board is supported by the Editorial Advisory Board and a team of Senior Advisors, to ensure that the journal is publishing the best work from the front line of research in the field. The journal publishes high-quality, relevant scientific and clinical research papers, reviews, commentaries, pro-con debates, historical vignettes, correspondence, case presentations and book reviews.
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