The effects of a large arteriovenous fistula (AVF) on pulmonary perfusion remains to be elucidated. We aimed to study, for the first time, the real-time acute effects of a large AVF on regional distribution of pulmonary perfusion in a novel porcine model. Ten healthy swine under general anesthesia were studied. AVF was created by the connection of femoral artery and femoral vein using high-diameter perfusion cannulas. The AVF was closed and after 30 min of stabilization the first values were recorded. The fistula was then opened, and new data were collected after reaching stable state. Continuous hemodynamic monitoring was performed throughout the protocol. The following functional images were analyzed by electrical impedance tomography (EIT): perfusion and ventilation distributions. We found an increased cardiac output and right ventricular work, which was strongly correlated to an increased pulmonary artery mean pressure (r=0.878, P=0.001). The ventral/dorsal ratio of pulmonary perfusion decreased from 1.9+/-1.0 to 1.5+/-0.7 (P=0.025). The percentage of total pulmonary blood flow through the dorsal lung region increased from 38.6+/-11.7 to 42.2+/-10.4 (P=0.016). In conclusion, we have used EIT for the first time for studying the acute effects of a large AVF on regional distribution of pulmonary perfusion in a novel porcine model. In this new experimental model of hyperkinetic circulation caused by AVF, we documented an increased percentage of total pulmonary blood flow through the dorsal lung region and a more homogeneous perfusion distribution. Key words Arteriovenous fistula, Hyperkinetic circulation, Tissue perfusion, Animal model, Pulmonary blood flow.

• MeSH
• arteria pulmonalis diagnostické zobrazování   patofyziologie   MeSH
• arteriovenózní píštěl patofyziologie   diagnostické zobrazování   MeSH
• arteriovenózní zkrat MeSH
• plíce krevní zásobení   diagnostické zobrazování   MeSH
• plicní oběh * fyziologie   MeSH
• prasata MeSH
• vena femoralis diagnostické zobrazování   MeSH
• zvířata MeSH
• Check Tag
• ženské pohlaví MeSH
• zvířata MeSH
• Publikační typ
• časopisecké články MeSH

• Klíčová slova
• electrical impedance tomography, lung volume, mechanical ventilation, pulmonary imaging, ventilation, ventilation distribution,
• Publikační typ
• časopisecké články MeSH

Low-volume lung injury encompasses local concentration of stresses in the vicinity of collapsed regions in heterogeneously ventilated lungs. We aimed to study the effects on ventilation and perfusion distributions of a sequential lateral positioning (30°) strategy using electrical impedance tomography imaging in a porcine experimental model of early acute respiratory distress syndrome (ARDS). We hypothesized that such strategy, including a real-time individualization of positive end-expiratory pressure (PEEP) whenever in lateral positioning, would provide attenuation of collapse in the dependent lung regions. A two-hit injury acute respiratory distress syndrome experimental model was established by lung lavages followed by injurious mechanical ventilation. Then, all animals were studied in five body positions in a sequential order, 15 min each: Supine 1; Lateral Left; Supine 2; Lateral Right; Supine 3. The following functional images were analyzed by electrical impedance tomography: ventilation distributions and regional lung volumes, and perfusion distributions. The induction of the acute respiratory distress syndrome model resulted in a marked fall in oxygenation along with low regional ventilation and compliance of the dorsal half of the lung (gravitational-dependent in supine position). Both the regional ventilation and compliance of the dorsal half of the lung greatly increased along of the sequential lateral positioning strategy, and maximally at its end. In addition, a corresponding improvement of oxygenation occurred. In conclusion, our sequential lateral positioning strategy, with sufficient positive end-expiratory pressure to prevent collapse of the dependent lung units during lateral positioning, provided a relevant diminution of collapse in the dorsal lung in a porcine experimental model of early acute respiratory distress syndrome.

• Klíčová slova
• acute respiratory disease syndrome, body position changes, lung collapse, mechanical ventilation, ventilator-induced lung injury,
• Publikační typ
• časopisecké články MeSH

BACKGROUND: Among the challenges for personalizing the management of mechanically ventilated patients with coronavirus disease (COVID-19)-associated acute respiratory distress syndrome (ARDS) are the effects of different positive end-expiratory pressure (PEEP) levels and body positions in regional lung mechanics. Right-left lung aeration asymmetry and poorly recruitable lungs with increased recruitability with alternating body position between supine and prone have been reported. However, real-time effects of changing body position and PEEP on regional overdistension and collapse, in individual patients, remain largely unknown and not timely monitored. The aim of this study was to individualize PEEP and body positioning in order to reduce the mechanisms of ventilator-induced lung injury: collapse and overdistension. METHODS: We here report a series of five consecutive mechanically ventilated patients with COVID-19-associated ARDS in which sixteen decremental PEEP titrations were performed in the first days of mechanical ventilation (8 titration pairs: supine position immediately followed by 30° targeted lateral position). The choice of lateral tilt was based on X-Ray. This targeted lateral position strategy was defined by selecting the less aerated lung to be positioned up and the more aerated lung to be positioned down. For each PEEP level, global and regional collapse and overdistension maps and percentages were measured by electrical impedance tomography. Additionally, we present the incidence of lateral asymmetry in a cohort of forty-four patients. RESULTS: The targeted lateral position strategy resulted in significantly smaller amounts of overdistension and collapse when compared with the supine one: less collapse along the PEEP titration was found within the left lung in targeted lateral (P = 0.014); and less overdistension along the PEEP titration was found within the right lung in targeted lateral (P = 0.005). Regarding collapse within the right lung and overdistension within the left lung: no differences were found for position. In the cohort of forty-four patients, ventilation inequality of > 65/35% was observed in 15% of cases. CONCLUSIONS: Targeted lateral positioning with bedside personalized PEEP provided a selective attenuation of overdistension and collapse in mechanically ventilated patients with COVID-19-associated ARDS and right-left lung aeration/ventilation asymmetry. TRIAL REGISTRATION: Trial registration number: NCT04460859.

• Klíčová slova
• Acute respiratory distress syndrome, Body position, Coronavirus disease, Mechanical ventilation, Positive end-expiratory pressure, Ventilator-induced lung injury,
• MeSH
• atelektáza prevence a kontrola   terapie   MeSH
• COVID-19 terapie   MeSH
• dospělí MeSH
• elektrická impedance MeSH
• lidé středního věku MeSH
• lidé MeSH
• polohování pacienta metody   MeSH
• poškození plic mechanickou ventilací prevence a kontrola   MeSH
• prospektivní studie MeSH
• SARS-CoV-2 MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• syndrom dechové tísně terapie   MeSH
• umělé dýchání metody   MeSH
• ventilace umělá s výdechovým přetlakem metody   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• pozorovací studie MeSH

• MeSH
• biologický monitoring přístrojové vybavení   metody   MeSH
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• oxygenoterapie metody   MeSH
• plicní embolie diagnóza   patofyziologie   terapie   MeSH
• poměr plicní ventilace a perfuze * MeSH
• rychlost toku krve * MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• tomografie metody   MeSH
• vyšetření u lůžka MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• úvodníky MeSH