Critical Care ( IF 8.8 ) Pub Date : 2024-08-26 , DOI: 10.1186/s13054-024-05066-z Ricardo Castro 1, 2 , Eduardo Kattan 1, 2 , Glenn Hernández 1, 2
To the Editor,
First, we would like to express our appreciation for the recent study titled "Physiological effects and safety of bed verticalization in patients with acute respiratory distress syndrome," authored by Bouchant et al. and recently published in Critical Care [1]. This innovative exploration of bed verticalization in patients with acute respiratory distress syndrome (ARDS) offers valuable insights into potential improvements in respiratory mechanics and oxygenation.
However, after a thorough review of this article, several important concerns have arisen that warrant further discussion and clarification.
Fluid responsiveness and other hemodynamic data. While the study mentioned the use of fluid optimization based on preload dependency data, it did not provide details regarding the patients' fluid responsiveness status. Knowing whether patients were fluid-responsive or unresponsive at various stages of the verticalization process is crucial for interpreting the hemodynamic consequences of the experiment. Extreme fluid responsiveness can put patients at risk of hemodynamic instability, hypoperfusion, hyperadrenergic compensation, and limited reserve for oxygen demand. This is precisely what we believe occurred in some patients, as reported by the authors.
As shown in Table 2, patients were managed with a positive end-expiratory pressure (PEEP) of 12 cmH2O at all times. This is an important contributing factor to hemodynamic instability, as a PEEP above 10 cmH2O can significantly reduce cardiac output in the supine position [2, 3], let alone in a vertical position. Thus, more detailed reporting of fluid responsiveness status or surrogates, such as stroke volume variation or pulse pressure variation, would better inform cardiopulmonary interactions in these patients and improve the clarity and applicability of the findings. Was the overall increase in heart rate throughout the experiment even greater in patients who decompensated? What was the trajectory of systolic arterial pressure?
Guideline Applicability. The authors referenced the Guidelines for Perioperative Hemodynamic Optimization from the Société Française d'Anesthésie et de Réanimation [4] to manage fluid optimization in ARDS patients. However, it is important to consider the appropriateness and applicability of these perioperative guidelines in the context of ARDS management. Patients with ARDS face unique physiological challenges, including altered lung mechanics and gas exchange, along with secondary cardiovascular derangement, which may not be fully addressed by perioperative optimization strategies designed for surgical patients.
Addressing these concerns could significantly enhance the clarity and applicability of the study findings and contribute to better recommendations for improving the outcomes of patients with ARDS. We look forward to the authors’ response and the possibility of further discussion of these critical aspects of this important study.
Best regards,
Ricardo Castro.
Eduardo Kattan.
Glenn Hernández.
No datasets were generated or analysed during the current study.
- ARDS:
-
Acute respiratory distress syndrome
- PEEP:
-
Positive end-expiratory pressure
Bouchant L, Godet T, Arpajou G, Aupetitgendre L, Cayot S, Guerin R, et al. Physiological effects and safety of bed verticalization in patients with acute respiratory distress syndrome. Crit Care. 2024;28:262.
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Jardin F, Farcot J-C, Boisante L, Curien N, Margairaz A, Bourdarias J-P. Influence of positive end-expiratory pressure on left ventricular performance. N Engl J Med. 1981;304:387–92.
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Authors and Affiliations
Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Av. Diagonal Paraguay #362 6th Floor, 8330049, Santiago Centro, RM, Chile
Ricardo Castro, Eduardo Kattan & Glenn Hernández
Hospital Clínico UC-CHRISTUS, Pontificia Universidad Católica de Chile, Santiago, Chile
Ricardo Castro, Eduardo Kattan & Glenn Hernández
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Contributions
R.C. wrote the first draft of the manuscript. E.K. and G.H. commented on previous versions. All authors read and approved the final manuscript.
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Correspondence to Ricardo Castro.
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The authors declare no competing interests.
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Castro, R., Kattan, E. & Hernández, G. Comment on the article “Physiological effects and safety of bed verticalization in patients with acute respiratory distress syndrome”, from Bouchant et al.. Crit Care 28, 275 (2024). https://doi.org/10.1186/s13054-024-05066-z
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中文翻译：
评论 Bouchant 等人的文章“急性呼吸窘迫综合征患者床垂直化的生理效应和安全性”。
致编辑：
首先，我们要对最近由 Bouchant 等人撰写并最近发表在《重症监护》上的题为“急性呼吸窘迫综合征患者床垂直化的生理效应和安全性”的研究表示赞赏 [1]。这种对急性呼吸窘迫综合征 （ARDS） 患者床垂直化的创新探索为呼吸力学和氧合的潜在改善提供了有价值的见解。
然而，在对本文进行全面审查后，出现了几个值得进一步讨论和澄清的重要问题。
液体反应性和其他血流动力学数据。虽然该研究提到了使用基于预负荷依赖性数据的液体优化，但它没有提供有关患者液体反应状态的详细信息。了解患者在垂直化过程的各个阶段是液体反应性还是无反应性，对于解释实验的血流动力学后果至关重要。极度的液体反应性会使患者面临血流动力学不稳定、灌注不足、肾上腺素能高下代偿和需氧量储备有限的风险。正如作者所报告的那样，这正是我们认为发生在一些患者中的情况。
如表 2 所示，患者始终以 12 cmH2O 的呼气末正压 （PEEP） 进行管理。这是导致血流动力学不稳定的重要因素，因为 PEEP 高于 10 cmH2O 会显着降低仰卧位的心输出量 [2， 3]，更不用说垂直位了。因此，更详细地报告液体反应状态或替代指标，例如每搏输出量变化或脉压变化，将更好地告知这些患者的心肺相互作用，并提高结果的清晰度和适用性。在整个实验过程中，失代偿患者的心率总体增加是否更大？收缩动脉压的轨迹是什么？
指南适用性。作者引用了 Société Française d'Anesthésie et de Réanimation [4] 的围手术期血流动力学优化指南来管理 ARDS 患者的液体优化。然而，在 ARDS 管理的情况下，重要的是要考虑这些围手术期指南的适当性和适用性。ARDS 患者面临独特的生理挑战，包括肺力学和气体交换改变，以及继发性心血管紊乱，这些挑战可能无法通过专为手术患者设计的围手术期优化策略得到完全解决。
解决这些问题可以显著提高研究结果的清晰度和适用性，并有助于为改善 ARDS 患者的预后提供更好的建议。我们期待作者的回应以及进一步讨论这项重要研究的这些关键方面的可能性。
此致敬意
里卡多·卡斯特罗。
爱德华多·卡坦。
格伦·埃尔南德斯。
在当前研究期间没有生成或分析数据集。
- ARDS：
-
急性呼吸窘迫综合征 - 窥视：
-
呼气末正压
Bouchant L、Godet T、Arpajou G、Aupetitgendre L、Cayot S、Guerin R 等人。急性呼吸窘迫综合征患者床垂直化的生理效应和安全性。暴击护理。2024;28:262.
文章： PubMed PubMed Central Google Scholar
Jardin F， Farcot JC， Boisante L， Curien N， Margairaz A， Bourdarias JP.呼气末正压对左心室性能的影响。N Engl J Med. 1981 年;304:387–92.
文章 PubMed 谷歌学术
Jardin F，Vieillard-Baron A.临床实践中的右心室功能和正压通气：从血流动力学亚群到呼吸器设置。重症监护医学 2003;29:1426–34.文章 Google Scholar
Vallet B、Blanloeil Y、Cholley B、Orliaguet G、Pierre S、Tavernier B 等人。围手术期血流动力学优化指南。Ann French 麻醉复苏。2013;32：e151-8。文章 Google Scholar
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作者和单位
智利天主教大学医学院重症监护医学系，Av. Diagonal Paraguay #362 6th Floor， 8330049， Santiago Centro， RM， Chile
里卡多·卡斯特罗，爱德华多·卡坦和格伦·埃尔南德斯
智利圣地亚哥天主教大学 Clínico UC-CHRISTUS 医院
里卡多·卡斯特罗，爱德华多·卡坦和格伦·埃尔南德斯
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R.C. 写了手稿的初稿。E.K. 和 G.H. 对以前的版本进行了评论。所有作者都阅读并批准了最终稿件。
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Castro， R.， Kattan， E. & Hernández， G. 对Bouchant等人的文章“床垂直化的生理效应和安全性在急性呼吸窘迫综合征患者中的生理效应和安全性”的评论。Crit Care28， 275 （2024）。https://doi.org/10.1186/s13054-024-05066-z
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