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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Mechanical power &#40;MP&#41; has been defined as the energy applied per cycle multiplied by respiratory rate &#40;RR&#41;&#46; Also&#44; it has been associated with the development of ventilator-induced lung injury &#40;VILI&#41; and mortality in patients with acute respiratory distress syndrome &#40;ARDS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Controlling some of the variables that condition MP has become the paradigm of ventilatory strategy in ARDS&#58; <span class="elsevierStyleItalic">a&#41;</span> using appropriate levels of positive end-expiratory pressure &#40;PEEP&#41; to improve alveolar recruitment and functional residual capacity &#40;FRC&#41;&#59; <span class="elsevierStyleItalic">b&#41;</span> limiting tidal volume &#40;TV&#41; above the FRC &#40;strain&#41;&#59; <span class="elsevierStyleItalic">c&#41;</span> controlling transpulmonary pressure &#40;stress&#41; or its surrogate&#44; driving pressure &#40;DP&#41;&#46; We may&#44; however&#44; have paid less attention to other determinants of MP like inspiratory flow&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">ARDS is a heterogeneous condition with open alveolar units coexisting with units occupied by edema and collapsed units&#46; How can inspiratory flow impact such a heterogeneous lung parenchyma&#63; In a randomized study&#44; Santini et al&#46; compared the effects of low &#40;400&#8239;mL&#47;s&#41;&#44; medium &#40;800&#8239;mL&#47;s&#41;&#44; and high &#40;1200&#8239;mL&#47;s&#41; inspiratory flows demonstrating a worsening of the Pendelluft phenomenon and an uneven distribution of TV with higher inspiratory flow rates&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The time constant of the units varies&#44; and those with longer time constants could be being ventilated inadequately with shorter inspiratory times and higher flow rates&#44; thus leading to overdistension of the units ventilated earlier&#44; increased DP&#44; and more damage to the lung&#47;s&#46; On the other hand&#44; rapid and repeated deformations with high flow rates could also lead to a heterogeneous distribution of MP&#44; thus triggering intracycle rupture of the interstitial matrix separating the alveolar units and&#44; ultimately&#44; causing alveolar structural damage&#44; especially in units with more deteriorated viscoelastic properties&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We could hypothesize that the existence of an MP threshold for each alveolar unit&#44; dependent upon inspiratory peak flow&#44; is a contributing factor to VILI&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">From our own point of view&#44; the use of low inspiratory flows would be part of the measures aimed at homogenizing lung ventilation along with the search for optimal PEEP to improve FRC and prone positioning&#46; However&#44; using low flows is associated with the risk of making expiratory time insufficient to achieve complete lung emptying&#44; thus favoring the appearance of auto-PEEP&#46; Also&#44; asynchronies may occur in the context of low flows if the patient has preserved respiratory drive and high flow demand&#46; Finally&#44; we cannot overlook the importance of flow morphology &#40;constant&#47;decelerating&#41; without being able to clarify the impact of each on lung injury&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Proper monitoring followed by the addition of these concepts into the search for an individualized ventilatory strategy poses an interesting and necessary challenge&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Therefore&#44; advocating for a comprehensive strategy aimed at minimizing ventilatory parameters in ARDS to avoid VILI&#44; including all the variables that impact MP &#40;TV&#44; DP&#44; PEEP&#44; respiratory frequency&#44; and flow&#41; seems like the right thing to do</p></span>"
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Letter to the Editor
Inspiratory flow: The lost variable?
Flujo inspiratorio: ¿la variable perdida?
Héctor Hernández Garcés
Corresponding author
hektorhernandez84@gmail.com

Corresponding author.
, Alberto Belenguer Muncharaz, Rafael Zaragoza Crespo
Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Mechanical power &#40;MP&#41; has been defined as the energy applied per cycle multiplied by respiratory rate &#40;RR&#41;&#46; Also&#44; it has been associated with the development of ventilator-induced lung injury &#40;VILI&#41; and mortality in patients with acute respiratory distress syndrome &#40;ARDS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Controlling some of the variables that condition MP has become the paradigm of ventilatory strategy in ARDS&#58; <span class="elsevierStyleItalic">a&#41;</span> using appropriate levels of positive end-expiratory pressure &#40;PEEP&#41; to improve alveolar recruitment and functional residual capacity &#40;FRC&#41;&#59; <span class="elsevierStyleItalic">b&#41;</span> limiting tidal volume &#40;TV&#41; above the FRC &#40;strain&#41;&#59; <span class="elsevierStyleItalic">c&#41;</span> controlling transpulmonary pressure &#40;stress&#41; or its surrogate&#44; driving pressure &#40;DP&#41;&#46; We may&#44; however&#44; have paid less attention to other determinants of MP like inspiratory flow&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">ARDS is a heterogeneous condition with open alveolar units coexisting with units occupied by edema and collapsed units&#46; How can inspiratory flow impact such a heterogeneous lung parenchyma&#63; In a randomized study&#44; Santini et al&#46; compared the effects of low &#40;400&#8239;mL&#47;s&#41;&#44; medium &#40;800&#8239;mL&#47;s&#41;&#44; and high &#40;1200&#8239;mL&#47;s&#41; inspiratory flows demonstrating a worsening of the Pendelluft phenomenon and an uneven distribution of TV with higher inspiratory flow rates&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The time constant of the units varies&#44; and those with longer time constants could be being ventilated inadequately with shorter inspiratory times and higher flow rates&#44; thus leading to overdistension of the units ventilated earlier&#44; increased DP&#44; and more damage to the lung&#47;s&#46; On the other hand&#44; rapid and repeated deformations with high flow rates could also lead to a heterogeneous distribution of MP&#44; thus triggering intracycle rupture of the interstitial matrix separating the alveolar units and&#44; ultimately&#44; causing alveolar structural damage&#44; especially in units with more deteriorated viscoelastic properties&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We could hypothesize that the existence of an MP threshold for each alveolar unit&#44; dependent upon inspiratory peak flow&#44; is a contributing factor to VILI&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">From our own point of view&#44; the use of low inspiratory flows would be part of the measures aimed at homogenizing lung ventilation along with the search for optimal PEEP to improve FRC and prone positioning&#46; However&#44; using low flows is associated with the risk of making expiratory time insufficient to achieve complete lung emptying&#44; thus favoring the appearance of auto-PEEP&#46; Also&#44; asynchronies may occur in the context of low flows if the patient has preserved respiratory drive and high flow demand&#46; Finally&#44; we cannot overlook the importance of flow morphology &#40;constant&#47;decelerating&#41; without being able to clarify the impact of each on lung injury&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Proper monitoring followed by the addition of these concepts into the search for an individualized ventilatory strategy poses an interesting and necessary challenge&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Therefore&#44; advocating for a comprehensive strategy aimed at minimizing ventilatory parameters in ARDS to avoid VILI&#44; including all the variables that impact MP &#40;TV&#44; DP&#44; PEEP&#44; respiratory frequency&#44; and flow&#41; seems like the right thing to do</p></span>"
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ISSN: 21735727
Original language: English
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Idiomas
Medicina Intensiva (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?