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we might expect a specific hemodynamic profile&#44; with less prevalence of RV failure&#46; Hemodynamic profile of COVID-19 patients based on echocardiographic features have been previously described&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main objective of our study was to describe how MV &#40;FiO2 and PEEP&#41; in patients with ARDS caused by SARS-CoV2 affects hemodynamics&#46; Hemodynamic response was evaluated by conventional monitoring &#40;invasive blood pressure monitoring&#41; as well as echocardiography&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the first and second wave of the COVID-19 pandemic we performed a single-centre&#44; prospective&#44; observational study&#44; which included consecutive patients with a diagnosis of ARDS caused by SARS-CoV2 who required treatment with invasive MV&#46; Inclusion criteria stated that patients were &#62;18 y&#46;o&#44; had no previous cardiac nor respiratory chronic condition and were in the first 72&#160;h of MV&#46; The patients were treated with a protective ventilatory strategy&#44; following the ARDSnet ventilation approach&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Study variable were hemodynamic parameters&#44; echocardiographic biventricular function and respiratory mechanics&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Two transthoracic echocardiograms separated by an interval of 30&#160;min&#44; were performed during the first 72&#160;h after initiation of MV&#46; All patients were managed with a low PEEP high FiO2 strategy which was the ventilatory approach of our unit&#44; to keep a SaO2&#160;&#62;&#160;90&#37;&#46; The first echocardiogram &#40;baseline&#41; was done with ventilatory parameters set by the attending physician&#44; without any additional intervention&#46; The second echocardiogram was performed after a period of 30&#160;min&#44; either increasing the PEEP 2&#8211;4&#160;cmH2O if a FiO2&#160;&#62;&#160;60&#37; was necessary to reach the SaO2 goal or increasing the FiO2 to 100&#37; if the SaO2 goal were reached with a lower FiO2&#44; observe the hemodynamic response&#46; After this maneuver&#44; the patient was treated with the baseline ventilator settings&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Previously to the realization of the echocardiogram&#44; arterial blood gas analysis was performed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We included 20 patients&#44; with moderate ARDS &#40;baseline PaO2&#47;FiO2 162&#44;69&#160;&#177;&#160;58&#46;80&#41;&#46; Respiratory and hemodynamic variables are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Except for one patient who needed low dose norepinephrine support&#44; all patients showed hemodynamic stability with a mean arterial pressure &#40;MAP&#41; of 84&#46;52&#160;&#177;&#160;13&#46;09&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">We observed that in both groups&#44; ventilatory changes did not have a significant effect on hemodynamics except for a trend to a decrease in pulmonary acceleration time in the PEEP group &#40;115&#44;67&#160;&#177;&#160;8&#44;45&#160;ms baseline vs 111&#44;17&#160;&#177;&#160;15&#46;91&#160;ms&#44; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#46;47&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All patients had preserved both left and right ventricular ejection fraction&#46; None of the patients developed RV failure&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the PEEP group&#44; the slight increase in PEEP worsened pulmonary compliance but this was not followed by a hemodynamic worsening&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Despite the low oxygenation levels&#44; this cohort of patients with SARS CoV2 shows that MV caused a low impact on hemodynamics&#46; We obtained two groups of patients in which we observe that despite the differences in oxygenation &#40;ratio of arterial partial pressure of oxygen to fraction of inspired oxygen PaO2&#47;FiO2 &#40;116&#44;98&#160;&#177;&#160;34&#44;10 in PEEP group vs 222&#44;46&#160;&#177;&#160;88&#44;96 in FiO2 group&#44; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#44;001&#41; the hemodynamic behavior is similar&#46; All patients except one showed hemodynamic stability and they all presented a preserved RV function&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Despite that the most frequently observed phenotype was Type L&#44; our cohort consists entirely of patients with phenotype H&#46; However&#44; the patients in our study present low systemic hemodynamic compromise&#44; low right and left ventricular impact because of the changes in MV &#40;PEEP and FiO2&#41;&#46; A possible explanation could be the described abolition of the HPV&#46; This circumstance would avoid the increment in pulmonary vascular resistance and RV compromise&#44; despite low alveolar O2 pressure and collapse&#46; Moreover&#44; given the use of low PEEP in our patients&#44; the creation of overdistension areas could be avoided&#44; along with capillary collapse and RV overload&#46; Given the low RV compromise&#44; we would probably trigger low LV compromise due to septal interdependence&#44; which would explain at least in part the low systemic compromise&#44; at least in our series&#46; Regarding the low impact of the changes in MV&#44; this could be explained by 1&#41; due to the lack of hypothetical HPV&#44; there would be little vasoreactivity to the O2 changes &#40;there wouldn&#8217;t be any vasoconstriction relief when increasing the FiO2&#41; therefore no changes are observed in theFiO2 change group&#41; although it is highly probable that the monitoring techniques we used are not sensitive enough to detect the changes&#46; 2&#41; In the PEEP change group although an overdistention trend was observed&#44; a possible explanation of the observed low hemodynamic impact could be precisely the low PEEP that was used&#44; probably starting at low transpulmonary pressure and low end expiratory volumes&#46; The increment in these two last variables&#44; as a consequence of PEEP increment&#44; could have not resulted in an excessively unfavourable situation for the relation between the pulmonary volume and pulmonary vascular resistance&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Our study is concordant with the hemodynamic findings mentioned by Evrard et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the size of the cohort being similar&#46; However&#44; in our sample&#44; as mentioned&#44; no patient showed ventricular dysfunction&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">An increase in PEEP tended to worsen pulmonary mechanics but without an enormous impact in hemodynamics&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The main limitation of the study is the small sample size which does not allow to draw more generalized conclusions regarding the objective of our research&#46; Another limitation of our study is that the hemodynamic monitoring did not include advanced techniques that are able to detect cardiovascular change with high sensitivity&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our result regarding the impact of MV on hemodynamics may be relevant at the time of choosing the best management strategy for this kind of patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In memoriam</span></p><p id="par0095" class="elsevierStylePara elsevierViewall">In memoriam of our dear friend&#44; Juan Martinez-Milla MD&#44; PhD&#44; who will always belong to the heart of our team&#46;</p></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SAP - Systolic Arterial Pressure&#44; DAP - Dyastolic Arterial Pressure&#44; MAP - Mean Arterial Pressure&#44; HR - Heart Rate&#44; CVP - Central Venous Pressure&#44; PPV - Pulse Pressure Variation&#44; RA - right atrium PPlat &#8211; Plateau Pressure&#44; PPeak &#8211; peak pressure&#44; FiO2 - Fraction of inspired oxygen&#44; PaO2 - Partial Pressure of Oxygen&#44; PaCO2 - Partial Pressure of Carbon Dioxide&#44; Hb &#8211; Hemoglobin&#44; SaO2 - Oxygen Saturation&#44; LVOT VTI - Left Ventricular Outflow Tract Velocity Time Integral&#44; RVOT VTI - Right Ventricular Outflow Tract Velocity Time Integral&#44; PVAT - Pulmonary Velocity Acceleration Time&#44; TAPSE - Tricuspid Annular Plane Systolic Excursion&#44; RVD - Right Ventricular Diameter&#44; LVD - Left Ventricular Diameter&#44; SD - standard deviation&#44; DP - driving pressure&#44; PBW - predicted body weight&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PEEP GROUP&#44; N&#160;&#61;&#160;7</th><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="7" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">FIO2 GROUP&#44; N&#160;&#61;&#160;13</th></tr><tr title="table-row"><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">First echocardiogram</th><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Second echocardiogram</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">First echocardiogram</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Second echocardiogram</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ttest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ttest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="15" align="left" valign="\n
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                  \t\t\t\t">Conventional hemodynamics</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;159&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;295&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">DAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">66&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;658&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;221&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">TV&#47;PBW &#40;ml&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Compliance &#40;ml&#47;cmH20&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="15" align="left" valign="\n
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                  \t\t\t\t">Arterial blood gas analysis</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">PaO2 &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PaCO2 &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hb &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Echocardiographic parameters</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PVAT &#40;ms&#41;&nbsp;\t\t\t\t\t\t\n
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Scientific Letter
Low hemodynamic impact of moderate ARDS caused by SARS-CoV2
El SDRA moderado causado por el SARS-COv2 tiene un bajo impacto hemodinámico
Ana-Maria Ioana, Oscar Gonzalez-Lorenzob, Andrea Kallmeyer Mayorb, César Pérez-Calvoa, Arnoldo Santosa,
Autor para correspondencia
asantos@fjd.es

Corresponding author.
a Department of Intensive Care Medicine, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
b Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
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    "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>"
    "titulo" => "Low hemodynamic impact of moderate ARDS caused by SARS-CoV2"
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            "entidad" => "Department of Intensive Care Medicine&#44; Hospital Universitario Fundaci&#243;n Jim&#233;nez D&#237;az&#44; Avda&#46; Reyes Cat&#243;licos&#44; 2&#44; 28040 Madrid&#44; Spain"
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        "titulo" => "El SDRA moderado causado por el SARS-COv2 tiene un bajo impacto hemodin&#225;mico"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It has been proposed that SARS CoV2 patients who require invasive mechanical ventilation &#40;MV&#41; might represent a particular type of ARDS with a different ventilatory profile&#46; On the other hand&#44; they may also present with a distinct physiopathology element&#44; consisting of a blunted hypoxic pulmonary vasoconstriction &#40;HPV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Two SARS-Cov2 ARDS phenotypes have been described by Gattinoni et al&#46; The majority of these patients represent Type L&#44; characterized by higher compliance&#44; and for which lower pressure ventilation is recommended because they don&#8217;t have an extensive recruitable area and higher PEEP levels could negatively impact the right ventricle &#40;RV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Therefore&#44; we might expect a specific hemodynamic profile&#44; with less prevalence of RV failure&#46; Hemodynamic profile of COVID-19 patients based on echocardiographic features have been previously described&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main objective of our study was to describe how MV &#40;FiO2 and PEEP&#41; in patients with ARDS caused by SARS-CoV2 affects hemodynamics&#46; Hemodynamic response was evaluated by conventional monitoring &#40;invasive blood pressure monitoring&#41; as well as echocardiography&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the first and second wave of the COVID-19 pandemic we performed a single-centre&#44; prospective&#44; observational study&#44; which included consecutive patients with a diagnosis of ARDS caused by SARS-CoV2 who required treatment with invasive MV&#46; Inclusion criteria stated that patients were &#62;18 y&#46;o&#44; had no previous cardiac nor respiratory chronic condition and were in the first 72&#160;h of MV&#46; The patients were treated with a protective ventilatory strategy&#44; following the ARDSnet ventilation approach&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Study variable were hemodynamic parameters&#44; echocardiographic biventricular function and respiratory mechanics&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Two transthoracic echocardiograms separated by an interval of 30&#160;min&#44; were performed during the first 72&#160;h after initiation of MV&#46; All patients were managed with a low PEEP high FiO2 strategy which was the ventilatory approach of our unit&#44; to keep a SaO2&#160;&#62;&#160;90&#37;&#46; The first echocardiogram &#40;baseline&#41; was done with ventilatory parameters set by the attending physician&#44; without any additional intervention&#46; The second echocardiogram was performed after a period of 30&#160;min&#44; either increasing the PEEP 2&#8211;4&#160;cmH2O if a FiO2&#160;&#62;&#160;60&#37; was necessary to reach the SaO2 goal or increasing the FiO2 to 100&#37; if the SaO2 goal were reached with a lower FiO2&#44; observe the hemodynamic response&#46; After this maneuver&#44; the patient was treated with the baseline ventilator settings&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Previously to the realization of the echocardiogram&#44; arterial blood gas analysis was performed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We included 20 patients&#44; with moderate ARDS &#40;baseline PaO2&#47;FiO2 162&#44;69&#160;&#177;&#160;58&#46;80&#41;&#46; Respiratory and hemodynamic variables are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Except for one patient who needed low dose norepinephrine support&#44; all patients showed hemodynamic stability with a mean arterial pressure &#40;MAP&#41; of 84&#46;52&#160;&#177;&#160;13&#46;09&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">We observed that in both groups&#44; ventilatory changes did not have a significant effect on hemodynamics except for a trend to a decrease in pulmonary acceleration time in the PEEP group &#40;115&#44;67&#160;&#177;&#160;8&#44;45&#160;ms baseline vs 111&#44;17&#160;&#177;&#160;15&#46;91&#160;ms&#44; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#46;47&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All patients had preserved both left and right ventricular ejection fraction&#46; None of the patients developed RV failure&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the PEEP group&#44; the slight increase in PEEP worsened pulmonary compliance but this was not followed by a hemodynamic worsening&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Despite the low oxygenation levels&#44; this cohort of patients with SARS CoV2 shows that MV caused a low impact on hemodynamics&#46; We obtained two groups of patients in which we observe that despite the differences in oxygenation &#40;ratio of arterial partial pressure of oxygen to fraction of inspired oxygen PaO2&#47;FiO2 &#40;116&#44;98&#160;&#177;&#160;34&#44;10 in PEEP group vs 222&#44;46&#160;&#177;&#160;88&#44;96 in FiO2 group&#44; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#44;001&#41; the hemodynamic behavior is similar&#46; All patients except one showed hemodynamic stability and they all presented a preserved RV function&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Despite that the most frequently observed phenotype was Type L&#44; our cohort consists entirely of patients with phenotype H&#46; However&#44; the patients in our study present low systemic hemodynamic compromise&#44; low right and left ventricular impact because of the changes in MV &#40;PEEP and FiO2&#41;&#46; A possible explanation could be the described abolition of the HPV&#46; This circumstance would avoid the increment in pulmonary vascular resistance and RV compromise&#44; despite low alveolar O2 pressure and collapse&#46; Moreover&#44; given the use of low PEEP in our patients&#44; the creation of overdistension areas could be avoided&#44; along with capillary collapse and RV overload&#46; Given the low RV compromise&#44; we would probably trigger low LV compromise due to septal interdependence&#44; which would explain at least in part the low systemic compromise&#44; at least in our series&#46; Regarding the low impact of the changes in MV&#44; this could be explained by 1&#41; due to the lack of hypothetical HPV&#44; there would be little vasoreactivity to the O2 changes &#40;there wouldn&#8217;t be any vasoconstriction relief when increasing the FiO2&#41; therefore no changes are observed in theFiO2 change group&#41; although it is highly probable that the monitoring techniques we used are not sensitive enough to detect the changes&#46; 2&#41; In the PEEP change group although an overdistention trend was observed&#44; a possible explanation of the observed low hemodynamic impact could be precisely the low PEEP that was used&#44; probably starting at low transpulmonary pressure and low end expiratory volumes&#46; The increment in these two last variables&#44; as a consequence of PEEP increment&#44; could have not resulted in an excessively unfavourable situation for the relation between the pulmonary volume and pulmonary vascular resistance&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Our study is concordant with the hemodynamic findings mentioned by Evrard et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the size of the cohort being similar&#46; However&#44; in our sample&#44; as mentioned&#44; no patient showed ventricular dysfunction&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">An increase in PEEP tended to worsen pulmonary mechanics but without an enormous impact in hemodynamics&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The main limitation of the study is the small sample size which does not allow to draw more generalized conclusions regarding the objective of our research&#46; Another limitation of our study is that the hemodynamic monitoring did not include advanced techniques that are able to detect cardiovascular change with high sensitivity&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our result regarding the impact of MV on hemodynamics may be relevant at the time of choosing the best management strategy for this kind of patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In memoriam</span></p><p id="par0095" class="elsevierStylePara elsevierViewall">In memoriam of our dear friend&#44; Juan Martinez-Milla MD&#44; PhD&#44; who will always belong to the heart of our team&#46;</p></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SAP - Systolic Arterial Pressure&#44; DAP - Dyastolic Arterial Pressure&#44; MAP - Mean Arterial Pressure&#44; HR - Heart Rate&#44; CVP - Central Venous Pressure&#44; PPV - Pulse Pressure Variation&#44; RA - right atrium PPlat &#8211; Plateau Pressure&#44; PPeak &#8211; peak pressure&#44; FiO2 - Fraction of inspired oxygen&#44; PaO2 - Partial Pressure of Oxygen&#44; PaCO2 - Partial Pressure of Carbon Dioxide&#44; Hb &#8211; Hemoglobin&#44; SaO2 - Oxygen Saturation&#44; LVOT VTI - Left Ventricular Outflow Tract Velocity Time Integral&#44; RVOT VTI - Right Ventricular Outflow Tract Velocity Time Integral&#44; PVAT - Pulmonary Velocity Acceleration Time&#44; TAPSE - Tricuspid Annular Plane Systolic Excursion&#44; RVD - Right Ventricular Diameter&#44; LVD - Left Ventricular Diameter&#44; SD - standard deviation&#44; DP - driving pressure&#44; PBW - predicted body weight&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">First echocardiogram</th><th class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Second echocardiogram</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ttest&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ttest&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Conventional hemodynamics</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">SAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#177;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="15" align="left" valign="\n
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                  \t\t\t\t">Ventilatory mechanics</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">TV abs &#40;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">TV&#47;PBW &#40;ml&#47;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Mean airway pressure &#40;cmH2O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PEEP &#40;cmH2O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PPeak &#40;cmH2O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PPlat &#40;cmH2O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">DP &#40;cmH20&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Compliance &#40;ml&#47;cmH20&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="15" align="left" valign="\n
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                  \t\t\t\t">Arterial blood gas analysis</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PaO2 &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;0001637&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">PaCO2 &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Study variables are shown&#58; conventional hemodynamics&#44; ventilatory mechanics&#44; arterial blood gas analysis and echocardiographic parameters&#46; The two groups PEEP and FiO2 were created depending on the Fi02 requirements in order to maintain SaO2&#160;&#62;&#160;90&#37;&#44; as described in the text&#46; The first echocardiogram was performed with mechanical ventilation set by the attending physician&#46; The second echocardiogram was performed after mechanical ventilation changes described in the text&#46;</p>"
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Información del artículo
ISSN: 02105691
Idioma original: Inglés
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