Marco Pozzi

In vivo calibration of esophageal pressure in the mechanically ventilated patient makes measurements reliable.

BackgroundEsophageal pressure (Pes) can provide information to guide mechanical ventilation in acute respiratory failure. However, both relative changes and absolute values of Pes can be affected by inappropriate filling of the esophageal balloon and by the elastance of the esophagus wall. We evaluated the feasibility and effectiveness of a calibration procedure consisting in optimization of balloon filling and subtraction of the pressure generated by the esophagus wall (Pew).MethodsAn esophageal balloon was progressively filled in 36 patients under controlled mechanical ventilation. VBEST was the filling volume associated with the largest tidal increase of Pes. Esophageal wall elastance was quantified and Pew was computed at each filling volume. Different filling strategies were compared by performing a validation occlusion test.ResultsFifty series of measurements were performed. VBEST was 3.5 ± 1.9 ml (range 0.5–6.0). Esophagus elastance was 1.1 ± 0.5 cmH2O/ml (0.3–3.1). Both Pew and the result of the occlusion test differed among filling strategies. At filling volumes of 0.5, VBEST and 4.0 ml respectively, Pew was 0.0 ± 0.1, 2.0 ± 1.9, and 3.0 ± 1.7 cmH2O (p < 0.0001), whereas the occlusion test was satisfactory in 22 %, 98 %, and 88 % of cases (p < 0.0001).ConclusionsUnder mechanical ventilation, an increase of balloon filling above the conventionally recommended low volumes warrants complete transmission of Pes swings, but is associated with significant elevation of baseline. A simple calibration procedure allows finding the filling volume associated with the best transmission of tidal Pes change and subtracting the associated baseline artifact, thus making measurement of absolute values of Pes reliable.

Swine influenza A (H1N1) virus (SIV) infection requiring extracorporeal life support in an immunocompetent adult patient with indirect exposure to pigs, Italy, October 2016

We describe a case of severe swine influenza A(H1N1) virus infection in an immunocompetent middle-aged man in October 2016 in Italy who had only indirect exposure to pigs. The patient developed a severe acute distress respiratory syndrome which was successfully supported by extracorporeal membrane oxygenation and treated with antiviral therapy. The sole risk factor for influenza was a body mass index > 30 kg/m2. After a month of hospitalisation, the patient was discharged in good health.

Technical aspects of bedside respiratory monitoring of transpulmonary pressure

Background: To determine the prognostic value of tumor length in predicting overall survival (OS) for patients with esophageal cancer. Methods: Patients who were diagnosed with esophageal cancer between 2010 and 2014 were identified from the Surveillance Epidemiology and End Results (SEER) data. We performed Kaplan-Meier survival analysis and developed a Cox regression proportional hazard model to explore the effect of tumor length on survival. Results: A total of 6,897 esophageal cancer patients were identified. The patients were classified according to tumor length: 2,334 patients had a tumor length ≤3 cm, and 4,563 patients had a tumor length >3 cm. Patients with a tumor length >3 cm were more likely to have poorer histological grade (P 3 cm than in those with a tumor length ≤3 cm both in the Cox regression univariate analysis [hazard ratio (HR): 1.790; 95% CI: 1.667–1.922; P=0.000] and the multivariate analysis (HR: 1.447; 95% CI: 1.341–1.561; P=0.000). A stratified analysis based on different T stages showed that the HR for death was 1.84 (P=0.000) for T1 stage patients, 1.227 (P=0.046) for T2 stage patients, and 1.157 (P=0.012) for T3 stage patients; there was no difference in survival for T4 stage patients. Conclusions: Tumor length significantly influences the OS of esophageal cancer patients, especially in early T stage patients. Further prospective trials are needed to validate the prognostic value of tumor length among esophageal cancer patients.

Authors’ reply: Two severe human cases due to swine influenza A (H1N1)v in October 2016 in Europe were chronologic coincident yet distinct events

F Rovida 1 , A Piralla 1 , FC Marzani 2 , A Moreno 3 , G Campanini 1 , F Mojoli 2 4 , M Pozzi 2 , A Girello 1 , C Chiapponi 5 , F Vezzoli 6 , P Prati 7 , E Percivalle 1 , A Pavan 8 , M Gramegna 9 , GA Iotti 2 4 , F Baldanti 1 10 1. SS Virologia Molecolare, SC Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy 2. Anestesia e Rianimazione, Dipartimento di Emergenza ed Urgenza, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy 3. Istituto Zooprofilattico Sperimentale della Lombardia ed Emilia Romagna, Brescia, Italy 4. Unità di Anestesia, Rianimazione e Terapia Antalgica, Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia, Pavia, Italy 5. Istituto Zooprofilattico Sperimentale della Lombardia ed Emilia Romagna, Parma, Italy 6. Istituto Zooprofilattico Sperimentale della Lombardia ed Emilia Romagna, Lodi, Italy 7. Istituto Zooprofilattico Sperimentale della Lombardia ed Emilia Romagna, Pavia, Italy 8. Agenzia di Tutela della Salute, Pavia, Italy 9. Direzione Generale Sanità, Regione Lombardia, Milano, Italy 10. Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia, Pavia, Italy

Temperature Monitoring During Ecmo: An in Vitro Study

The need of heat exchanger in the ECMO circuit is controversial. Moreover, how to monitor patient central temperature during extracorporeal support is still not clear, but potentially useful for the detection of “unexpressed” fever, eventually related to septic complications.

Automatic monitoring of plateau and driving pressure during pressure and volume controlled ventilation

Plateau pressure (Pplat) limitation is routinely used to avoid ventilator-induced lung injury. Recently, driving pressure (ΔP) was strongly associated with survival in ARDS patients [1].

Artificial Lung Gas Exchanges Depend On Ecmo Settings

Artificial membrane lung (AL) gas exchanges are usually evaluated according to PaO2/FiO2 ratio. in addition, dead space ventilation and shunt fraction can be measured by the same equations used for native lungs [1].

Weaning Failure for Disproportionate Hypoxemia Caused by Paradoxical Response to Positive End-Expiratory Pressure in a Patient with Patent Foramen Ovale

Weaning Failure for Disproportionate Hypoxemia Caused by Paradoxical Response to Positive End-Expiratory Pressure in a Patient with Patent Foramen Ovale Guido Tavazzi, Marco Pozzi, Gabriele Via, Silvia Mongodi, Antonio Braschi, and Francesco Mojoli Anesthesia, Intensive Care and Pain Therapy, University of Pavia, Pavia, Italy; and Anesthesia and Intensive Care, Emergency Department, Foundation IRCCS Policlinico San Matteo, Pavia, Italy