Positive Pressure Ventilation for Respiratory Disease – a flawed, non-physiological solution. Further evidence from COVID-19
Main Article Content
Abstract
“Modern” larger mammals developed over the last 65 million years, after the demise of the dinosaurs. All mammals, including hominids, breathe by negative pressure.
Between 1928 and the 1950’s negative-pressure ventilation using so-called “iron lungs” saved countless poliomyelitis epidemic patients, but during the 1950s, when these devices were in short supply, they were largely replaced by smaller, practical, positive pressure ventilation devices and techniques. These had been used previously for thirty years by anaesthetists in operating theatres to enable general anaesthesia for surgery.
However, positive pressure ventilation for longer term respiratory support was quickly recognised to have disadvantages, including the need for intubation and sedation, reduction of cardiac output from reduced systemic venous return, ventilator acquired pneumonia, and ventilator-induced lung injury. Subsequently, lower tidal volumes and plateau inspiratory pressures were introduced to reduce mortality. There is an extensive publication history of these disadvantages over the last 60 years.
Additionally, the limitations of positive pressure ventilation have been further starkly revealed in COVID-19 pneumonia, a condition where the incidences of pneumothorax and pneumomediastinum have been especially prominent and where mechanical ventilation has been shown to stimulate the expression of angiotensin-converting enzyme-2 (ACE2; the receptor for the SARS-Cov-2 virus in the lung). Mechanical ventilation of patients with COVID-19 pneumonia has been shown to facilitate viral propagation in the lung, further accelerating the pulmonary pathology that had necessitated mechanical ventilation in the first place.
The deleterious effects of COVID-19 on the cardiovascular system have been stressed in much of the recent COVID-19 literature worldwide. Acute myocardial injury and chronic damage to the cardiovascular system have been reported. A potential consequence of using positive pressure ventilation is that by forcing air into lungs, which share the space within the chest, it inevitably increases the pressure on the heart and the major veins leading to it. High levels of positive end-expiratory pressure increase intrathoracic pressure, reducing venous return to the heart and decreasing the cardiac index.
The question, therefore, is whether we should continue to pursue development of positive pressure ventilation methods alone, or, whether respiratory medicine needs to re-investigate and develop negative pressure ventilation, the physiological way that the mammalian cardiorespiratory system evolved to function optimally.
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References
2. Dail CW. “Glossopharyngeal Breathing” by Paralyzed Patients: A Preliminary Report". Calif Med. 1951;75 (3): 217-218
3. Dail CW, Affeldt JE. Glossopharyngeal breathing (video). Los Angeles: Department of Visual Education, College of Medical Evangelists; 1954.
4. Webber B Higgens J. Glossopharyngeal breathing what, when and how? (video). Asian Studios Ltd. Holbrook, Horsham, West Sussex, England; 1999.
5. JOHN MAYOW (1641-1674) JAMA. 1966; 197 (5):364-365.
6. Dalziel J. On sleep and apparatus for promoting artificial respiration. Br Assoc Adv Sci. 1838; 1:128.
7. Macintosh RR. New use of the Both respirator. Lancet. 1940;2:745.
8. Kelleher WH. A new pattern of “iron lung” for the prevention and treatment of airway complications in paralytic disease. Lancet. 1961;ii:1113–6.
9. Braun N. Chapter 2: Negative pressure non-invasive ventilation (NPNIV): history, rational, and application. IN: Nocturnal non-invasive ventilation: theory, evidence, and clinical practice. New York, NY: Springer Science; 2015.
10. Lassen HC.A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen. Lancet 1953; 1:37-41.
11. Wilson JL.The use of the respirator in poliomyelitis. New York, NY: National Foundation of Infantile Paralysis Inc; 1942.
12. Wilson DJ. Living with polio: the epidemic and its survivors. Chicago, IL: University of Chicago Press; 2005. ISBN 0-226- 90103–3.
13. Bergman R. Eight hundred cases of poliomyelitis treated in the Sahlin respirator. Acta Paediat Scand.1948; 36:470
14. Plum F, Lukas DS. An evaluation of the cuirass respirator in acute poliomyelitis with respiratory insufficiency. Am J Med Sci. 1951; 221:417-24.
15. Pask EA. Maintenance of respiration in respiratory paralysis. Proc R Soc Med.1955; 48:239-244.
16. Sauret JM, Guitart AC, Frojan GR, et al. Intermittent short-term negative pressure ventilation and increased oxygenation in COPD patients with severe hypercapnic respiratory failure. Chest. 1991; 100:455-9.
17. Corrado A, Gorini M, De Paolo E, et al. Iron lung treatment of acute on chronic respiratory failure: 16 years of experience. Monaldi Arch Chest Dis. 1994; 49:552-5.
18. Corrado A, Gorini M. Negative-pressure ventilation: is there still a role? Eur Respir J. 2002; 20(1):187-97.
19. Corrado A, Gorini M. Part 3: Negative pressure ventilation. In: Elliot M, Nava S, Schönfofer B, Hodder A, Hodder Education, Hachette UK Co, Editors. In: Non-invasive ventilation and weaning: principles and practice. London: Edward Arnold publishers; 2010. ISBN 9780340941322.
20. Corrado A, Gorini M. Negative-pressure ventilation. Chapter 16 In: Tobin MJ, editors. Principles and practice of mechanical ventilation 3rd edition. New York, NY: The McGraw Hill Companies; 2013. ISBN 978-6-17- 193118–8.
21. Raymandos K, Militoris U, Capewell M et al. Negative- versus positive-pressure ventilation in intubated patients with acute respiratory distress syndrome. Crit Care. 2012;16: R37. 1.
22. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet. 1967; 2:319–23
23. Mead J, Takishima T, Leith D. Stress distribution in lungs: a model of pulmonary elasticity. J Appl Physiol. 1970; 28:596–608.
24. Pingleton SK. Complications of acute respiratory failure. Am Rev Respir Dis. 1988; 137: 1463-93.
25. de Prost N, Ricard J-D, Saumon G, Dreyfuss D. Ventilator-induced lung injury: historical perspectives and clinical implications. Ann Intensive Care. 2011;1:28. doi:10.1186/2110-5820-1-28
26. Johnson TH, Altman AR. Pulmonary interstitial gas: first sign of barotrauma due to PEEP therapy. Crit Care Med. 1979; 7:532-5.
27. McGuinness G, Zhan C, Rosenberg N, et al. Increased Incidence of Barotrauma in Patients with COVID-19 on Invasive Mechanical Ventilation. Radiology. 2020;297: E252-62.
28. Gazivoda VP, Ibrahim M, Kangas-Dick A et al Outcomes of Barotrauma in Critically Ill COVID-19 Patients with Severe Pneumonia. J Intensive Care Med. 2021; 36:1176-83.
29. Lemmers HL, Abu Hilal M, Bona C et al. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty? ERJ Open Research. 2020 Nov.16; 6(4)
DOI: https://doi.org/10.1183/23120541.00385-2020
30. Howard D, Coulthard MG, Speight C, et al. Negative pressure ventilation for COVID-19 respiratory failure: a phoenix from the ashes? Arab Board Med J. 2022; 23:5-13.
31. van Egmond J, Booij LH. The role of pleural pressure in inducing pneumothorax and other adverse effects of positive pressure ventilation. J Thorac Dis. 2024 Nov.18;16(11):8103. doi: 10.2103 7/jtd-24-497
32. Pattupara A, Modi V, Goldberg J et al. Pulmonary barotrauma during non-invasive ventilation in patients with COVID-19. Chest 2020;158: A337. doi: 10.1016/j.chest.2020.08.334
33. Yam LYC, Chen RC, Zhong NS. SARS: ventilatory and intensive care. Respirology 2003; 8(s1): pS31-35. doi.org/10.1046/j.1440-1843.2003. 00521.x
34. Peiris JSM, Chu CM, Cheng VC et al. Clinical progression and viral load in a community outbreak of coronavirus associated SARS pneumonia: a prospective study. Lancet. 2003;316(9371):1767–72.
35. Liu XQ, Chen SB, He GQ. Management of critical severe acute respiratory syndrome. Chin J Tuberc Respir Dis. 2003; 26:329–33.
36. Karagiannidis C, Hentschker C, Westhoff M et al. Observational study of changes in utilization and outcomes in mechanical ventilation in COVID-19. PLoS One 2022;17: e0262315.
37. Lucchini A, Villa M, Fumagalli L et al. Patients' recollections of helmet-CPAP treatment during COVID-19 pandemic: A qualitative study. Nurs Crit Care. 2024;29(1):49-57 https://doi.org/10.1111/nicc.12951
38. Huang S, Kaipainen A, Strasser M, et al. Mechanical Ventilation Stimulates Expression of ACE2, the Receptor for SARS-Cov-2. Preprints.org; 2020. DOI: 10.20944/preprints202005.0429.v1.
39. Pelosi P, Rocco PR. The lung and the brain: a dangerous crosstalk. Crit Care. 2011;15(3):168
40. Kamuf J, Garcia-Bardon A, Ziebart A et al Lung injury does not aggravate mechanical ventilation-induced early cerebral inflammation or apoptosis in an animal model. PLoS One. 2018 9; 13(8): e020 2131
41. Hopkins RO, Weaver LK, Pope D, et al. Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999; 160: 50–6.
42. Bilotta F, Giordano G, Sergi P, et al. Harmful effects of mechanical ventilation on neurocognitive functions. Critical Care. 2019; 23:273 https://doi.org/10.1186/s13054-019-2546-y
43. Nouraei SA, Ma E, Patel A, et al. Estimating the population incidence of adult postintubation laryngotracheal stenosis. Clin Otolaryngol. 2007; 32(5):411-12
44. Li M, Yiu Y, Merrill T, et al. Risk Factors for Post-tracheostomy Tracheal Stenosis. Otolaryngol Head Neck Surg. 2018;159:698–704.
45. Hillel AT, Karatayli-Ozgursoy S, Samad I et al. Predictors of posterior glottic stenosis: A multi-institutional case-control study. Ann Otol Rhinol Laryngol. 2016; 125:257–63
46. Botta, M, Tsonas AM, Pillay J et al. Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): A national, multicentre, observational cohort study. Lancet Respir Med. 2021; 9:139–48.
47. Fiacchini G, Tricò D, Ribechini A et al. Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients with COVID-19. JAMA Otolaryngol Head Neck Surg. 2021; 147: 70–6
48. Hessami A, Shamshirian A, Heydari K, et al. Cardiovascular diseases burden in COVID-19: Systematic review and meta-analysis. Am J Emerg Med. 2021; 46:382-391 doi: 10.1016/j.ajem.2020.1 0.022. Epub 2020 Oct 16. PMID: 33268238; PMCID: PMC7561581.
49. Harrison SL, Buckley BJ, Rivera-Caravaca JM, et al. Cardiovascular risk factors, cardiovascular disease, and COVID-19: an umbrella review of systematic reviews. Eur Heart J Qual Care Clin Outcomes. 2021; 21;7(4):330-339 doi: 10.1093/ehj qcco/qcab029. PMID: 34107535; PMCID: PMC829 4691.
50. Martin D. Novel approaches to intensive care medicine. BMJ. 2020; 369:190-1.
51. Dorinski PM, Whitcomb ME. The effect of PEEP on cardiac output. Chest.1983;84:210-16.
52. Torelli L, Zoccali G, Casarin M, et al. Comparative evaluation of the haemodynamic effects of continuous negative external pressure (CNEP) and positive end-expiratory pressure (PEEP) in mechanically ventilated trauma patients. Intensive Care Med. 1995;21:67-70.
53. Borelli M, Benini A, Denkewitz T, et al. Effects of continuous negative extrathoracic pressure versus positive end-expiratory pressure in acute lung injury patients. Crit Care Med. 1998;26:1025-31.
54. Torjesen I. Covid-19: When to start invasive ventilation is ‘the million-dollar question’. BMJ. 2021; 372: n121. https//doi.org/10.1136/bmj. n121
55. Burkle CM, Zepeda FA, Bacon DR, et al. A historical perspective on use of the laryngoscope as a tool in anesthesiology. Anesthesiology.2004; 100(4):1003-6. doi: 10.1097/00000542-200404000-00034
56. The Exovent Development Group. Exovent: a study of a new negative pressure ventilatory support device in healthy adults. Anaesthesia. 2021; 76:623-8. doi.org/10.1111/anae.15350.
57. Diaper J, Bendjalid K, Neto Da Venda E, et al. Preliminary experience with continuous negative pressure ventilation (CNEP) in COVID-19 patients requiring respiratory support. Swiss Medical Weekly. 2021;151(SUPPL 254):7S.16:R37.
58. https://pod-point.com/guides/the-200-year-history-of-electricvehicles.podPOINT.August 2nd.2024.
59. https://group.mercedes-benz.com/company/tradition/company-history/1885-1886.2024.
60. Bhugra D. How to advocate for vulnerable groups? J R Soc Med. 2024;117:333–5.
https://doi.org/10.1177/01410768241274640