• Tommaso Mauri, Elena Spinelli, Bertrand Pavlovsky, Domenico Luca Grieco, Irene Ottaviani, Maria Cristina Basile, Francesca Dalla Corte, Gabriele Pintaudi, Eugenio Garofalo, Annalisa Rundo, Carlo Alberto Volta, Antonio Pesenti, and Savino Spadaro.
• Department of Anesthesia, Critical Care and Emergency, Institute for Treatment and Research, Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy; the Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
• Anesthesiology. 2021 Dec 1; 135 (6): 106610751066-1075.

BackgroundExperimental and pilot clinical data suggest that spontaneously breathing patients with sepsis and septic shock may present increased respiratory drive and effort, even in the absence of pulmonary infection. The study hypothesis was that respiratory drive and effort may be increased in septic patients and correlated with extrapulmonary determinant and that high-flow nasal cannula may modulate drive and effort.MethodsTwenty-five nonintubated patients with extrapulmonary sepsis or septic shock were enrolled. Each patient underwent three consecutive steps: low-flow oxygen at baseline, high-flow nasal cannula, and then low-flow oxygen again. Arterial blood gases, esophageal pressure, and electrical impedance tomography data were recorded toward the end of each step. Respiratory effort was measured as the negative swing of esophageal pressure (ΔPes); drive was quantified as the change in esophageal pressure during the first 500 ms from start of inspiration (P0.5). Dynamic lung compliance was calculated as the tidal volume measured by electrical impedance tomography, divided by ΔPes. The results are presented as medians [25th to 75th percentile].ResultsThirteen patients (52%) were in septic shock. The Sequential Organ Failure Assessment score was 5 [4 to 9]. During low-flow oxygen at baseline, respiratory drive and effort were elevated and significantly correlated with arterial lactate (r = 0.46, P = 0.034) and inversely with dynamic lung compliance (r = -0.735, P < 0.001). Noninvasive support by high-flow nasal cannula induced a significant decrease of respiratory drive (P0.5: 6.0 [4.4 to 9.0] vs. 4.3 [3.5 to 6.6] vs. 6.6 [4.9 to 10.7] cm H2O, P < 0.001) and effort (ΔPes: 8.0 [6.0 to 11.5] vs. 5.5 [4.5 to 8.0] vs. 7.5 [6.0 to 12.6] cm H2O, P < 0.001). Oxygenation and arterial carbon dioxide levels remained stable during all study phases.ConclusionsPatients with sepsis and septic shock of extrapulmonary origin present elevated respiratory drive and effort, which can be effectively reduced by high-flow nasal cannula.Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved.

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