Tracking lung recruitment and regional tidal volume at the bedside. Antonio Pesenti
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1 Tracking lung recruitment and regional tidal volume at the bedside Antonio Pesenti
2 Conflicts of Interest Maquet: Received research support and consultation fees Drager: Received research support and consultation fees GE: Received research support and consultation fees Patents on CO2 removal by acidification (University of Milan Bicocca)
3 ELECTRICAL IMPEDANCE TOMOGRAPHY (EIT): WHAT DOES IT MEASURE?
4 WHAT IS EIT? 1. Low-amplitude alternate electric current applied to 2 electrodes, 14 electrodes monitor resulting current and calculate impedance I
5 WHAT IS EIT? 2. Alternate current application rotates around patient s chest and generates a map (tomography) of regioal impedance I
6 2. Alternate current application rotates around patient s chest and generates a map (tomography) of regioal impedance. WHAT IS EIT?
7 EIT - OUTPUT Alternating current rotation is very fast (up to 50 Hz) and enhables continuous monitoring of regional lung impedance changes. Changes in regional lung impedance should reflect regional distribution of tidal ventilation. Mauri, Pesenti et al. Unpublished data
8 EIT - OUTPUT Changes in end-expiratory regional lung impedance should mirror changes in end-exp lung volume (EEL). Mauri, Pesenti et al. Unpublished data
9 EIT Lung imaging technique, available at the bedside, non-invasive, no X-ray. EIT measures: 1. Regional distribution of tidal ventilation 2.Regional changes in end-expiratory lung volume Of one lung slice, cm thick.
10 EIT ROLE AT THE BEDSIDE OF ICU PATIENTS EIT limitations: - Spatial resolution - Single-slice imaging - Measure air content, not Ftis% EIT strenghts: - Bedside - No X-rays - Continuous EIT is no surrogate for CT scans. Our hp: EIT may help study lung mechanical properties and recrutiment when CT scan is not appropriate.
11 REGIONAL ENTILATION DURING SPONTANEOUS BREATHING 10 ALI/ARDS pts undergoing PS Semi-recumbent position EIT monitoring. 20 min phases, randomized: 1. PEEP low (7±2 cmh 2 O) vs. PEEP high (12±3 cmh 2 O) 2. PS low (3±2 cmh 2 O) vs. PS high (12±2 cmh 2 O) Mauri, Pesenti et al. Submitted
12 ALEOLI WITH ALTERED MECHANICAL PROPERTIES TIDAL ENTILATION HETEROGENEOUS DISTRIBUTION OF TIDAL ENTILATION HETEROGENEOUS DISTRIBUTION OF INSP PRESSURE AND OLUME MECHANICAL INTERDEPENDENCE ILI INCREASED REGIONAL STRESS AND STRAIN Mead et al. JAP 1970
13 PEEP AND REGIONAL ENTILATION Mauri, Pesenti et al. Submitted
14 DIAPHRAGM USE AND REGIONAL ENTILATION Mauri, Pesenti et al. Submitted
15 1 PEEP AND REGIONAL ENTILATION * * Non-dep vent, % Dep vent, % 30 * p < PEEP low PEEP high Higher PEEP was associated with increased ventilation of dependent regions. Mauri, Pesenti et al. Submitted
16 1 DIAPHRAGM USE AND REGIONAL ENTILATION * * Non-dep vent, % Dep vent, % 30 * p < PS high PS low Lower PS was associated with increased ventilation of dependent regions. Mauri, Pesenti et al. Submitted
17 PS study PEEP study PHYSIOLOGICAL ALIDATION During all study phases, the % of tidal ventilation reaching dependent lung regions was correlated with oxygenation (improved a/q matching?).
18 REGIONAL ENTILATION DURING SPONTANEOUS BREATHING 1. Higher PEEP and lower PS levels are associated with increased ventilation of dependent lung regions. 2. Underlying mechanisms may differ (alveolar recruitment vs. increased diaphragm activity) and this may, in part, explain differences in regional heterogeneity changes. 3. More homogenous distribution of tidal ventilation in ARDS may reduce risk of ILI. Mauri, Pesenti et al. Submitted
19 WHY DID WE STUDY SIGH? Sigh, alternative to PEEP: improves oxygenation with limited hemodynamic effect. Patroniti et al. Anesthesiology sigh/min, PS Foti et al. Intensive Care Med sigh/min, CM Pelosi et al. AJRCCM sigh/min, CM
20 WHY TO STUDY SIGH? One medical student during 30 min of quiet (?!??) breathing (i.e., studying to pass our residency program test). Approx 1 Sigh/3 min. Sigh is a normal way to prevent lung collapse in nature. Mauri, Pesenti et al. Unpublished data
21 ALTERNATIES TO PEEP FOR RECRUITMENT 11 acute respiratory failure pts (p/f 300 mmhg, PEEP 5 cmh 2 O) undergoing PS, semi-recumbent position, EIT monitoring 20 min phases, randomized (PEEP, PS and FiO 2 unchanged): 1. PS 2. PS SIGH (35 cmh 2 O x 3-4 sec)/min 3. PS + 1 SIGH/min 4. PS + 2 SIGH/min Mauri, Pesenti et al. Unpublished data
22 Me SIGH EFFECTS /min 0.5/min 1/min 2/min Sigh rate No effects on Me, RR, mean Paw, p0.1 and hemodynamics Mauri, Pesenti et al. Unpublished data
23 SIGH EFFECTS 120 P < PaO /min 0.5/min 1/min 2/min 20 0 Sigh rate Oxygenation increased with application of Sigh. Mauri, Pesenti et al. Unpublished data
24 EIT: SIGH MECHANISMS UNEILED Sigh promoted iso-peep increase in EEL (recruitment?) Mauri, Pesenti et al. Unpublished data
25 DEELI (DEEL) EIT: SIGH MECHANISMS UNEILED /min 0.5/min 1/min 2/min 0 Sigh rate At variance from PEEP: no effects on ventilation distribution and heterogeneity. Mauri, Pesenti et al. Unpublished data
26 SIGH Sigh improves oxygenation with minimal effects on mean Paw and hemodynamics. Sigh increases EEL, doesn t affect ventilation distribution Increase in EEL seems to be induced by alveolar recruitment
27 CASE 1: POST-OP RESPIRATORY FAILURE
28 CASE 1 75 yo, BMI 33, PMH: hypertension Major abdominal surgery. Post-op resp failure Helmet CPAP, PEEP 5 cmh 2 O e FiO 2 50%
29 EIT PEEP 5 PEEP 10 NATURAL SIGH
30 CASE 3: COPD EXACERBATION
31 UNIFORM PEEPi Ppeak increases after PEEPext > PEEPi
32 EELIgl PEEPi 58 yo, COPD pt Intubated, on CM t 10 ml/kg, RR 10/min PEEPi = 7 cmh 2 O from ZEEPext PEEPe 15 cmh 2 O PEEPe 6 cmh 2 O ZEEPe Time
33 RM SEERE ARDS EEL PEEP Pplat SatO etco
34 CONCLUSIONS EIT role at the bedside of ICU pts: Study of lung mechanical properties and recrutiment when CT scan is not feasible. Enhances understanding of underlying pathophysiology therapy titration Future perspectives: EIT to monitor non-intubated, spontaneously breathing, severe acute respiratory failure pts.
35
36 CLINICAL CASE 1: DIFFICULT WEANING
37 CASE 1: DIFFICULT WEANING Female, 69 yo. PMH: arterial hypertension, smoke. Cardiac arrest. AP, ARDS, lung fibrosis 33 days on M, PS +10
38 EIT - PS
39 ariable PS Compared to conventional PS, variability in pressure support improved the elastance of the respiratory system, peak airway pressure, oxygenation, and intrapulmonary shunt. Spieth PM et al. Anesthesiology 2009
40 EIT ariable PS
41 EIT ariable PS PS ariable PS
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