Application of Lung Protective Ventilation MUST Begin Immediately After Intubation

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1 Conflict of Interest Disclosure Robert M Kacmarek Managing Severe Hypoxemia!" FOCUS Bob Kacmarek PhD, RRT Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts I disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am presenting: Company Relationship Content Area Covidien Consultant Mech Vent Maquet Honorarium/Lecturing Mech Vent Ventilator Management in Acute Hypoxemic Respiratory Failure!" Application of Lung Protective Ventilation MUST Begin Immediately After Intubation ARDSnet NEJM 2000;342:1301 A V T of 6 (4 to 8) ml/kg PBW results in a lower mortality than a V T of 12 ml/kg PBW Mortality 31% vs. 39.8% p = Plateau Pressure and V T Small tidal volumes are used to avoid over distension Over distension is best evaluated by Transpulmonary pressure TPP = Pao Ppl The plateau pressure is the best bedside non-invasive reflection of the transpulmonary pressure! The critical variable to monitor to avoid VILI is the plateau pressure not the tidal volume 1

2 Plateau Pressure more Important than V T P PLAT < 28 cmh 2 O, mortality reduced regardless of V T Lower the P PLAT, better the outcome Plat > 28 cmh 2 O, V T 4 to 5 ml/kg PBW Plat 25 to 28 V T 6 ml/kg PBW P PLAT < 25 cmh 2 O maintain V T 6 to 8 ml/kg PBW or higher if patients has a strong ventilatory demand! Better to allow a little larger V T then to heavily sedate and force a very low V T and potentially prolonging mechanical ventilation! In Severe Acute Hypoxemic Respiratory Failure Tidal Volumes MUST be Maintained between 4 to 6 m/kg PBW or lower to insure Plateau Pressures do not exceed 28 to 30 cm H 2 O Permissive Hypercapnia is generally the rule Acceptable ph > 7.15 ARDSnet NEJM 2000;342:1301 Increasing Plateau Pressure Decreased chest wall compliance Esophageal pressure Bladder pressure Marked obesity Massive fluid resuscitation A decrease in chest wall compliance decreases TPP Plateau pressure acceptable up to 35 cm H 2 O or higher Controlled Ventilation 22 cmh 2 O = 25 cmh 2 O (3 cmh 2 O) Controlled Ventilation Stiff Chest Wall TTP = Pplat - Ppl 13 cmh 2 O = 25 cmh 2 O (12 cmh 2 O) Younes ARRD 1992;145:114 2

3 Assisted Volume Ventilation: Assisted Volume Ventilation: 28 cmh 2 O = 25 cmh 2 O (-3 cmh 2 O) 28 cmh 2 O = 15 cmh 2 O (-13 cmh 2 O) Assisted Pressure Ventilation: Assisted Pressure Ventilation: 28 cmh 2 O = 25 cmh 2 O (-3 cmh 2 O) 38 cmh 2 O = 25 cmh 2 O (-13 cmh 2 O) Improving Oxygenation in the Mechanically Ventilated Patient Hemodynamic stability Patient-ventilator synchrony Bronchial hygiene Paralysis/Sedation Increase F I O 2 Recruitment and optimal PEEP Prone Positioning High Frequency Oscillation Inhaled pulmonary vasodilators ECMO Papazian Ab ICM 2009;35:S6 RCT neuromuscular blockade (cisatracurium) first 48 hrs of MV vs. placebo in severe acute HRF All patients P/F < 150 mmhg 177 cisatracurium vs. 166 placebo 28 day mortality 23.7% vs. 33.3%, p = 0.05 Pneumothorax rate 11.7% vs. 5.1%, p=0.03 Organ failure free days 3.6, p =0.002 Greater number ventilator free days 3

4 Control ALVEOLI: PaO 2 = mmhg or SpO 2 = 88-95% PEEP FiO Higher PEEP PEEP FiO Setting PEEP PEEP/F I O 2 algorithm either stated or unstated Increasing PEEP trial Oxygenation Lung Mechanics Cardiovascular Stability Pressure Volume Curve (P flex ) Decelerating PEEP Trial Borges, Amato, Kacmarek et al AJRCCM 2006 Suarez-Sipmann CCM 2007;35:214 Performance of RM - PCV Pressure control ventilation, F I O 2 1.0: PEEP cmh 2 O Peak Inspir Press cmh 2 O Inspir Time: 1 to 2 sec Rate: 15 to 25/min Time 1 to 3 min Initial RM PEEP 25 cmh 2 O, PIP 40 cmh 2 O Set PEEP at 25, ventilate VC, V T 4 to 6 ml/kg PBW, increase rate, avoid auto-peep Measure dynamic compliance Decrease PEEP 2 cm H 2 O 4

5 Performance of RM - PCV Measure dynamic compliance Repeat until max compliance determined Optimal PEEP max comp PEEP+2 cm H 2 O Repeat recruitment maneuver and set PEEP at the identified settings, adjust ventilation After PEEP and ventilation set and stabilized, decrease F I O 2 until PO 2 in target range If response is poor, repeat RM, PEEP 30, Peak Pressure 45 If response is poor, repeat RM, PEEP 35, Peak Pressure 50 Amato et al NEJM 1998;338:347 AMATO NEJM Trial Kacmarek et al CCM 2016(1);44:32 Kacmarek Villar et al CCM 2016;44(1):32 Open lung approach (OLA) vs. ARDSnet PIP, Pplat and driving pressure all higher in ARDSnet PEEP approximately 5 cmh 2 O higher in OLA FIO 2 lower, PaO 2 higher, P/F higher, V T lower, RR higher, PCO 2 higher (day 1) in OLA No difference pneumothorax, cardiac arrest, hypotension, desaturation, arrhythmias Leme JAMA Published online Post op Cardiac Surgical patients, LPV ALL RM, P-V curve (5-30 cmh 2 O) admit, 4hr Intensive RM PCV 45/30 60 sec x 3, PEEP 13 Moderate RM CPAP sec x 3, PEEP 8 Leme JAMA Published online

6 Girardis JAMA on line All patients admitted to Med/Sur ICU expected to be intubated > 72 hours Conser O 2 PO 2 70 to 100 (87), SpO 2 94 to 98% Standard O 2 up to 150 (103), SpO 2 97 to 100% Other Approaches Prone Positioning Inhaled Pulmonary Vasodilators High Frequency Oscillation ECMO Mure CCM 1997;25:1539 Stoker Chest 1997;111:1008 RCT s Prone Positioning Gattinoni NEJM 2001; 345:568 Guerin JAMA 2004;292:2379 Curley JAMA 2005;294:248 Mancebo AJRCCM 2006;173:1233* Fernandez ICM 2008 Online* Taccone JAMA;2009;302:1977* All RCT s Negative!!! Sud ICM 2010;36:585 6

7 Guerin NEJM 2013;May 20 th, 2013 Chatte AJRCCM 1997;155: periods of prone positioning 2 apical atelectasis 1 IV catheter loss 1 IV catheter compression 1 extubation 1 transient supraventricular tachycardia Froese CMM 1997;25:906 Cools Lancet 2010;375:2082 Young NEJM 2013;368(9):806 OSCAR Trial Sud BMJ 2010;340:2327 7

8 Ferguson NEJM 2013;368(9):795 OSCILLATE Trial HFO in ARDS Do not recommend the use of HFO for the management of Pediatric or Adult patients with ARDS! RCT s i in ARDS: No improvement in Outcome with i! Dellinger et al CCM 1998;26:15-23 Michael et al AJRCCM 1998;157: Troncy et al AJRCCM 1998;157: Lundin et al ICM 1999;25; Phase III Trial Unpublished Data 2000 Q (Decreased blood flow) Selective Pulmonary Vascular Dilation by Inhaled Q Shunting and V/Q mismatch PaO 2 ECMO Peek Lancet 2009;374:135 CESAR Trial Positive trial but big concerns with protocol Australian, New Zealand ECMO JAMA 2009;302:1888, H1N1 Experience MV H1N1 patients 194 of these 61 required ECMO Kumar JAMA 2009;302:1872, Canadian H1N1 Experience MV H1N1 patients 136 of these 6 required ECMO MGH experience 2009 MV H1N1 patients 22 of these 4 required ECMO, however 20 of the 22 were transferred from other institution to receive ECMO Ventilator Management in Severe Acute Hypoxemic Respiratory Failure!" Hemodynamic stability Patient-ventilator synchrony Bronchial hygiene Paralysis/Sedation Increase F I O 2 Recruit Lung PEEP 25 to 35, Pressure control 15 cm H 2 O Identify optimal PEEP by decremental PEEP trial, Best Compliance PEEP plus 2, generally 15 to 25 cmh 2 O Select V T that maintains Pplat < 28 cmh 2 O, generally 4 to 6 ml/kg PBW RR, maximum rate avoiding autopeep < 40/min 8

9 Ventilator Management in Severe Acute Hypoxemic Respiratory Failure!" Expect permissive hypercapnia Lowest F I O 2 maintaining PO 2, accept permissive hypoxemia, > 55 mmhg Consider paralysis 1 st 48 hours Consider prone positioning Consider inhaled pulmonary vasodilators Consider ECMO HFO Not recommended Thank You 9