11 th Annual Congress Turkish Thoracic Society. Mechanical Ventilation in Acute Hypoxemic Respiratory Failure

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1 11 th Annual Congress Turkish Thoracic Society Mechanical Ventilation in Acute Hypoxemic Respiratory Failure Lluis Blanch MD PhD Senior Critical Care Center Scientific Director Corporació Parc Taulí Universitat Autónoma de Barcelona Sabadell, Spain Belek-Antalya. April 23 27, 2008

2 Objectives Safety Efficacy Oxygenation Ventilation Work of Breathing Comfort / Synchrony Surveillance of Flow & Pressure

3 Basic Principles Maintain Comfort Prevent Distress/ Fatigue Workload Mis-Matching of Flow & Timing Avoid Iatrogenesis Overpressure Baro trauma & VILI Hemodynamic compromise Intracranial Pressure Minimize Intubation Time Offset Physiologic Disturbances Reduce VO2 Minimize Workload

4 Key Decisions Intubation? Breath Size and Timing Flow Control: Peak 4-7 x Minute Ventilation Requirement (depends on profile & disease) Consider APCV or Pressure Support To Maintain End-Expiratory Volume Gas Exchange Prevention of Baro- Bio Trauma Other To Offset Auto-PEEP

5 Am J Respir Crit Care Med 2005; 172:

6 Mean PaCO2 60 mmhg Mean PaCO2 (FiO mmhg) Mean PaCO2 (FiO2 > mmhg)

7 Targets during MV in Patients with ARDS VT 6 PEEP VT 6 VT 12 PEEP VT 12 ARDS Network N Eng J Med 2000; 342: VT 6 Amato MBP et al. N Eng J Med 1998; 338: ARDS Network N Eng J Med 2004; 351:327-36

8 Targets during Mechanical Ventilation Gas Exchange ARDS Network. N Eng J Med 2000; 342:

9 Increasing Respiratory Rate in ARDS Vieillard-Baron A et al. Crit Care Med 2002; 30:

10 Double Triggering During Assisted Mechanical Ventilation Thille AW, Brochard L Intensive Care Med 2007;33:744

11 Respir Care April 2007 Vol 52 No 4

12 Human ARDS Albaiceta GM, Blanch L, Lucangelo U. Current Opinion in Critical Care 2008;14:80-86

13 VT selection PEEP selection

14 Stroke & Acute Lung Injury RM VT PEEP

15 Assessment of Pulmonary Morphology in ALI Significance of Lower Inflection Point in the P-V V Curve Overdistension ZEEP LIP + 2 cmh 2 O LIP + 7 cmh 2 O Vieira et al. Am J Resp Crit Care Med 1999; 159:

16 Assessment of Pulmonary Morphology in ALI Absence of Lower Inflection Point in the P-V V Curve Overdistension ZEEP PEEP 10 cmh 2 O PEEP 15 cmh 2 O Vieira et al. Am J Resp Crit Care Med 1999; 159:

17 Lung Morphology & Distribution of Densities Lobar Diffuse Patchy Puybasset L et al. Intensive Care Med 2000; 26:

18 Inspiratory P-V Curves in ARDS patients with Different CT Patterns Patchy Lobar Diffuse Rouby et al. Intensive Care Med 2000;26:1046

19 2100 Pt # Pt # Volume (ml) Volume (ml) Pel (cm H2O) Pel (cm H2O) 2100 Pt # Pt # Volume (ml) Volume (ml) Pel (cm H2O) Pel (cm H2O) Maggiore S et al. AJRCCM 2001; 164:

20 PEEP Selection in ARDS PEEP P2 at PEEP 5 = 12 > PEEP 7 P2 at PEEP 12 = 28 Overdistension Albaiceta GM, Blanch L, Lucangelo U. Current Opinion in Critical Care 2008

21 PEEP Selection in ARDS PEEP P2 at PEEP 5 = 12 > PEEP 7 P2 at PEEP 12 = 17 Recruitment Albaiceta GM, Blanch L, Lucangelo U. Current Opinion in Critical Care 2008

22 The Effects of Changing VT in Patients with ARDS Roupie E et al. Am J Respir Crit Care Med 1995;152:121.

23 Time course of Airway Pressure During Constant-Flow Inflation Lucangelo U, Bernabè F, and Blanch L. Resp Care 2005; 50 : 55-65

24 ARDSNet: V T 6 ml/kg & Pplat t < 30 cm H 2 O Table PEEPlow/F i O 2 high PEEP (cm H 2 O) ARDSNet 13,2 ± 2,4 Stress index 6,8 ± 2,2 P < 0,01 F i O 2 0,3 0,4 0,5 0,5 0,6 0,7 0,7 0,7 0,8 0,9 0,9 1,0 PEEP Est rs (cm H 2 O/L) 34,7 ± 6,6 31,2 ± 7,4 < 0,01 Stress Index Strategy Est L (cm H 2 O/L) 28,6 ± 6,7 26,3 ± 7,1 < 0,01 Est cw (cm H 2 O/L) 5,9 ± 2,4 6,2 ± 2,4 NS P a O 2 /F i O ± ± 32 NS P a CO 2 (mm Hg) 46 ± 6 42 ± 6 < 0,01 Plasma Open & Close b< 1 Protective b = 1 Overdistension b > 1 ARDSNet Stress Index

25

26 Patients r=-0.85 p<0.01 Am J Respir Crit Care Med 2002; 165:

27 ARDS Inclusion PEEP Trial (2 h) Randomization RM no RM

28 AJRCCM 2000;161: Lavage Pneumonia Responses to PEEP & VT differ among models of ALI

29 PaO2 Vol. Rec. [Prot.] RM Responders Loss of Lung Aeration: Diffuse RM Non Responders Loss of Lung Aeration: Focal

30 TEE: transgastric LV end-diastolic short axis The Impact of 10 s & 20 s Lung RM on Hemodynamics

31 16 pigs, saline lung lavage Histology of Liver Tissue RM + High PEEP Low PEEP RM + High PEEP was associated with more prominent inflammatory reaction in the liver sinusoids and increased levels of hyaluronan levels and other serum markers of liver injury (LDH, AST, lactate). Elevated serum levels of HA may indicate impaired uptake by damage to the endothelium of the liver sinusoids or increased release because of degradation of matrix hyaluronan in the liver.

32 TIPS to ventilate ALI/ARDS patients Minimize alveolar overdistension during inspiration: Pplat < 30 cmh 2 O, VT low 5-7 ml/kg Minimize alveolar de-recruitment during expiration: moderate, high PEEP Decrease transpulmonary cycling pressure (difference between Pplat and PEEP) Adjuncts to mechanical ventilation: RM, HFOV,.? If yes, in expert hands & in selected patients

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