Ventilation update Anaesthesia departmental PGME. Tuesday 10 th December Dr Alastair Glossop Consultant Anaesthesia and Critical Care

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1 Ventilation update Anaesthesia departmental PGME Tuesday 10 th December Dr Alastair Glossop Consultant Anaesthesia and Critical Care

2 What s fashionable in ICU ventilation? Acute respiratory distress syndrome (ARDS) Lung protection Rescue therapies ECMO Oscillation Prone ventilation Ventilator associated pneumonia (VAP)

3 Acute respiratory distress syndrome Defined by AECC in 1994 (ALI and ARDS) Undergone recent rebranding? reducing incidence Ventilator care bundles Lung protective ventilation Restrictive transfusion Significant associated morbidity and mortality Area of great interest in ICM

5 Put simply P/F ratio Mortality Ventilation strategies (mmhg and kpa) (% with 95% CI) Mild < 300 (40) 27% (24 30) Consideration of NIV Moderate <200 (27) 32% (29 34) Lung protective strategies Severe < 100 (13) 45% (42 48) Rescue therapies

6 Management of ARDS Despite rebranding ARDS is still bad news Mild category May respond to early intervention with NIV Response confers better prognosis Sharper focus on Protecting lungs at risk or already damaged Rescue therapies

7 31% mortality in low TV group vs 39.8 % in controls (p = 0.007)

8 ARDSnet principles Low tidal volumes (6mls / kg) Plateau pressures < 30cmH 2 0 High PEEP Higher RR Permissive hypercapnea Permissive hypoxia Some criticisms of trial since Principles are regarded as best practice in ARDS

9 Refractory hypoxaemia Severe ARDS with refractory hypoxaemia: Strict adherence to ARDSnet principles NMBD (Cisatracurium used early may reduce time spent on IMV) Haemodynamic optimisation (aggressive diuresis) Consideration of steroids (caution in flu) Consideration of rescue therapy ECMO Oscillation Prone ventilation

: ventilation We aimed (ECMO) randomly treatment potentially essure) or to limited or severe tention to t resource ing events time costatment by ed ECMO; t disability 05 0 97, life-years (95% CI

10 : ventilation We aimed (ECMO) randomly treatment potentially essure) or to limited or severe tention to t resource ing events time costatment by ed ECMO; t disability , life-years (95% CI Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial Giles JPeek, Miranda Mugford, Ravindranath Tiruvoipati, Andrew Wilson, Elizabeth Allen, Mariamma M Thalanany, Clare L Hibbert, Ann Truesdale, Felicity Clemens, Nicola Cooper, Richard K Firmin, Diana Elbourne, for the CESAR trial collaboration Lancet 2009; 374: Summary Published Online September 16, 2009 DOI: /S (09) Background Severe acute respiratory failure in adults causes high mortality despite improvements in ventilation techniques and other treatments (eg, steroids, prone positioning, bronchoscopy, and inhaled nitric oxide). We aimed to delineate the safety, clinical efficacy, and cost-effectiveness of extracorporeal membrane oxygenation (ECMO) compared with conventional ventilation support. See Comment page 1307 Lancet 2009; 374: Published Online September 16, 2009 DOI: /S (09) See Department of Error See Comment page 1307 page Methods 1330 In this UK-based multicentre trial, we used an independent central randomisation service to randomly See Department of Error Department assign 180 adults of Cardiothoracic ECMO in a 1:1 ratio came to receive continued to conventional great management prominance or referral to consideration for treatment during H1N1 pandemic Surgery by ECMO. (G JPeek Eligible MD, patients were aged years and had severe (Murray score >3 0 or ph <7 20) but potentially page 1330 R K Firmin MBBS) and Department of Cardiothoracic reversible respiratory failure. Exclusion criteria were: high pressure (>30 cm H₂O of peak inspiratory pressure) or Department of Extracorporeal Surgery (G JPeek MD, Membrane high FiO₂ (>0 Oxygenation 8) ventilation for more than 7 days; intracranial bleeding; any other contraindication to limited R K Firmin MBBS) and (G heparinisation; JPeek, R Tiruvoipati or any contraindication FRCSEd, to continuation of active treatment. The primary outcome was death or severe Department of Extracorporeal R disability K Firmin), at Glenfield 6 months Hospital, CESAR study results much Membrane Oxygenation lauded after randomisation or before discharge from hospital. Primary analysis was by intention to Leicester, UK; School of (G JPeek, R Tiruvoipati FRCSEd, treat. Only researchers who did the 6-month follow-up were masked to treatment assignment. Data about resource Medicine, Health use and economic 16% Policy and outcomes increase (quality-adjusted life-years) were in collected. survival Studies of the key cost generating without events severe disability in R K Firmin), Glenfield Hospital, Leicester, UK; School of Practice, University of East were undertaken, and we did analyses of cost-utility at 6 months after randomisation and modelled lifetime costutility. M This Mugford study is DPhil, registered, number ISRCTN ECMO arm Medicine, Health Policy and Anglia, Norwich, UK Practice, University of East (Prof Anglia, Norwich, UK M M Thalanany MSc); (Prof M Mugford DPhil, Department of Health Sciences, Findings 766 patients were screened; 180 were enrolled and randomly allocated to consideration for treatment by M M Thalanany MSc); University of Leicester, ECMO (n=90 patients) or to receive conventional management (n=90). 68 (75%) patients actually received ECMO; Department of Health Sciences, Leicester, UK (Prof A Wilson MD, University of Leicester, N 63% Cooper (57/ 90) PhD); of patients Medical allocated to consideration for treatment by ECMO survived to 6 months without disability Leicester, UK (Prof A Wilson MD, Statistics compared Unit, with 47% London (41/ 87) School of those allocated to conventional management (relative risk 0 69; 95% CI , N Cooper PhD); Medical of Hygiene and Tropical p=0 03). Referral to consideration for treatment by ECMO treatment led to a gain of 0 03 quality-adjusted life-years Statistics Unit, London School Medicine, London, UK

11 However 24% of ECMO group didn t receive ECMO 5.5% died during transfer Mortality alone no significant difference between the two groups ECMO increases cost and hospital LOS Compliance with ARDSnet principles 84% in ECMO group, 60% in controls Reflects practice of a single centre of excellence

12 Oscillation (HFOV) HFOV being used increasingly Anecdotally loved by those experienced in its use Theoretical benefits plausible Not supported by a large body of quality RCTs but some evidence to support its use

14 UK study of patients with P/F ratio < day mortality of 41% in both groups

16 Trial stopped early due to an excess mortality of 12% in HFOV group (p = 0.005) Control arm mortality of 35% (compared to 41% in UK trial)

17 Prone ventilation Rescue therapy that is scientifically plausible Cheap, doesn t involve transferring patients or expensive equipment Some drawbacks: Tube displacement Pressure sores / injuries ballache Early evidence suggested improves oxygen but no mortality benefit

18 Multicentre study of 466 patients with P/F ratio < day mortality as primary outcome measure

19 28 mortality 16% in prone group vs 32% in controls (p< 0.001) 16 hour sessions spent prone (on average 4 per patient) strict 6mls per kg (volume controlled ventilation)

20 Ventilator associated pneumonia Most common nosocomial infection in ICU patients Increased mortality, ITU LOS, cost implications No gold standard diagnostic criteria Development of new pulmonary infection in patients receiving IMV Duration > 48 hours ETT or tracheostomy in situ Requires treatment with antibiotics Potentially avoidable with adherence to bundles

22 STH VAP rates

23 Tapergaurd tubes Constant cuff pressure Subglottic irrigation port Reduced aspiration and biofilm generation All ICU patients Also available in emergency theatres and ED

24 Meta analysis of 13 RCTs and 2442 patients Subglottic drainage demonstrated to: Reduce rates of VAP Increase time to VAP in intubated patients Reduce length of IMV and ICU length of stay No mortality benefit

25 In summary ARDSnet principles still strong Lower TVs and high PEEP P/F ratios give us a better idea of when to really start worrying Prone if P/F < 100 ECMO if that fails Doing simple things well makes a big difference 6mls/kg

26 Questions? For sale: Novalung oscillator 1 careful owner Used twice Reduced in price for quick sale

Management of Respiratory Failure: The Surgical Perspective. When Traditional Respiratory Support Techniques fail. ARDS: Evidence Based Practice

Critical Care Medicine and Trauma Management of Respiratory Failure: The Surgical Perspective Jasleen Kukreja, M.D. Division of Cardiothoracic Surgery University of California San Francisco When Traditional