Difficult Ventilation in ARDS Patients
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1 Thank you for viewing this presentation. We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author by the author
2 ERS International Congress 2016 London, UK Monday, September 5, 07:00 08:15 Difficult Ventilation in ARDS Patients CC3 Problematic application of mechanical ventilation MJ Schultz for the PROVE Network (
3 Disclosures I have no real or perceived conflicts of interest that relate to this presentation MJ Schultz for the PROVE Network (
4 Aims of the Presentation understand the diagnosis of ARDS understand the concepts of VILI understand lung protective ventilation understand rescue ventilation strategies MJ Schultz for the PROVE Network (
5 60 year old male, 2 days of sore throat, coughing and productive sputum admission through ER: respiratory insufficient
6 Blood gas analysis: PaO 2 6 kpa, PaCO 2 2 kpa, ph 7.2 CXR: massive bilateral infiltrates
7 sputum: Gram+ cocci PCR: H1N1 +
8 diagnosis? next steps?
9 Agenda ventilation induced lung injury ARDS tidal volume and pressure reduction rescue therapies MJ Schultz for the PROVE Network (
10 [ADJUSTED FROM] Serpa Neto A. Swiss Medical Weekly 2015; 45:w14211
11 Barotrauma
12 Volutrauma Webb & Tierney. Am. Rev. Respir. Dis. 1974;110:556
13 Atelectotrauma
14 Slutsky A. NEJM 2013; 369:2126 Biotrauma
15 Agenda ventilation induced lung injury ARDS tidal volume and pressure reduction rescue therapies MJ Schultz for the PROVE Network (
16 Who is Afraid of Red, Yellow and Blue? Barnet Newman, 1966, Museum for Contemporary Art, Amsterdam, the Netherlands
17 LungSafe Practice of Ventilation in ICUs Worldwide international observational study 2,396 patients with mild, moderate or severe ARDS Bellani G. JAMA 2016; 315:788 V T (ml/kg PBW) V T (ml/kg PBW) assist assisted RR (/minute) total set PEEP (cm H 2 O) Mild (N = 722) Moderate (N = 1110) Severe (N = 564) 7.8 ± ± ± ± ± ± 6 17 ± ± ± ± 6 18 ± ± ± ± ± 14 7 [5 10] 8 [5 10] 10 [8 12] FiO 2 (%) 40 [40 50] 60 [50 70] 100 [80 100]
18 Was ARDS Correctly Recognized and Identified in LUNGSAFE? prevalence of 23% clinical recognition of ARDS ranged from 51% (mild) to 79% (severe) Bellani G. JAMA 2016; 315:
19 PRoVENT Practice of Ventilation in ICUs Worldwide international observational study 1,022 patients, 937 without ARDS Serpa Neto A. The PRoVENT study [SUBMITTED]
20 119 centers 1,022 patients PRoVENT Practice of Ventilation in ICUs Worldwide 85 patients with ARDS (8,3%) Serpa Neto A. The PRoVENT study [SUBMITTED] 30%
21 The Berlin Definition Timing Chest Imagine a Acute Respiratory Distress Syndrome Within 1 week of a known clinical insult or new/worsening respiratory symptoms Bilateral opacities not fully explained by effusions, lobar/lung collapse, or nodules Origin of Edema Respiratory failure not fully explained by cardiac failure or fluid overload; Need objective assessment (e.g., echocardiography) to exclude hydrostatic edema if no risk factor present Mild Moderate Severe Oxygenation b with with with 200<PaO 2 /FiO 2 < <PaO 2 /FiO 2 <200 PaO 2 /FiO2<100 PEEP 5 cmh 2 O c,d PEEP 5 cmh 2 O PEEP 5 cmh 2 O a chest X-ray or CT Scan b if altitude higher than 1000m correction factor should be made as follows: PaO 2 /FiO 2 x (barometric pressure/760) c or CPAP d this may be delivered non-invasively in the mild ARDS group, e.g., CPAP Ferguson N. ICM 2012; 38:1573
22 4,188 Patients with ARDS from 4 Multicenter Clinical Data Sets ARDS Definition Task Force. JAMA 2013; 307:2526 AUROC of 0.58 [ ]
23 AECC and Berlin are Neither Sensitive nor Specific 356 patients had criteria for ARDS at time of death Berlin sensitivity and specificity 63 and 89% Thille A. AJRCCM 2013; 187:761 Proportion of Patients No Lesion Other Diagnostic Pneumonia DAD Mild (N = 49) No Lesion Other Diagnostic Pneumonia DAD Moderate (N = 141) No Lesion Other Diagnostic Pneumonia DAD Severe (N = 166)
24 AECC and Berlin are Neither Sensitive nor Specific 356 patients had criteria for ARDS at time of death DAD more frequently found after 72 hours Thille A. AJRCCM 2013; 187:761 Proportion of Patients with DAD < 72 hours > 72 hours P = 0.38 Mild (N = 49) P < 0.01 Moderate (N = 141) P < 0.01 Severe (N = 166)
25 No Independently Association between Severity (Berlin) and Mortality 6 month French study 278/3,504 ARDS Cox proportional hazard regression analysis Hernu R. ICM 2013; 39:2161
26 Early Response to Conventional Care, Including PEEP, Predicts Outcome retrospective analysis of a RCT (PGE 1 ) 74 patients with ARDS receiving placebo Bone R. CHEST 1989; 96:849
27 Mortality in P/F groups at 0 and 24 Hours after Diagnosis prospective study in 586 patients in 38 ICUs age, opportunistic pneumonia, MOD, P/F at 24 hours Artigas A. ICM 1998; 24:1018
28 Clinical Classification after 24 Hours Improves Prognostication Villars J. CCM 2015; 43:346
29 Clinical Classification after 24 Hours Improves Prognostication Bos L. ICM 2015; 41:2004
30 P/F under Standardized Ventilator Settings Improves Prognostication Villars J. BMJ Open 2015; 5:e006812
31 Conclusion (I) ARDS is a challenging diagnosis AECC and Berlin definitions are not helpful consider the effect of standard therapy and re look after 24 hours MJ Schultz for the PROVE Network (
32 Agenda ventilation induced lung injury ARDS tidal volume and pressure reduction rescue therapies MJ Schultz for the PROVE Network (
33 What is the origin of the tidal volume size discussion?
34 High tidal volumes were advised to be used during intraoperative ventilation to recruit those lung parts that collapse at end of expiration, as such preventing the need for higher levels of FiO 2 and PEEP Bendixen H. NEJM 1963; 269: 991
35 Use of Lower Tidal Volumes Benefits Patients with ARDS RCT, Brazil 53 ARDS patients 6 ml/kg plus PEEP > LIP vs. conservative settings Amato M. NEJM 1998; 338;347
36 Use of Lower Tidal Volumes Benefits Patients with ARDS RCT, USA, 821 ARDS patients 6 vs. 12 ml/kg stopped early ARDS Network. NEJM 2000; 342:1301
37 LungSafe Practice of Ventilation in ICUs Worldwide international observational study 2,396 patients with mild, moderate or severe ARDS Bellani G. JAMA 2016; 315:788 V T (ml/kg PBW) V T (ml/kg PBW) assist assisted RR (/minute) total set PEEP (cm H 2 O) Mild (N = 722) Moderate (N = 1110) Severe (N = 564) 7.8 ± ± ± ± ± ± 6 17 ± ± ± ± 6 18 ± ± ± ± ± 14 7 [5 10] 8 [5 10] 10 [8 12] FiO 2 (%) 40 [40 50] 60 [50 70] 100 [80 100]
38 Use of Lower Tidal Volumes Benefits Patients without ARDS 2,184 ICU patients without ARDS from 7 studies outcome: duration of ventilation Serpa Neto A. ICM 2014; 40:950 [METANALYSIS]
39 Use of Lower Tidal Volumes Benefits Patients without ARDS 2,184 ICU patients without ARDS from 7 studies outcome: hospital stay and ARDS development Serpa Neto A. CCM 2015; 43:4155 [METANALYSIS]
40 PRoVENT Practice of Ventilation in ICUs Worldwide international observational study 1,022 patients, 937 without ARDS Serpa Neto A. The PRoVENT study [SUBMITTED]
41 4 New Trials of Low Tidal Volume Ventilation in Patients without ARDS PReVENT, Netherlands EPALI, Spain ISIC IMIC, SE Asia a new ARDS Network trial (PETHAL) MJ Schultz for the PROVE Network (
42 What is the origin of the PEEP level discussion?
43 Preclinical studies and clinical investigations showed that a strategy using high levels of PEEP improved lung aeration, and usually also oxygenation
44 Use of Higher PEEP Benefits Patient with Moderate or Severe ARDS 2,299 ICU patients with ARDS from 3 investigations outcome: death Briel M. JAMA 2010; 303:865 [METANALYSIS]
45 Trade off Between Alveolar Recruitment and Overdistension Bellardine Black CL et al. Crit Care Med 2007, 35:870-8 Black C. CCM 2007; 35:870
46 High PEEP Prevents Alveolar Collapse but Increases Hyperinflation 48 healthy rats intratracheal challenge with E. coli LPS 1 hour of ventilation after 24 hours Samary C. Anesthesiology 2015; 123:423
47 LungSafe Practice of Ventilation in ICUs Worldwide international observational study 2,396 patients with mild, moderate or severe ARDS Bellani G. JAMA 2016; 315:788 V T (ml/kg PBW) V T (ml/kg PBW) assist assisted RR (/minute) total set PEEP (cm H 2 O) Mild (N = 722) Moderate (N = 1110) Severe (N = 564) 7.8 ± ± ± ± ± ± 6 17 ± ± ± ± 6 18 ± ± ± ± ± 14 7 [5 10] 8 [5 10] 10 [8 12] FiO 2 (%) 40 [40 50] 60 [50 70] 100 [80 100]
48 Use of Higher PEEP Does not Benefit Patient without ARDS metaanalysis of 21 RCTs in patients without ARDS primary outcome death Serpa Neto A. in preparation
49 Agenda ventilation induced lung injury ARDS tidal volume and pressure reduction 2.0 rescue therapies MJ Schultz for the PROVE Network (
50 Energy transfer?
51 Lungs Conserve Energy during each Respiratory Cycle ( Lung Hysteresis ) 10 13% of energy is transferred energy transfer is proportional to (ΔP) 2 x Crs [COURTISY FROM] Serpa Neto A
52 High PEEP Prevents Alveolar Collapse but Increases Hyperinflation* 48 healthy rats, intratracheal challenge with E. coli LPS 1 hour of ventilation after 24 hours Samary C. Anesthesiology 2015; 123:423
53 Low PEEP and low ΔP Prevents Pulmonary Inflammation* 48 healthy rats, intratracheal challenge with E. coli LPS 1 hour of ventilation after 24 hours Samary C. Anesthesiology 2015; 123:423
54 Independent Association between Driving Pressure and Mortality Brazilian RCT in 53 ARDS patients 6 ml/kg plus PEEP > LIP plus Pdelta < 20 cm H 2 O) vs. conservative settings Amato M. NEJM 1998; 338;347
55 Factors with an Independent Association with Mortality observational study, Argentina 235 ARDS patients P/F, SOFA, ph, BE and Pdelta Estensorro E. Crit Care Med 2002; 30:2450
56 Driving Pressure and Survival in Patients with ARDS 3,562 patients from 9 investigations driving P as independent variable, mediation analysis Amato M. NEJM 2015; 372:747 [METANALYSIS]
57 Driving Pressure and Survival in Patients with ARDS 3,562 patients from 9 investigations driving P as independent variable, mediation analysis Amato M. NEJM 2015; 372:747 [METANALYSIS]
58 Decrease in ΔP after ECMO Start is Associated with a Better Outcome 545 patients from 12 investigations, 1,653 ECMO days median settings in the first 3 days of ECMO A Serpa Neto for the PROVE Network (
59 ΔP and FiO 2 are Associated with Death in ECMO Patients OR [95% CI], p HR [95% CI], p Age, years 1.04 [ ], [ ], BMI, kg/m [ ], [ ], Interval MV ECMO, hours 1.00 [ ], [ ], Ventilator parameters 1 ΔP, cm H 2 O Laboratory Parameters Lactate A Serpa Neto for the PROVE Network ( [ ], [ ], < [ ], [ ], Multivariate logistic regression and Cox proportional hazard model BMI: body mass index; OR: odds ratio; HR: hazard ratio; CI: confidence interval; FiO 2 : inspired fraction of oxygen 1, median value of the first three days after ECMO
60 LungSafe Practice of Ventilation in ICUs Worldwide* international observational study 2,396 patients with mild, moderate or severe ARDS Bellani G. JAMA 2016; 315:788
61 Intraoperative Driving Pressure and PPC in Surgery Patients 2,171 patients from 15 RCTs driving P as independent variable, mediation analysis Serpa Neto A. Lancet Respir Med 2016; 4:272 [METANALYSIS]
62 Ventilation During General Anesthesia for Surgery Ventilation in Intensive Care Unit patients with Uninjured Lungs Ventilation in Intensive Care Unit patients with (ARDS) mild ARDS moderate and severe ARDS Protective ventilation includes: Protective ventilation includes: Protective ventilation includes: Protective ventilation includes: Tidal volume size < 8 ml/kg predicted body weight evidence comes from 3 RCTs and 1 metaanalysis Tidal volume size 6 ml/kg predicted body weight evidence comes from 1 RCT, 1 metaanalysis and 2 IPD meta analyses Tidal volume size 6 8 ml/kg predicted body weight evidence comes from 2 RCTs and 1 metaanalysis Tidal volume size 6 8 ml/kg predicted body weight evidence comes from 2 RCTs and 1 metaanalysis Level of PEEP 2 cm H 2 O evidence comes from 1 RCT and 1 IPD metaanalysis Level of PEEP?? Convincing RCT evidence is lacking Level of PEEP 5 10 cm H 2 O evidence comes from 1 IPD metaanalysis of 3 RCTs Level of PEEP 10 cm H 2 O evidence comes from 1 IPD metaanalysis of 3 RCTs Low driving pressure suggestion comes from several studies and 1 IPD metaanalysis of 15 RCTs Driving pressure?? studies are lacking Low driving pressure suggestion comes from several observational studies and 1 IPD metaanalysis of 9 studies Low driving pressure suggestion comes from several observational studies and 1 IPD metaanalysis of 9 studies
63 Conclusion (II) the goal is prevention of additional lung injury through low tidal volumes, the lowest possible level of PEEP, and the lowest driving pressure (energy) MJ Schultz for the PROVE Network (
64 Agenda ventilation induced lung injury ARDS tidal volume and pressure reduction 2.0 rescue therapies MJ Schultz for the PROVE Network (
65 How are lungs recruited?
66 Ways to Recruit sustained inflation PEEP, I:E, recruitment maneuvers proning (assisted ventilation) MJ Schultz for the PROVE Network (
67 Sustained Inflation maybe adjust (i.e., raise) PEEP careful in hemodynamic instable patients MJ Schultz for the PROVE Network (
68 PEEP, I:E in steps of 5 cm H 2 O, up to 15 cm H 2 O inverse ratio ventilation careful in hemodynamic instable patients beware of over distension MJ Schultz for the PROVE Network (
69 Recruitment Through PEEP
70 PEEP, I:E in steps of 5 cm H 2 O, up to 15 cm H 2 O inverse ratio ventilation careful in hemodynamic instable patients beware of over distension MJ Schultz for the PROVE Network (
71 Three Recruitment Maneuver Sustained Inflation Techniques Incremental PEEP Pressure Control Ventilation Lim S. CCM 2004; 32:2378
72 Why Prone? decreased V/Q mismatch? or recruitment and decrease in driving pressure MJ Sch ultz for the PROVE Network (
73 How Prone (May) Work(s) Supine Prone less mismatch less compression by the heart Spronk P. NJCC 2005; 9;77
74 How Prone (May) Work(s) Supine Prone change in position of the trachea recruitment of depending lung tissue Spronk P. NJCC 2005; 9;77
75 Prone Ventilation Improves Outcome of Patients with Severe ARDS 10 RCTs, 1,867 patients PaO 2 /FiO 2 < 100 mmhg vs. PaO 2 /FiO mmhg Sud S. ICM 2010; 36:585
76 Prone Ventilation Improves Outcome of Patients with Severe ARDS RCT 466 patients with severe ARDS 28 day mortality Guerin C. NEJM 2013; 368:2159
77 Prone Ventilation Improves Outcome of Patients with Severe ARDS Beitler J. ICM 2014; 40:332
78 Conclusion (III) several ways to recruit the lungs simple to complex short to long interventions MJ Schultz for the PROVE Network (
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