Pro - Con Debate APRV vs Conventional Ventilation. Pro Jon Marinaro, MD

Transcription

1 Pro - Con Debate APRV vs Conventional Ventilation Pro Jon Marinaro, MD

2 PRO

3 CON

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5 Volume Assist Control Mode

6 ARDS MORTALITY OVER LAST 50 YEARS

7 53 year old female with 50% Flame Burn to Chest, Flanks & Buttocks

8 Arrival +19,323 cc

9 +30,932 cc s BiVent Started +36,645 cc s

10 +41,007 cc s +47,810 cc s +55,356 cc s +62,489 cc s

11 +81,054 cc s +87,054 cc s BiVent Stopped after this Xray +98,919 cc s +110,328 cc s

12 To OR not on BiVent BiVent Stopped BiVent Initiated

13 40% Burn Patient taken off early BiVent placed on SIMV-VC

14 ARRIVAL

15 +22,429 cc

16 +33,552 cc

17 +36,491 cc

18 BiVent Stopped

19 41 yo male, dx w/ p-anca microscopic polyangiitis 2/2 cocaine cut w/ Levamisol, intubated respiratory failure now with pulmonary hemorrhage

20 3/ / VC Rate 28 TV % PEEP 14 MV 22.6 PEAK Pressure 43, MAP BiVent 34/0 3/0.6 MV 11.4 Peak BiVent 32/0 3.5/0.5 MV 9.8 Peak 33

21 3/ / BiVent 32/0 3.5/0.5 MV 10.6 Peak 32 BiVent 28/0 4.5/0.5 MV 8.1 Peak 30

22 3/ / BiVent 25/0 5/0.6 MV CPAP PS 10/14 MV 12.3 MAP 14

23 3/ / PEEP 5 PS 10 MV 10.8 PEEP 5 PS 10 MV 10.8

24 BiVent

25 Basic Tenants of Ventilation FLOW PRESSURE VOLUME PRVC CMV SIMV APRV/BiVent AC CMV IMV Bi-Level PS

26 What is BiVent (APRV)? Technically BiVent is a time triggered, time cycled, pressure limited mode Allows Spontaneous Breathing throughout entire cycle Essentially it is CPAP with releases

27 Restores Functional Residual Volume Ventilation at low FRC worsens lung injury; Peep markedly attenuates this Am J Resp CCM 1994; 149:

28 BiVent Basics Indications Anyone on a ventilator Patients can be paralyzed and still be on BiVent COPD/Asthma it still worksjust use longer T low than usual (up to 50% release) Pediatrics ALI/ARDS Contraindications Patients that are underresuscitated Difficult patients to use it with Traumatic Brain Injury Patients

29 ARDS Causality We Can t Control Early Pulmonary Contusions Fractures Near Drowning Smoke Inhalation ISS>16 Trauma Score <13 Metabolic Acidosis Blunt Trauma Shock Multiple Transfusions Gastric Aspiration Neurosurgery Late Pneumonia Sepsis DIC

30 ARDS Causality We Can Control Atelectrauma-Cyclic opening and closing of alveoli» Am J Resp CCM 1998; 157: High plateau pressures» ARMA trial Low-tidal volume ventilation in presence of ATX» J Clin Invest 1997; 99: » Am J Resp CCM 1999; 160: Large tidal volumes» Am Rev Resp Disease 1990;142; » ARMA trial

31 What We are Normally Taught Oxygen Parameters FIO2 PEEP Ventilation Parameters Respiratory Rate Tidal Volume

32 This is Crazy

33 PEEP Over Sedation Volume Status Patient Position Underlying Disease Etc.. FiO2 PO 2 PCO 2 Respiratory Rate Tidal Volume

34 Basic Physiology to understand how to ventilate and oxygenate someone Why are people hypoxic in the ICU?? How do we get oxygen into the body?? How do we get rid of CO2??

35 Causes of Hypoxemia S-Shunt-anatomic: PDA/VSD/ASD H-Hypoventilation A-Altitude V-V/Q mismatch D-Diffusion

36 How CO2 Gets Out and O2 Gets In

37 We Already Use this Knowledge to Treat ARDS Increase Peep Reverse I:E Prone ino Open Lung Ventilation-APRV Why not do it for Atelectasis?

38 Atelectasis Acute Lung Injury ARDS

39 Why APRV? Allows 70% reduction of paralytics and 30-40% reduction in sedation» REDUCED NEUROMUSCULAR BLOCKADE REQUIREMENTS IN PATIENTS RECEIVING AIRWAY PRESSURE RELEASE VENTILATION-Huie;Chest 2005» Am J Respir Crit Care Med 1994; 149: » ******Am J Respir Crit Care Med 2001; 164:43 49***** Putenson» Crit Care 2001; 5: » *******Eur J Anaesthesiol 1997; 14: ******» Chest 1988; 94: » Arch Surg 1993; 128: » Eur J Anaesthesiol 1994; 11:37 42 Allows spontaneous breathing and coughing Allow for lower PIP, Plateau Airway pressures with equal ventilation and oxygenation» Pediatr Crit Care Med 2001 Vol. 2, No. 3» Arch Surg 1993; 128: » Chest 1989; 96: » Eur J Anesth 1994; 11:37 42» Eur J Anesth 1994; 11:37 42 Shortened ventilator days, ICU and hospital stays» Am J Respir Crit Care Med 2001; 164:43 49» Eur J Anaesthesiol 1997; 14:

40 Pulmonary Effects of Spontaneous Breathing Thicker, posterior diaphragm moves more than anterior» Anesthesiology 2002; 97: Distributes ventilation to dependent lung areas and thereby improves ventilation perfusion matching» Am J Respir Crit Care Med 1999; 159: » Anesthesiology 1974; 41: Redistribution of ventilation and endexpiratory gas to dependent lung regions promotes alveolar recruitment» Anesthesiology 2003; 99: » Anesth Analg 1973; 52:

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42 Physiologic Effects Increases Cardiac Index» Am J Respir Crit Care Med 1994; 150: » Anesthesiology 1994; 81: » Crit Care Med 1992; 20: » Crit Care Med 1994; 22: » Am J Respir Crit Care Med 1999; 159: » Am J Respir Crit Care Med 1994; 149: Promotes venous return to the heart and right and left-ventricular filling, thereby increasing cardiac output and DO2» Anesth Analg 1977; 56:88 96 Increase in intestinal mucosal blood flow» Anesthesiology 2003; 99:

43 Physiologic Effects Patients with ARDS and cardiac dysfunction, improved cardiac output and DO2, while vasopressor use decreased substantially» Crit Care 2001; 5: VO2 is not measurably altered by adequately supported spontaneous breathing in critically ill patients.» Crit Care Med 1998; 26: » Am J Respir Crit Care Med 1999; 159: » Am J Respir Crit Care Med 1994; 150: » Anesthesiology 1994; 81:

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45 Jain S Inten Care Med Exp 2016 All APRV? Stock & Downs 1987 Davis 1993 Peak Airway Pressure is Different End Expiratory Pressure is Different Gama De Abreu 2010 Roy 2013 Inspiratory Time is Different Expiratory Time is Different

46 Jain S. Intensive Care Med Exp 2016 Setting Expiratory Duration using the Expiratory Flow Curve -60L x 0.75 = -45L EEF PEF EEF/PEF= /-60 = 0.75 EEF/PEF= /-60 = 0.75

47 Conclusion: For patients sustaining significant trauma APRV seems to have a similar safety profile as the LVt. Trends for APRV patients to have increased ventilator days..may be explained by the initial worse physiologic derangement demonstrated by higher Acute Physiology and Chronic Health Evaluation II scores. TLow: EEF/PEF 25% - 75% (Not TCAV)

48 Jain S Inten Care Med Exp 2016 Not All Breaths Defined as APRV are Equivalent

49 No more than all Volume Controlled breaths are equivalent

50 Volume Assist Control Mode

51 These two parameters resulted in a reduction in mortality

52 It is not just the Mode but the precise Setting within the mode and the protocol used to adjust these settings in response to changes in the patients lung pathology

53 Mode ARDSnet Protocol Volume Controlled VA-C Mode Mode Settings LVt ( 6cc/kg) LPplat ( 30cmH 2 O) Mode Adjustments FiO 2 and PEEP adjusted by changes in Oxygenation

54 Time Controlled Adaptive Ventilation: TCAV Protocol Ventilator Components Open valve CPAP with a quick release No triggers to deliver a mechanical Vt Ventilator settings P High : Set sufficiently high to recruit alveoli T High : ~90% of the breath P Low : Always set a zero T Low : Set by slope of the expiratory flow curve

55 Yes TCAV can Reduce ARDS Incidence Comfortable: can be applied to all patients at intubation Simply CPAP with a quick release No dyssynchrony problems Solves the problem: Never gives the lung a chance to collapse Uses our understanding of viscoelastic alveolar mechanics Extended inspiratory time nudges open the lung Minimal expiratory time prevents lung collapse by two mechanisms: Time and Pressure (i.e. Time Controlled Lung Instability) Open stable lung eliminates the mechanisms of VILI (dynamic strain & S-C) Open stable lung eliminates strong respiratory drive Personalized and adaptive lung stabilization (Set by changes in lung elastance) Personalized and adaptive tidal volume (Open lung large Vt and vice versa) Solid supportive animal data on the mechanism of TCAV protection at the alveolar level and efficacy in clinically applicable animal ARDS model Solid Expert Experience and meta-analysis of clinical efficacy

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57 APRVNETWORK.ORG

58 Nieman et al. Intensive Care Medicine Experimental (2017) 5:8

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66 Conclusion: Compared with LTV, early application of APRV in patients with ARDS improved oxygenation and respiratory system compliance, decreased Pplat and reduced the duration of both mechanical ventilation and ICU stay

67 APRV is associated with Reduced incidence of VAP in patients with Pulmonary Contusions Walkey et al. JOT 3/2011 Investigated whether APRV is associated with a decreased risk for VAP in patients with pulmonary contusion. Retrospective cohort study-64 patients Onset to APRV initiation.83 days ( )

68 APRV Prevents VAP in Pulmonary Contusions VAP rate contusion vs Non-Contusion 18.3 vs 7.7/1,000 ventilator days VAP rate APRV vs Not APRV 9.7 vs 33/1,000 Univariate analysis showed that APRV was associated with a decreased incidence of VAP. Cox proportional hazards regression, supported a protective effect of APRV from VAP.

69 APRV Prevents VAP in Pulmonary Contusions PaO2/FiO2 ratios were higher during APRV compared with conventional ventilation APRV group had higher LIS and received more transfusions Conclusion: APRV in patients with pulmonary contusion is associated with a reduced risk for VAP.

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71 Be Pro-Active Use APRV Early Don t Get Conned

72 QUESTIONS?

73 Data Supporting the Efficacy of TCAV Roy S, Sadowitz B, Andrews P, Kuhn M, Ghosh A, Gatto LA, Marx W, Dean D, Lin X, Wang G, Ge L, Vodovotz Y, Nieman G, Habashi N. Early stabilizing ventilation prevents acute respiratory distress syndrome: A novel timing-based ventilatory intervention to avert lung injury. J Trauma Acute Care Surg. 2012;73:391 Roy S, Habashi N, Sadowitz B, Andrews P, Ge L, Wang G, Roy P, Singh A, Ghosh A, Kuhn M, Satalin J, Gatto LA, Lin X, Dean D, Vodovotz Y, Nieman GF. Early airway pressure release ventilation prevents ARDS: A novel preventive approach to lung injury. Shock. 2013;30:28-38 Emr B, Gatto LA, Roy S, Satalin J, Ghosh A, Snyder K, Andrews P, Habashi N, Marx W, Ge L, Wang G, Dean DA, Vodovotz Y, Nieman G. Airway pressure release ventilation prevents ventilator induced lung injury in normal lungs. JAMA Surgery, 2013,Nov; 148(11): Roy S, Emr B, Sadowitz B, Gatto LA, Ghosh A, Satalin J, Snyder KP, Ge l, Wang G, Marx W, Dean DA, Andrews P, Singh A, Scalea T, Habashi N, Nieman GF. Preemptive application of airway pressure release ventilation (APRV) prevents development of acute respiratory distress syndrome (ARDS) in a rat traumatic hemorrhagic shock model. Shock. 2013;40(3):

74 Data Supporting the Efficacy of TCAV Andrews PL, Shiber JR, Jaruga-Killeen E, Roy S, Sadowitz B, O Toole RV, Gatto LS, Nieman GF, Scalea T, Habashi N. Early application of airway pressure release ventilation may reduce mortality in high-risk trauma patients: A systematic review of observational trauma ARDS literature. J Trauma Acute Care Surg. 2013;75: Kollisch-Singule M, Emr B, Smith B, Roy S, Jain S, Satalin J, Snyder K, Andrews P, Habashi N, Bates J, Marx W. Nieman G, Gatto L. Mechanical breath profile of APRV minimizes micro-strain in acute lung injury. JAMA Surgery. 2014;13:59 Emr B, Gatto LA, Kollisch-Singule M, Emr B, Bradford S, Ruiz C, Roy S, Meng Q, Jain S, Satalin J, Snyder K, Ghosh A, Marx W, Andrews P, Habashi N, Nieman GF, Gatto LA. Airway pressure release ventilation (APRV) reduced conducting airway micro-strain in lung injury. J Am College Surg, 2014;219: Smith BJ, Lundblad LKA, Kollisch-Singule M, Satalin J, Nieman G, Habashi N, Bates JHT. Predicting the response of the injured lung to the mechanical breath profile. J Apply Physiol 2015;118:932 Smith BJ, Lundblad LKA, Kollisch-Singule M, Satalin J, Nieman G, Habashi N, Bates JHT. Predicting the response of the injured lung to the mechanical breath profile. J Apply Physiol 2015;118:932

75 Data Supporting the Efficacy of TCAV Kollisch-Singule M, Jain S, Andrews P, Smith BJ, Hamlington-Smith KL, Roy S, DiStefano D, Nuss e, Satalin J, Meng Q, Marx W, Bates JHT, Gatto LA, Nieman G, Habashi NM. Effect of airway pressure release ventilation on dynamic alveolar heterogeneity. JAMA Surgery 2015;3:35 Kollisch-Singule M, Emr B, Jain SV, Andrews P, Satalin J, Liu J, Porcellio E, Kenyon V, Wang G, Marx W, Gatto LA, Nieman GF, Habashi NM. The Effects of Airway Pressure Release Ventilation on Respiratory Mechanics in an Extrapulmonary ARDS Model. Intensive Care Med Exp Kollisch-Singule M, Jain SV, Satalin J, Andrews P, Searles Q, Liu Z, Zhou Y, Wang G, Meier AH, Gatto LA, Nieman GF, Habashi NM. Limiting ventilator associated lung injury in a pre-term porcine neonatal model. Journal of Pediatric Surgery 2017;52:50-55 Pedro L. Silva, Fernanda F. Cruz, Cynthia S. Samary, Lillian Moraes, Raquel Magalhães, Marcos V. Fernandes, Rebeca Bose, Vera L. Capelozzi, Josh Satalin, Louis A. Gatto, Penny Andrews, Nader Habashi, Gary Nieman, Patricia R. Rocco. Personalized Mechanical Ventilation Strategy Minimizes Ventilator-Induced Lung Injury in Experimental Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017;195:A7525

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