Phenotyping of ARDS and non ARDS Patients
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1 Critical Care Canada Forum 2018 Sheraton Toronto, Toronto, Canada November 8, 2018; 11:05h 11:25h Phenotyping of and non Patients Berlin & Kigali, RALE score, Reclassification, Driving Pressure and Mechanical Power MJ Schultz for the PROVE Network ( and MORU (
2 Disclosures no disclosures MJ Schultz for the PROVE Network ( and MORU (
3 Incomplete Understanding of the Biology of poor recognition of poor prognostication of poor track records of phase II and III trials MJ Schultz for the PROVE Network ( and MORU (
4 Who is Afraid of Red, Yellow and Blue Stedelijk Museum Amsterdam [museum for contemporary art]
5 Who is Afraid of Red, Yellow and Blue NO PERIOPERATIVE VENTILATION
6 Agenda Berlin Definition & Kigali Modification RALE score reclassification driving pressure & mechanical power conclusions MJ Schultz for the PROVE Network ( and MORU (
7 Berlin Definition for is Neither Sensitive nor Specific 356 patients had criteria for at time of death sensitivity and specificity of Berlin Proportion of Patients No Lesion Other Diagnostic Pneumonia No Lesion Other Diagnostic Pneumonia DAD No Lesion Other Diagnostic Pneumonia DAD were 63% and 89% 0 DAD Thille A. Am J Resp Crit Care Med 2013; 187:761 Mild (N = 49) Moderate (N = 141) Severe (N = 166)
8 Berlin Definition for is Neither Sensitive nor Specific 356 patients had criteria for at time of death DAD more frequently found Proportion of Patients with DAD < 72 hours > 72 hours P = 0.38 P < 0.01 P < 0.01 after 72 hours 0 Thille A. Am J Resp Crit Care Med 2013; 187:761 Mild (N = 49) Moderate (N = 141) Severe (N = 166)
9 Association between Berlin Severity and Mortality is not Independent 6 month study in France 278/3,504 Cox proportional hazard regression analysis Hernu R. Intensive Care Med 2013; 39:2161
10 4,188 Patients with from 4 Multicenter Clinical Data Sets Definition Task Force. JAMA 2013; 307:2526 AUROC of 0.58 [ ]
11 P/F under Standardized Ventilator Settings Improves Prognostication Villar J. BMJ Open 2015; 5:e006812
12 From the AECC Criteria to the Berlin Definition predictive validity for mortality remains poor cutoffs by consensus (i.e., not data driven) non standardized way of data capturing Bernard G. Intensive Care Medicine 2016; 42:640
13 Agenda Berlin Definition & Kigali Modification RALE score reclassification driving pressure & mechanical power conclusions MJ Schultz for the PROVE Network ( and MORU (
14 Resource rich: trend to less invasive monitoring
15 Resource poor: ABGA and CXRs not available
16 Comparison of S/F and P/F S/F = *(P/F) (P < ; r=0.89) S/F = *(P/F) (P < 0.001, R 2 =0.66) Rice T. Chest 2007; 132:410 Pisani L. Annals Intensive Care 2017; 7:108
17 normal lung: lung sliding (M-mode: sea shore) + A-lines (reverberations) wet lung: B-lines appears wetter lung: B-lines dominate and fuse collapsed lung: lung visible the less air is in the lung, the easier is the detection of lung abnormalities by US Lung Ultrasound
18 Kigali Modification of the Berlin Definition Riviello E. Am J Resp Crit Care Med 2016; 193:52
19 Kigali Modification of the Berlin Definition 1,046 hospital admissions in Kigali, Rwanda S/F 315 and bilateral opacities on LUS or CXR Riviello E. Am J Resp Crit Care Med 2016; 193:52
20 Kigali Modification(s!) Confirmed in Amsterdam single center observational study 153 patients Berlin Definition as reference all were intubated Pisani L. Intensive Care Med 2018; 44:523
21 Agenda Berlin Definition & Kigali Modification RALE score reclassification driving pressure & mechanical power conclusions MJ Schultz for the PROVE Network ( and MORU (
22 Evaluation of Alveolar Opacities on CXRs of 174 Patients quadrants scored for extent of consolidation (0 4) and density of opacification (1 3) product, max = 48 Warren M. Thorax 2018; 73:840 Radiographic Pulmonary Edema (RALE) Score
23 Evaluation of Alveolar Opacities on CXRs of 174 Patients quadrants scored for extent of consolidation (0 4) and density of opacification (1 3) product, max = 48 Warren M. Thorax 2018; 73:840
24 Diagnostic Performance of RALE in Patients Ventilated > 24 Hours 153 patients, 23 with RALE score of admission CXR excellent predictive value for NO Zimatore C. in preparation
25 Agenda Berlin Definition & Kigali Modification RALE score reclassification driving pressure & mechanical power conclusions MJ Schultz for the PROVE Network ( and MORU (
26 Early Response to Conventional Care Predicts Outcome retrospective analysis of a RCT (PGE 1 ) 74 patients with receiving placebo Bone R. Chest 1989; 96:849
27 Persistent Patients in the Conveniently sized LUNG SAFE international study 2,298 patients with outcomes 90 day mortality LUNG SAFE investigators. Intensive Care Med 2018; 44:564
28 Persistent Patients in the Conveniently sized LUNG SAFE international study 2,298 patients with outcomes 90 day mortality LUNG SAFE investigators. Intensive Care Med 2018; 44:564
29 Reclassification after 24H Improves Prognostication Villars J. Crit Care Med 2015; 43:346
30 Reclassification after 24H Improves Prognostication Bos L. Intensive Care Med 2015; 41:2004
31 Agenda Berlin & Kigali RALE score reclassification driving pressure & mechanical power conclusions MJ Schultz for the PROVE Network ( and MORU (
32 Driving Pressure is Associated with Outcome from 3,562 patients from 9 investigations ΔP as independent variable mediation analysis Amato M. New Engl J Med 2015; 372:747 [METANALYSIS]
33 Driving Pressure is Associated with Outcome from 2,396 patients with mild, moderate or severe probability of hospital death in ΔP quintiles LUNG SAFE Investigators. JAMA 2016; 315:788
34 Modifiable Ventilatory Factors Associated with Outcome 469 ICUs in 50 countries 2,377 patients with on day 1 2 LOWESS curves LUNG SAFE Investigators. Intensive Care Med 2017; 42:1865
35 Decrease in ΔP after ECMO Start is Associated with a Better Outcome 545 patients from 12 investigations ECMO days median settings in the first 3 days of ECMO Serpa Neto A. Intensive Care Med 2017; 42:1672
36 NO Modifiable Ventilatory Factors Associated with Outcome 119 ICUs in 16 countries Hospital Mortality (%) Pmax 18 cm H 2 O Pmax > 18 cmh 2 O Hospital Mortality (%) PEEP 5 cm Η 2 O PEEP > 5 cm H 2 O 935 patients without RR (95% CI) 1.79 ( ) p = RR (95% CI) 2.61 ( ) p = RR (95% CI) 1.22 ( ) p = Overall Cohort At Risk of Not At Risk of ΔP 12 cm H 2 O ΔP > 12 cm H 2 O RR (95% CI) 1.60 ( ) p = RR (95% CI) 1.50 ( ) p = RR (95% CI) 1.33 ( ) p = Overall Cohort At Risk of Not At Risk of V T 7.9 ml/kg PBW V T > 7.9 ml/kg PBW risk for according to LIPS Hospital Mortality (%) RR (95% CI) 1.50 ( ) p = RR (95% CI) 1.36 ( ) p = RR (95% CI) 1.27 ( ) p = Overall Cohort At Risk of Not At Risk of Hospital Mortality (%) RR (95% CI) 1.19 ( ) p = RR (95% CI) 1.41 ( ) p = RR (95% CI) 1.15 ( ) p = Overall Cohort At Risk of Not At Risk of PRoVENT Investigators. Ann Intensive Care 2018; 8:39
37 MP Unifies Variables Known to be Related with Development of VILI 8,207 patients MP = 0.098*RR* V T *(Ppeak ½* ΔP) worse outcomes with higher MP NO Serpa Neto A. Intensive Care Med 2018; in press
38 Poor Predictive Validity of ΔP and MP in Patients Ventilated > 24H 839 patients on controlled ventilation 90 day mortality predictive validity (adding to APACHE IV prediction) NO van Meenen D. in preparation
39 Overall Conclusions recognition AECC, Berlin, Kigali should we use them (at all)? recognition RALE score, LUS prognostication reclassification prognostication driving pressure and power not really useful MJ Schultz for the PROVE Network ( and MORU (
Difficult Ventilation in ARDS Patients
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