Breathing: Conventional. Matter?

Transcription

1 Breathing: Conventional Ventilation Does the Mode Matter? Brian K. Walsh, RRT NPS, FAARC Director of Respiratory Care Children s Medical Center Dallas

2 Disclosure Research relationships: Maquet NAVA GE VRI, FRC Draeger EIT Masimo SpHb Editor for Neonatal and Pediatric Respiratory Care 3 rd ed.

3 Ground rules Despite the fact that HFV is no longer seen as unconventional, I will stick to traditional < 150 bpm modes of ventilation. I have also excluded ECMO and NIV from my analysis. My bias modes of ventilationdo notmatter. However, I will attempt to place my bias aside and provide you evidence. I have attempted focus on the pediatric population.

4 What does the evidence say? Pubmed search: (filtered for humans, English, reviews, RCT, clinical trials, meta analysis) Modes of ventilation (respiration) 77 articles 23 if you limited it to 0 18 years of age. Not one mode of ventilation reduced Not one mode of ventilation reduced mortality.

5 Why isn t there more data out there? Very diverse patient population Small patient population Investigational i review boards Liability Manufacture's support

6 Only one setting on the mechanical ventilation has proven to reduce mortality. Tidal volumes

7 Tidal volume appears to be important So why do most NICU / PICU utilize pressure targeted modes of ventilation? Historical No evidence that it is a worse mode of ventilation Maybe more comfortable Allows you to control PIP More physiologic? i

8 Patient Interactions Make a Difference

9 What about spontaneous effort? Should we control or encourage spontaneous breathing? Energy expenditure Bucking the ventilator Comfort Waxing or waning effort Vent Respiratory muscle fti fatigue or atrophy Patient

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11 What?

12 Do modes of ventilation effect regional distribution of ventilation? Is there one mode of ventilation that is better? Likely not the mode of ventilation, but the patient interaction. Many of our patients have gravitational atelectasis. Should we individualize?

13 AC Volume AC Pressure PSV

14 Authors conclusions

15 Modes of Ventilation in Neonates HFPPV (>60 bpm) vs. CMV Cochrane Database review Jan 2008

16 What we have found from neonates Cochrane Database review Jan 2008

17 Is simple better?

18 Conclusion from neonates PTV/SIMV vs. CMV = duration of ventilation Synchronization maybe helpful. PTV vs. SIMV = duration of weaning. Synchronization and support for every breath maybe helpful as well.

19 What about mixed modes of SIMV with PS Appears to foster weaning in neonates. ventilation?

20 Adaptive Pressure Control Appears to lower PIPs compared to VC and PC Targets tidal volumes Promotes inspiratoryi flow synchrony. Weans PIP as patient awakens May lower support inappropriately.

21 Adaptive Support Ventilation

22 All these modes are so confusing.

23 ASV vs. PSV vs. APV Dr. Jaber, et al describes mode interactions in an randomized cross over over trail of 14 MV patients in the weaning phase of their disease. 100 ml of deadspaced was added. d

24 APRV

25 Data on APRV

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27 Neural Control of Mechanical Ventilation Central nervous system Ideal Technology Phrenic nerve Diaphragm excitation NAVA Diaphragm contraction Chest wall, lung and esophageal response Airway flow, pressure and volume changes Current Technology

28 NAVA Research demonstrates better synchrony even in the face of ETT leaks. Beck J, et al Pediatr Res 2007 Mar;61(3): ; Beck J, et al Pdi Pediatr Res 2009 Better unloading of respiratory muscles. Sinderby C. Chest 2007;131(3): This may lead to better patient comfort and earlier libration. Piquilloud, Intensive Care 2010 Still has many of the same contraindications of PSV. Compared with PSV, respiratory parameter variability was greater with NAVA, probably leading in part to the significant improvement in patient oxygenation and CO 2 removal. Coisel, Anesthesiology, V 113, No 4, 2010 May provide better oxygenation and limit over support (adults). Terzi, CritCareMed2010 Care Vol. 38, No. 9

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30 Piquilloud, Intensive Care 2010

31 Wasted effort? Asynchrony with ventilator Missed breath

32 Auto trigger?

33 Could NAVA be faster than flow triggering? In synch In synch with Vent

34 Piquilloud, Intensive Care 2010

35 Piquilloud, Intensive Care 2010

36 What maybe more important Positive feed back system. Diagnostic tool of EDI.

37 Over ventilation? SIMV 30/7 x 15 FIO2.35 ERT PS 8/5

38 Over ventilation with large tidal volumes a low RR Increased RR EDI during ERT Compliance improves

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40 NAVA

41 Wolf, G, Walsh, B Peds Critical Care, 2011

42 Electrical Activity of the Diaphragm Reflects Work of Breathing

43 Bring Back Negative Pressure Ventilation? TheHayek negative pressure ventilator was FDA approved in Ventilation This device offers cough assist HFCWO Secretion mode Offers pediatric i size shells hll

44 Tidbits of Suctioning High pressures can be created by PRVC during suctioning events. Neonatology 2011;99:78 82 Closed and opened suctioning creates atelectasis with all modes of ventilation. Intensive Care Med (2009) 35: Recovery appears to be longer on HFOV with open. Arch Dis Child Fetal Neonatal Ed : F436 F441 Recovery following suctioning takes longer in spontaneously breathing than the paralyzed and sedated. Respir Care 2009;54(3): Recruitment maneuvers do not appear to be helpful following suctioning. Australian Journal of Physiotherapy :

45 Open vs. Closed Suctioning

46 Mid Frequency Ventilation Frequencies higher than normal withlow tidal volumes. Traditionally this has been known not to improve alveolar ventilation. Air trapping is a concern Tidal volume measurements were less accurate. But is this really true with newer generation But is this really true with newer generation ventilators?

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48 What about smart PSV?

49 Future of modes ventilation Close loop modes will be the future. Smartcare/PS RR, V T, ETCO 2 ASV Intelligent design Doing more with the current data. Full lldisclosure (information i integration) i

50 Conclusion Modes of ventilation likely do not improve outcomes. Your mode choice could be individualized, but you must understand the complications. You may underestimatethe the risk, benefit, and cost associated. We should continue to support modes of ventilation what encourage or support spontaneous breathing. Stick to what you know. If you do venture out and try a new mode, make sure you know that mode of ventilation.

51 Question? Brian com