Kontroversen in der Intensivmedizin. ARDS gibt es Neues?

Transcription

1 Kontroversen in der Intensivmedizin ARDS gibt es Neues? Disclosure: MQ is a member of International Advisory Boards from Covidien, Gambro, Maquet, Novalung and Pulsion Zürich Michael Quintel Universitätsmedizin Göttingen UMG Georg-August Universität Göttingen

2 American European Consensus Conference on ARDS ALI ARDS acute onset bilateral infiltrations in chest x-ray absence of cardiac insufficieny PaO 2 /FiO 2 ratio 300 mm Hg PaO 2 /FiO 2 ratio 200 mm Hg

3 ARDS mild moderate severe timing acute onset within 1 week of a known clinical insult or new/worsening respiratory symptoms hypoxemia PaO 2 /FiO with PEEP/CPAP 5 PaO 2 /FiO with PEEP 5 PaO 2 /FiO with PEEP 5 origin of edema respiratory failure associated to known risk factors and not fully explained by cardiac failure or fluid overload. Need objective assessment of cardiac failure or fluid overload if no risk factor are present radiological abnormalities bilateral opacities* bilateral opacities* opacities involving at least 3 quadrants* additional physiological derangement N/A N/A V E corr > 10 L/min or C RS <40 ml/cmh 2 O *not fully explained by effusions, nodules, masses, or lobar/lung collapse; use training set of CXRs; V E Corr = V E x PaCO 2 /40 (corrected for Body Surface Area)

4 ECMO ECCO 2 - R Increasing intensity of intervention HFOV ino neuromuscular blockade? prone positioning low moderate PEEP NIV higher PEEP low tidal volume ventilation increasing severity of lung injury mild ARDS moderate ARDS severe ARDS PaO 2 /FiO 2 with courtesy of M. V. Ranieri

5 Welcher Anteil des Paw wird in der Lunge wirksam? Stiff Soft Soft Stiff E L E w E L E w 25 5 cmh 2 O E tot E tot

6 Welcher Teil des Tidalvolumens induziert Strain für die Lunge? 33% 66% Das baby lung Konzept

7 EI "protected" delta vol (ml) EE 40 hyperinflated poorly aerated normally aerated not aerated Hounsfield Units Terragni -20 PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Gandini G, Herrmann P, Mascia L, Quintel M, Slutsky AS, Gattinoni L, Ranieri VM. Tidal Hyperinflation during Low Tidal Volume Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2007;175:160-6

8 EI Delta vol (ml) "not" protected EE Hounsfield Units hyperinflated poorly aerated normally aerated not aerated Terragni -20 PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Hounsfield Units Gandini G, Herrmann P, Mascia L, Quintel M, Slutsky AS, Gattinoni L, Ranieri VM. Tidal Hyperinflation during Low Tidal Volume Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2007;175:160-6

9 Stress PL transpulmonaler Druck Strain V T / FRC Bindeglied ist die spezifische Elastance PL = E lspec * V T FRC

10 Lung inhomogeneity in patients with acute respiratory distress syndrome. Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A, Brioni M, Carlesso E, Chiumello D, Quintel M,Bugedo G, Gattinoni L. Am J Respir Crit Care Med 2014; 189:149-58

11 TLC FRC collapse edema voxel: 0,8 x 0,8 x 5 mm = 3,2 mm 3

12 Lung inhomogeneity in patients with acute respiratory distress syndrome. Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A, Brioni M, Carlesso E, Chiumello D, Quintel M,Bugedo G, Gattinoni L. Am J Respir Crit Care Med 2014; 189:149-58

13 Lung inhomogeneity in patients with acute respiratory distress syndrome. Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A, Brioni M, Carlesso E, Chiumello D, Quintel M,Bugedo G, Gattinoni L. Am J Respir Crit Care Med 2014; 189:149-58

14 Lung inhomogeneity in patients with acute respiratory distress syndrome. Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A, Brioni M, Carlesso E, Chiumello D, Quintel M, Bugedo G, Gattinoni L. Am J Respir Crit Care Med 2014; 189:149-58

15 Lung inhomogeneity in patients with acute respiratory distress syndrome. Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E,Marino A, Brioni M, Carlesso E, Chiumello D, Quintel M, Bugedo G, Gattinoni L. Am J Respir Crit Care Med 2014; 189:149-58

16 ECMO ECCO 2 - R Increasing intensity of intervention HFOV ino neuromuscular blockade? prone positioning low moderate PEEP NIV higher PEEP low tidal volume ventilation increasing severity of lung injury mild ARDS moderate ARDS severe ARDS PaO 2 /FiO 2 with courtesy of M. V. Ranieri

17 Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, Davies AR, Hand LE, Zhou Q, Thabane L, Austin P, Lapinsky S, Baxter A, Russell J, Skrobik Y, Ronco JJ, Stewart TE; Lung Open Ventilation Study Investigators. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:637-45

18 Mercat A, Richard JC, Vielle B, Jaber S, Osman D, Diehl JL, Lefrant JY, Prat G, Richecoeur J, Nieszkowska A, Gervais C, Baudot J, Bouadma L, Brochard L; Expiratory Pressure (Express) Study Group Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299:646-55

19 PaO 2 zwischen 55 und 120 mmhg und/oder art. Sättigung zwischen 88 und 98 % Talmor D, Sarge T, Malhotra A, O'Donnell CR, Ritz R, Lisbon A, Novack V, Loring SH Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 2008; 359:

20 Talmor D, Sarge T, Malhotra A, O'Donnell CR, Ritz R, Lisbon A, Novack V, Loring SH Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 2008; 359:

21 Talmor D, Sarge T, Malhotra A, O'Donnell CR, Ritz R, Lisbon A, Novack V, Loring SH Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 2008; 359:

22 Am J Respir Crit Care Med :

23 Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, Pelosi P, Talmor D, Grasso S, Chiumello D, Guérin C, Patroniti N, Ranieri VM, Gattinoni L, Nava S, Terragni PP, Pesenti A, Tobin M, Mancebo J, Brochard L. The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 2014; 189:520-31

24 Chiumello D, Cressoni M, Carlesso E, Caspani ML, Marino A, Gallazzi E, Caironi P, Lazzerini M, Moerer O, Quintel M and Gattinoni L. Bedside selection of Positive End-Expiratory Pressure in mild, moderate and severe Acute Respiratory Distress Syndrome. Crit Care Med 2014; 42:

25 Chiumello D, Cressoni M, Carlesso E, Caspani ML, Marino A, Gallazzi E, Caironi P, Lazzerini M, Moerer O, Quintel M and Gattinoni L. Bedside selection of Positive End-Expiratory Pressure in mild, moderate and severe Acute Respiratory Distress Syndrome. Crit Care Med 2014; 42:

26 Crit Care Med 2014; 42:

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28 tissue weight [% total lung weight] potential for recruitment consolidated lung weight [gr] airway pressure [cm of water] 1266 ± * ± * overinflated normally-aerated poorly aerated Low potential High potential for lung recruitment for lung recruitment * * aerated nonaerated *P<0.01 vs. patients with a low potential for lung recruitment, P<0.01 vs. 5 cm of water of PEEP within the same group. Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, Russo S, Cornejo R, Bugedo G, NEJM 2006, 354:

29 ECMO ECCO 2 - R Increasing intensity of intervention HFOV ino neuromuscular blockade? prone positioning low moderate PEEP NIV higher PEEP low tidal volume ventilation increasing severity of lung injury mild ARDS moderate ARDS severe ARDS PaO 2 /FiO 2 with courtesy of M. V. Ranieri

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31 Young D, Lamb SE, Shah S, MacKenzie I, Tunnicliffe W, Lall R, Rowan K, Cuthbertson BH; OSCAR Study Group. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med 2013; 368:806-13

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36 50,0 45,0 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0,0 Paw Luecke T, Meinhardt JP, Herrmann P, Weisser G, Pelosi P, Quintel M. Setting mean airway pressure during high-frequency oscillatory ventilation accordig to the static pressure volume curve in surfactant-deficient lung injury: a computed tomography study. Anesthesiology 2003;99: ,0 6,0 Cardiac Output [l] ALI HFO Pflex HFO 3/2 PFlex HFO 2* PFlex 5,0 4,0 pao 2 [mmhg] 3,0 700,0 2,0 600,0 1,0 500,0 400,0 300,0 0,0 ALI HFO Pflex HFO 3/2 PFlex HFO 2* PFlex 200,0 100,0 0,0 6 adult pigs different CADP levels ALI HFO Pflex HFO 3/2 PFlex HFO 2* PFlex

37 Goddon S, Fujino Y, Hromi JM, Kacmarek RM Optimal mean airway pressure during high-frequency oscillation Anesthesiology 2001, 94:

38 Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P, Zhou Q, Matte A, Walter SD, Lamontagne F, Granton JT, Arabi YM, Arroliga AC, Stewart TE, Slutsky AS, Meade MO; OSCILLATE Trial Investigators; Canadian Critical Care Trials Group. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 2013; 368:

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40 ECMO ECCO 2 - R Increasing intensity of intervention HFOV ino neuromuscular blockade? prone positioning low moderate PEEP NIV higher PEEP low tidal volume ventilation increasing severity of lung injury mild ARDS moderate ARDS severe ARDS PaO 2 /FiO 2 with courtesy of M. V. Ranieri

41 Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, Malacrida R, Di Giulio P, Fumagalli R, Pelosi P, Brazzi L, Latini R. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 2001; 345:

42 Guerin C, Gaillard S, Lemasson S, Ayzac L, Girard R, Beuret P, Palmier B, Le QV, Sirodot M, Rosselli S, Cadiergue V, Sainty JM, Barbe P, Combourieu E, Debatty D, Rouffineau J, Ezingeard E, Millet O, Guelon D, Rodriguez L, Martin O, Renault A, Sibille JP, Kaidomar M. Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial. JAMA 2004; 292:

43 Mancebo J, Fernandez R, Blanch L, Rialp G, Gordo F, Ferrer M, Rodriguez F, Garro P, Ricart P, Vallverdu I, Gich I, Castano J, Saura P, Dominguez G, Bonet A, Albert RK. A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome. Am J Respir Crit Care Med 2006; 173:1233-9

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47 ECMO ECCO 2 - R Increasing intensity of intervention HFOV ino neuromuscular blockade? prone positioning low moderate PEEP NIV higher PEEP low tidal volume ventilation increasing severity of lung injury mild ARDS moderate ARDS severe ARDS PaO 2 /FiO 2 with courtesy of M. V. Ranieri

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49 Once the assigned Ramsay sedation score was 6 and the ventilator settings were adjusted, a 3-ml rapid intravenous infusion of 15 mg of cisatracurium besylate or placebo was administered, followed by a continuous infusion of 37.5 mg per hour for 48 hours.

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53 ECMO ECMO ECCO 2 - R ECCO 2 - R Increasing intensity of intervention HFOV ino neuromuscular blockade? prone positioning low moderate PEEP NIV higher PEEP low tidal volume ventilation increasing severity of lung injury mild ARDS moderate ARDS severe ARDS PaO 2 /FiO 2 with courtesy of M. V. Ranieri

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56 Zusammenfassung mit personal bias wirklich neu ist eigentlich nichts der Term ALI wurde aus der Terminologie eliminiert Potential für Recruitment und Monitoringverfahren werden zunehmend akkzeptierte Standards für eine adäquate PEEP-Selektion Rolle der HVOV nach 2 negativen RCT s kritisch zu bewerten Rolle von NMBA s weiter offen Bauchlage klare Datenlage (zu klar?) ECMO und ELS weiter keine Daten