QUELLES DIFFERENCES ENTRE BIPAP ET APRV?

QUELLES DIFFERENCES ENTRE BIPAP ET APRV?

JC RICHARD, A LYAZIDI Geneva

ARDS: Challenging the Berlin criteria

Conflicts of interest

• Our clinical research laboratory has received research grants for clinical research projects from the following companies: – Maquet (NAVA)

– Covidien (PAV+)

– Dräger (SmartCare)

– General Electric (FRC)

– Respironics (NIV)

– Fisher Paykel (Optiflow)

Assist-control Ventilation Volume vs. Pressure-targeted modes: what’s the difference?

Volume-control: TransPulmonary Pressure

is controlled

Pressure-control: TransPulmonary Pressure

is NOT controlled

Spontaneous Breathing (CPAP)

PCV

Not BiPap!!

METHODS: settings

Artificial lung settings

• CRrs: 30ml/cmH2O

• RRrs: 5 cmH2O/lt/min

• Pmus: -10 cmH2O

• RR: 20, 30 br/min

• Ti: 0.8 sec

Ventilator settings

• PAWinsp: 30 cmH2O

• PEEP : 15 cmH2O

• RR: 15/min

• I:E ratios: 1:3 and 3:1

Modes of ventilation

• Controlled MV

• Assist Control?

• Bilevel Pressure Ventilation?

• Pressure Support ventilation?

Pressure-Preset Modes

No i-synchronization

• APRV

Full i-synchronization

• BIPAPassist, , BiPAP PS Assist Pressure controlled, etc.

Partial i-synchronization

• BIPAP, DuoPAP, BiVent,

• Bilevel, etc.

Akoumianaki E et al. ESICM 2012

VT change in the presence of spontaneous breaths according to i-synchronization

No spontaneous breaths

6ml/kg/IBW

VT

(ml)

Non i-Synchronized modes Non i-Synchronized modes

10 ml/kg/IBW

6 ml/kg/IBW

VT

(ml)

4 ml/kg/IBW

VT

(ml)

Fully i-Synchronized modes

6 ml/kg/IBW

10 ml/kg/IBW

time (sec)

RESULTS: I:E 1/3, RR 20

Bench study: conclusions

In the presence of spontaneous breathing the same settings across different Pressure-Preset modes lead to different values of VT, Ptp and breathing variability

As i-synchronization increases, mean amplitude of VT and Ptp increase while variability decreases

Clinicians should be aware that i-synchronization may be harmful when high VT is undesirable (ARDS)

8 patients under BIPAP-APRV over 5 days

8 patients under BIPAP-APRV over 5 days

0

100

200

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700

0 0.5 1 1.5 2 2.5 3 3.5

0

10

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vt

CV

3 PATIENTS

APRV - BIPAP (PS= 0) - PAC

Volume Assist-Control

Pes (cm H2O)

Paw (cm H2O)

Flow (L/sec)

Akouniamaki E et al CHEST in press

Presure Assist-Control

Paw (cm H2O)

Flow (L/sec)

EAdi (µV)

Akouniamaki E et al CHEST in press

Entrainment: reverse triggering

Akouniamaki E et al CHEST in press

BIPAP APRV

PEEP set for

28 Pplat 30

ACV

PEEP set for

28 Pplat 30

NMBA during 24- 48 firts hours

Daily Sedation interruption trial

Daily PEEP reduction trial when PF > 150

Daily SBT when PF > 150 and with PEEP = 5

BIPAP APRV compared to ACV in ARDS patients

Jean-Christophe M Richard

Alain Mercat

Laurent Brochard

Vt = 6ml/kg PBW

BIPAP APRV (EXPRESS) at H24: • Target sedation based on (SB) as a %of total Vmn total • Delta Pressure for Vt ≤ 6 ml/kg

APRV for ARDS: proposals

Phase 1: ACV (sedation and paralysis) during 24 h

APRV: initial settings (EXPRESS) 1. Set Plow (PEEP)

2. Set Phigh = closed from Pplat

3. Set Thigh (0,8 sec to 1 sec)

4. Set Tlow to obtain the RR you want

5. FiO2 pour 90<SaO2<95% Pente 0,2 sec

Check Vt :

Adapt Phigh for Vt 6 ml/kg PBW (+/- 10%)

Set alarms :

VM (+ 1L/min et – 1 L/min compared to Vmin

Vt max = 8 ml/kg

Adapt settings according the 4 following targets:

1. Vt = 6mL/Kg PBW => change Phigh and/or Plow

2. Pplat < 30cmH2O => change Phigh and/or Plow

3. Ph: 7.35 to 7.38 => change Tlow to adapt RR

4. SaO2: 90 et 95% => change FiO2

Phase 1 start APRV

APRV for ARDS: proposals

18/06/2013 21

Phase 2 : Spontaneous ventilation

Stop paralysis and sédation (RASS –2 –3)

2 goals:

1. VM spont between10 et 50% of VM tot

(average on 6 hours trends)

2. RASS -2 - 3

SV < 10%

and

RASS < -2

SV < 10%

and

Sédation OK

SV > 50%

and

Sédation OK

SV > 50%

and

RASS > -2

Sédation pH: alcalosys?

If yes

Tlow

RR

Sédation pH: acidose

If yes

Tlow

RR

Si T° > 38°C

+/- cooling

Check goals (Spontaneous Vent and Vt ) every 8 or 12 h

Patient DATA

Trends

300 250 200 150 100 50

Low Tidal Volume Ventilation Low Tidal Volume Ventilation

Higher PEEP Higher PEEP

HFO HFO

Prone Positioning Prone Positioning

ECMO ECMO

Low – Moderate PEEP Low – Moderate PEEP

Neuromuscular Blockade

Neuromuscular Blockade

PaO2/FiO2

Increasing Severity of Lung Injury

Mild ARDS Moderate ARDS Severe ARDS

Incr

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Inte

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f In

terv

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tio

n

NIV NIV

ECCO2-R ECCO2-R

iNO iNO

Ferguson N et al ICM 2012

A Lyazidi E Akoumianaki JC Richard R Cordioli

Make it simple, not simpler.

A. Einstein