1 Sophisticated Ventilator Modes Sophisticated Ventilator Modes – When and How to Use When and How to Use Bob Kacmarek PhD, RRT Bob Kacmarek PhD, RRT Harvard Medical School Harvard Medical School Massachusetts General Hospital Massachusetts General Hospital Boston, Massachusetts Boston, Massachusetts 10 10-27 27-16 FOCUS 16 FOCUS Conflict of Interest Disclosure Robert M Kacmarek I disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am presenting: Company Relationship Content Area Medtronic Consultant Artificial Airways Medtronic Grant Mech Vent Venner Medical Grant Artificial Airways Orange Medical Consultant Mech Vent Teleflex Consultant Humidification PRVC and VS PRVC and VS Pressure regulated volume control and Pressure regulated volume control and Volume support Volume support Both target a preset V Both target a preset V T and adjust the level and adjust the level of pressure ventilation needed to ensure the of pressure ventilation needed to ensure the of pressure ventilation needed to ensure the of pressure ventilation needed to ensure the delivery of the V delivery of the V T PRVC PRVC - set rate, inspiratory time, minute set rate, inspiratory time, minute ventilation/V ventilation/V T and pressure limit and pressure limit VS VS - set minute ventilation/V set minute ventilation/V T and pressure and pressure limit limit PRVC PRVC Initial test breath ( 5 or 10 cmH Initial test breath ( 5 or 10 cmH 2 O ) O ) Calculate pressure needed to delivery V Calculate pressure needed to delivery V T Test breathes provided at some percentage of Test breathes provided at some percentage of the target V the target V the target V the target V T Then to pressure level needed to insure actual Then to pressure level needed to insure actual V T delivery delivery Subsequent pressure changes up to 3 cmH Subsequent pressure changes up to 3 cmH 2 O O per breath per breath Jabar ICM 2005;31:1181 Jabar ICM 2005;31:1181 Evaluate the response of volume support Evaluate the response of volume support ventilation vs. pressure support ventilation ventilation vs. pressure support ventilation with the addition of increased dead space with the addition of increased dead space – HME in 10 patients weaning! HME in 10 patients weaning! HME in 10 patients weaning! HME in 10 patients weaning! VS increased indexes of ventilatory work and VS increased indexes of ventilatory work and effort 2.4 to 4 times greater than with PS, effort 2.4 to 4 times greater than with PS, inducing respiratory distress in two patients! inducing respiratory distress in two patients! The pressure during VS decreased from The pressure during VS decreased from 15.0+6.5 to 9.1+4.8 cm H 15.0+6.5 to 9.1+4.8 cm H 2 O! O! Jabar ICM 2005;31:1181 Jabar ICM 2005;31:1181
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Sophisticated Ventilator Modes Sophisticated Ventilator Modes ––When and How to UseWhen and How to Use
Bob Kacmarek PhD, RRTBob Kacmarek PhD, RRT
Harvard Medical School Harvard Medical School
Massachusetts General HospitalMassachusetts General Hospital
I disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am presenting:
Company Relationship Content AreaMedtronic Consultant Artificial AirwaysMedtronic Grant Mech VentVenner Medical Grant Artificial AirwaysOrange Medical Consultant Mech VentTeleflex Consultant Humidification
PRVC and VSPRVC and VS
Pressure regulated volume control and Pressure regulated volume control and Volume supportVolume support
Both target a preset VBoth target a preset VTT and adjust the level and adjust the level of pressure ventilation needed to ensure theof pressure ventilation needed to ensure theof pressure ventilation needed to ensure the of pressure ventilation needed to ensure the delivery of the Vdelivery of the VTT
PRVC PRVC -- set rate, inspiratory time, minute set rate, inspiratory time, minute ventilation/Vventilation/VTT and pressure limitand pressure limit
VS VS -- set minute ventilation/Vset minute ventilation/VTT and pressure and pressure limitlimit
PRVCPRVC
Initial test breath ( 5 or 10 cmHInitial test breath ( 5 or 10 cmH22O )O )Calculate pressure needed to delivery VCalculate pressure needed to delivery VTT
Test breathes provided at some percentage of Test breathes provided at some percentage of the target Vthe target VTTthe target Vthe target VTT
Then to pressure level needed to insure actual Then to pressure level needed to insure actual VVTT deliverydeliverySubsequent pressure changes up to 3 cmHSubsequent pressure changes up to 3 cmH22O O per breathper breath
Jabar ICM 2005;31:1181Jabar ICM 2005;31:1181
Evaluate the response of volume support Evaluate the response of volume support ventilation vs. pressure support ventilation ventilation vs. pressure support ventilation with the addition of increased dead space with the addition of increased dead space ––HME in 10 patients weaning!HME in 10 patients weaning!HME in 10 patients weaning!HME in 10 patients weaning!VS increased indexes of ventilatory work and VS increased indexes of ventilatory work and effort 2.4 to 4 times greater than with PS, effort 2.4 to 4 times greater than with PS, inducing respiratory distress in two patients!inducing respiratory distress in two patients!The pressure during VS decreased from The pressure during VS decreased from 15.0+6.5 to 9.1+4.8 cm H15.0+6.5 to 9.1+4.8 cm H22O!O!
Jabar ICM 2005;31:1181Jabar ICM 2005;31:1181
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Proportional Assist Ventilation(PAV)
N ll Adj t d V ti lt A i tNeurally Adjusted Ventialtory Assist(NAVA)
PAV based on the equation of motionPAV based on the equation of motion
Increases or decreases ventilatory support in Increases or decreases ventilatory support in proportion to patient effort proportion to patient effort
Similar in concept to power steeringSimilar in concept to power steering
Tracks changes in patient effort and adjusts Tracks changes in patient effort and adjusts ventilator output to reduce workventilator output to reduce work
Introduced by Younes in 1992Introduced by Younes in 1992Younes M, ARRD 1992;145:121Younes M, ARRD 1992;145:121
Equation of Motion Equation of Motion for the respiratory systemfor the respiratory system
Paw + Pmus = V’ x R + Paw + Pmus = V’ x R + V x EV x E
The use of PAV vs. PSV in critically ill patients The use of PAV vs. PSV in critically ill patients for 48 hoursfor 48 hoursOn controlled ventilation > 36 hoursOn controlled ventilation > 36 hoursAbility to trigger vent > 10/minAbility to trigger vent > 10/minAbility to trigger vent > 10/minAbility to trigger vent > 10/minPaOPaO22 > 60 with F> 60 with FIIOO22 < 0.65 and total PEEP < 15 < 0.65 and total PEEP < 15 cmHcmH22OOpH > 7.30pH > 7.30No severe hemodynamic instabilityNo severe hemodynamic instabilityNo severe bronchospasmNo severe bronchospasmA stable neurological statusA stable neurological status
Failure rate 11% vs. 22%, p = 0.04Failure rate 11% vs. 22%, p = 0.04
Proportion of patients exhibiting ptProportion of patients exhibiting pt--vent vent dysdys synchrony 5 6% vs 29% p < 0 001synchrony 5 6% vs 29% p < 0 001dysdys--synchrony 5.6% vs. 29%, p < 0.001synchrony 5.6% vs. 29%, p < 0.001
The proportion of patients meeting The proportion of patients meeting criteria for unassisted breathing did not criteria for unassisted breathing did not differdiffer
Bosma CCM 2007;35:1048Bosma CCM 2007;35:1048PSV vs. PAV during sleep cross over study one PSV vs. PAV during sleep cross over study one night each mode randomly appliednight each mode randomly applied
Both set to decrease inspiratory WOB by 50%Both set to decrease inspiratory WOB by 50%
Arousals/hr 16 (2Arousals/hr 16 (2--74) vs. 9 (174) vs. 9 (1--41) p < 0.0241) p < 0.02
Overall sleep quality better PAV p < 0 05Overall sleep quality better PAV p < 0 05Overall sleep quality better PAV p < 0.05Overall sleep quality better PAV p < 0.05
MV and VMV and VTT lower and COlower and CO22 greater PAVgreater PAVAwakenings/hr 5.5 (1Awakenings/hr 5.5 (1--24) vs. 3.5 (024) vs. 3.5 (0--24)24)
Rapid eye movement 4% 90Rapid eye movement 4% 90--23) vs. 9% (9023) vs. 9% (90--31)31)
Slow wave sleep 1% (0Slow wave sleep 1% (0--10) vs. 3% (010) vs. 3% (0--16)16)
Asynchronies/hr 53Asynchronies/hr 53++59 vs. 2459 vs. 24++15 p < 0.0215 p < 0.02
Requires patients have an intact Requires patients have an intact ventilatory drive!ventilatory drive!
Requires ongoing assessment of lungRequires ongoing assessment of lungRequires ongoing assessment of lung Requires ongoing assessment of lung mechanics!mechanics!
Unable to deal with autoUnable to deal with auto--PEEP!!PEEP!!
Sinderby Nature Med 1999;5:1433Sinderby Nature Med 1999;5:1433
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Sinderby Nature Med 1999;5:1433Sinderby Nature Med 1999;5:1433 Sinderby Nature Med 1999;5:1433Sinderby Nature Med 1999;5:1433
Delisle Ann Inten Care 2011;1:42
Piquilloud ICM
2012;38: 1624
De la Oliva Submitted for PublicationDe la Oliva Submitted for Publication
12 pediatric patients 5 months to 12 pediatric patients 5 months to 12 years 12 years
PS PS optimized vs NAVAPS PS optimized vs NAVAPS, PS optimized vs. NAVAPS, PS optimized vs. NAVA
30 min trials each application30 min trials each application
Compared asynchronies, and Compared asynchronies, and Variability in ventilatory patternVariability in ventilatory pattern
Pedro de la Oliva Submitted for PublicationPedro de la Oliva Submitted for Publication
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Schmidt Critical Care 2015;19:56Schmidt Critical Care 2015;19:56
Compared PSV, PAV and NAVA at 100%: VCompared PSV, PAV and NAVA at 100%: VTT 6 to 6 to 8 ml/kg, at 50% and 150% in 16 pts8 ml/kg, at 50% and 150% in 16 pts
PAV and NAVA prevent increased VPAV and NAVA prevent increased VTT 150%150%
Coefficient of Variation of respiratory pattern higher Coefficient of Variation of respiratory pattern higher PAV and NAVA than PSVPAV and NAVA than PSV
Ineffective triggering lower PAV and NAVA, Ineffective triggering lower PAV and NAVA, double triggering lower PAV and PSVdouble triggering lower PAV and PSV
PAV and NAVA prevented overPAV and NAVA prevented over--distention, distention, improved improved neuroneuro--mechanical coupling, restored mechanical coupling, restored variability, and improved synchronyvariability, and improved synchrony
PAV vs. NAVAPAV vs. NAVAPAVPAV
Uses airway pressure and flow measurementsUses airway pressure and flow measurements
No specific equipment neededNo specific equipment needed
Available invasively/noninvasively (different ventilators)Available invasively/noninvasively (different ventilators)
Use with patients greater than 20 kgUse with patients greater than 20 kg
Affected by leaks (current invasive) and autoPEEPAffected by leaks (current invasive) and autoPEEP
NAVANAVAUses measurement of diaphragm EMG (EAdi) activityUses measurement of diaphragm EMG (EAdi) activity
Requires use of a special catheterRequires use of a special catheter
Available invasively/noninvasively Available invasively/noninvasively
Useful in neonates, children and adultsUseful in neonates, children and adults
Unaffected by leaks and autoPEEPUnaffected by leaks and autoPEEP
Major Question Regarding PAV and NAVA!
Who Knows Better How to Ventilate – the Clinician or the Patient?
PEEP: Established by limiting exhalation –autoPEEP!Ventilation: Change high to low CPAP and spontaneous breathing at high CPAP!spontaneous breathing at high CPAP! Increased effort to breathe!Markedly reduced intra-thoracic pressure!Induced lung Injury!
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Fast time constant lung unit opening and closing with each change from high to low CPAP
Kacmarek et al Chest 1995;108:1073
Ventilation
Change low to high CPAP frequently very large VT
Spontaneous breathing at highSpontaneous breathing at high CPAP low VT but! Increased effort to breathe!
Plateau Pressure and Tidal Volume: Small tidal volumes and low plateau pressures are used to avoid over distension
Over distension is best evaluated by Transpulmonary pressure
TPP = Pplat – Ppl
Chiumello AJRCCM 2008;178:346“Stress” is defined as the internal distribution of the counterforce per unit area that balances and reacts to an external load.
Lung Stress = Transpulmonary pressure“Strain” is the associated deformation of the structure.
Lung Strain = volume change (VT) to functional residual capacity ratioFRC is the resting FRC, any volume added by the addition of PEEP is added to the volume changeStress = k x Strain, where k equals the specific lung elastance (13.5 cmH2O/ml). If the Strain is 2 the Stress is 27 cmH2O - the TPP in which the FRC doubles.
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Neuman ICM 2002;28:1742
Airway Pressure Release Ventilation: End Inspiratory
Transpulmonary Pressure
TPP = Pplat - PplTPP Pplat Ppl
35 cmH2O = 22 cmH2O – (-13 cmH2O)
Airway Pressure Release Ventilation: End Inspiratory
Compared retrospective data from Shock Trauma to that of 16 other non-RCTs; 8 of which were retrospective reviews and in 7 the time period was entirely before p ythe ARDSnet or stated before the ARDSnetCompared 231 pts to 63,646 patients but did not match patients Incidence of ARDS 14.0% vs. 1.3% Hospital Mortality 14.1% vs. 3.9%
Kallet Respir Care 2011;56:190Daoud et al Respir Care 2012;57:1325
McMullen et al PLoS One 2012;7:e40190
No Data to support that APRV improves survival!improves survival!
No data to support that APRV decreases the length of ICU stay!
No data to support that APRV decreases the length of mechanical ventilation!
APRV – Caution!NO data to indicate APRV is beneficial for management or rescue in ARDS or trauma or any clinical application!