Lung Protective Mechanical
Ventilation
ARDS – Diagnosis and
Prevention
CCCF
October 29, 2012
09:30 – 09:50
SHERATON CENTRE TORONTO HOTEL
MJ|Schultz
Academic Medical Center, Amsterdam, The Netherlands
MJ|Schultz
Laboratory of Experimental Intensive Care and Anesthesiology
MJ|Schultz
Disclosures
• advisor of Hamilton, Maquet and
Novalung (cont.)
• speakers fee from Maquet and
Novalung (paid to institution)
• restricted research grant from Hamilton
(2006)
MJ|Schultz
Mechanical Ventilation – a Double–edged Sword?
MJ|Schultz
That’s the Way We Always Did it (and it Can not be Wrong?)
Agenda
• why lung–protective MV–strategies?
• lower tidal volumes
• are automatic modes safe?
• oxygen
• prevent ventilation?
MJ|Schultz
Animal Studies of MV
• ex vivo
• in vivo
Webb & Tierney. Am. Rev. Respir. Dis. 1974;110:556
Cytokine Responses of Healthy
Lungs Subjected to ex vivo MV
Meier T. Anesth Analg 2008; 107:1265
Animal Studies of MV
• ex vivo
• in vivo
Volutrauma in Healthy Lungs
Subjected to in vivo MV
Dreyfuss D. Am Rev Resp Dis 1988; 137:1159
Moderate VT Increases Lung Injury
Challenged with LPS
Altemeier WA. Am J Physiol 2004; 287:L533
Cytokine Responses and Cellular
Influx in Lungs to in vivo MV
Wolthuis EK. Crit Care 2009; 13:R1
control lower (L)VT higher (H)VT
Agenda
• why lung–protective MV–strategies?
• lower tidal volumes
• are automatic modes safe?
• oxygen
• prevent ventilation?
MJ|Schultz
Use of Lower Tidal Volumes
Benefits Patients with ARDS
ARDS Network. N Engl J Med. 2000; 342:1301
That’s the Way We Always Did it (and it Can not be Wrong?)
Results are not Relevant (???)
Also in Patients with Severe and
Persistent ARDS …
Villar J. Crit Care Med 2006; 34:1311
Hager DN. AJRCCM 2005; 172:1241
And in Patients with Mild ARDS …
Protective Ventilation Strategies in
ALI – Hospital Mortality
Putensen C. Annals of Internal Med 2009; 151:566
NoLow VT at
similar PEEP
High VT at
similar PEEPOdds ratio
Brochard 116 – –
Brower 52 13/26 12/26 1.17 [0.39 – 3.47]
Brower 861 134/342 171/429 0.68 [0.51 – 0.90]
Stewart 120 30/60 28/60 1.14 [0.56 – 2.34]
Summary 0.75 [0.58 – 0.96]
NoLow VT +
high PEEP
High VT +
low PEEPOdds ratio
Amato 53 13/29 17/24 0.33 [0.11 – 1.05]
Villars 95 17/50 24/45 0.41 [0.18 – 0.94]
Summary 0.38 [0.20 – 0.75]
Critically Ill Patients without
ARDS at Onset of MV
Gajic O. Crit Care Med 2004; 32:1817
Critically Ill Patients without
ARDS at Onset of MV
Determann RM. Crit Care 2010; 14:R1
Lower Tidal Volume and Risk
of Lung Injury and Mortality
Serpa Neto A. JAMA 2012; 308:1651
Lower Tidal Volume and Risk
of Lung Injury and Mortality
MJ|Schultz
Mechanical Ventilation as a
Mediator of MOF in ARDS
Ranieri VM. JAMA 2000; 284:43
Higher Tidal Volumes and Organ
Dysfunction after Cardiac Surgery
Lellouche F. Anesthesiology 2012; 116:1072
That’s the Way We Always Did it (and it Can not be Wrong?)
Agenda
• why lung–protective MV–strategies?
• lower tidal volumes
• are automatic modes safe?
• oxygen
• prevent ventilation?
MJ|Schultz
COPD
asthma
emphysema
ARDS, fibrosis, pneumonia
Tidal Volumes with ASV in a
Typical ICU–population
Arnal JM. Intensive Care Medicine 2008; 34:75
Tidal Volumes with ASV in Post–
cardiac surgery Patients
Dongelmans D. Anesthesia & Analgesia 2010; 107:932
Tidal Volumes with ASV in a
Bench–study
Dongelmans D. Int J Artif Org 2010; 33:302
Tidal Volumes with ASV using
Open Lung Approach
Dongelmans D, Anesthesiology 2011; 114:1138
Agenda
• why lung–protective MV–strategies?
• lower tidal volumes
• are automatic modes safe?
• oxygen
• prevent ventilation?
MJ|Schultz
Clinicians’ Response to Hyperoxia
in Ventilated Patients
de Graaff A. Intensive Care Medicine 2011; 37:46
PaO2
category
% of
samples
PaO2
[mean ± SD]
FiO2
[median, IQR]
PEEP
[median, IQR]
< 8 kPa 3.6 7.3 ± 0.7 0.5 [0.4 – 0.6] 10 [7 – 12]
8 – 10 kPa 16.8 9.2 ± 0.6 0.45 [0.4 – 0.5] 9 [5 – 12]
10 – 13 kPa 35.9 11.5 ± 0.8 0.4 [0.4 – 0.5] 8 [5 – 10]
13 – 16 kPa 21.4 14.4 ± 0.9 0.4 [0.4 – 0.42] 5 [5 – 10]
> 16 kPa 22.3 20.7 ± 6.0 0.4 [0.4 – 0.45] 5 [5 – 10]
Clinicians’ Response to Hyperoxia
in Ventilated Patients
FiO2 No change in
FiO2 (%)
change in
PEEP (%)
no
change
0.21 – 0.40 18287 6 17 78
0.41 – 0.6 8451 57 21 35
0.61 – 0.8 866 83 20 15
0.81 – 1.0 618 81 17 18
de Graaff A. Intensive Care Medicine 2011; 37:46
Association between Oxygen
Levels, FiO2 and Outcome
de Jonge E. Crit Care 2008; 12:R156
Hyperoxia and Outcome in
Patients after OHCA
Kilgannon J. JAMA 2010; 303:2165
Hyperoxia Causes a Decline in
Coronary Blood Flow
Farquhar H, Am Heart J 2009; 158:371
Oxygen Therapy for Patients with
Ischemic Stroke
Cornet A, Arch Int Med 2012; 172:289
N oxygen effect
Padma 2010 N = 40 10 L/min no differences in
outcome
Rønning 1999 N = 292 3 L/min increased mortality in a
subgroup of patients
with severe CVA (OR,
0.45; 95% CI, 0.23 –
0.90)
Unpublished
2009
N = 85 30–45 L/min study stopped because
of increased mortality in
oxygen–group
High PaO2–targets
Harmful?
• direct (toxicity)
• indirect (strategies)
That’s the Way We Always Did it (and it Can not be Wrong?)
Agenda
• why lung–protective MV–strategies?
• lower tidal volumes
• are automatic modes safe?
• oxygen
• prevent ventilation?
MJ|Schultz
HYPERINFLATION
DERECRUITMENT
66% not ventilated
33% ventilated
= 18 ml/kg
Hyperinflation Occurs in One–
third of Patients
Terragni PP. AJRCCM. 2007; 175:160
MV–induced Diaphragm Atrophy
Long term ventilation Short term ventilation
Levine S. NEJM. 2008; 358:13
Mortality of ARDS in the Era of
Lung Protective MV
Villar J. Intensive Care Med. 2011; 37:1932
Protective MV?
• do no harm
• VT < 6 ml/kg IBW and/or P < 30 cmH2O
• low FiO2
• PEEP to avoid collapse
• prone positioning?
• recruitment maneuvers?
• consider ‘rescue’ strategies (…, ECMO)
Protective MV?
• do no harm
• consider ‘rescue’ strategies (…, ECMO)
• VT < 6 ml/kg IBW and/or P < 30 cmH2O
• low FiO2
• PEEP to avoid collapse
• prone positioning?
• recruitment maneuvers?
Terminology of Extra–corporeal
SystemsExtra–corporeal
Lung Assist (ECLA)
Extra–corporeal
Life Support (ECLS)
Pumpless
A–V
+ Pump
V–V
+ Pump
V–A
Bein T. Crit Care Med. 2006; 34:1372
Extra–corporeal CO2–removal in
90 ARDS–patients
Zimmerman M. Crit Care. 2009; 13:R10
Extra–corporeal CO2–removal in
51 ARDS–patients
Fast CO2–removal by ECLA Allows
for More Protective MV
Terragni PP. Anesthesiology 2009; 111:826
CESAR trial – ECMO Centers
versus non–ECMO Centers
Peek G. Lancet 2009; 374:1351
Avoiding Intubation in Patients
with Acute Hypercapnic Failure
Kluge S. Intensive Care Medicine 2012; 38:1632
Kluge S. Intensive Care Medicine 2012; 38:1632
Avoiding Intubation in Patients
with Acute Hypercapnic Failure
ECLA to Avoid Intubation –
Risk/Benefit Assessment
Marcus Schultz
That’s the Way We Always Did it (and it Can not be Wrong?)
PaO2 =
PaCO2 =
PaO2 ↓
PaCO2 ↑↑
VA ↓
Primary
Ventilatory
Failure
Absolute
Respiratory
Failure
PaO2 ↓↓
PaCO2 ↑
PaO2 ↓
PaCO2 =
VA/Q ↓ VA ↑
Gas
Exchange
DisturbanceRR ↑↑
Partial
Respiratory
Failure
PaO2 ↓↓
PaCO2 ↑↑
VA ↓
Secondary
Ventilatory
Failure
Absolute
Respiratory
Failure
COPD, Neuromuscular diseases:
ECMO may reduce WOB and may
even prevent MV
COPD, Pneumonia, ARDS, Cardiogenic edema:
ECMO may improve gas exchange
and may allow lung–protective MV
NIV?
Conclusions
• lower tidal volumes, for all ventilated
patients
• cautious with automatic modes safe
• accept lower PaO2
• prevent ventilation