Spontaneous breathing efforts. Laurent Brochard
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1 Spontaneous breathing efforts during ARDS ventilation Laurent Brochard
2 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)
3 Timing Chest Imaging a Origin of Edema Oxygenation b Acute Respiratory Distress Syndrome Within 1 week of a known clinical insult or new/worsening respiratory symptoms Bilateral opacities not fully explained by effusions, lobar/lung collapse, or nodules Respiratory failure not fully explained by cardiac failure or fluid overload; Need objective assessment (e.g., echocardiography) to exclude hydrostatic edema if no risk factor present Mild Moderate Severe 200<PaO 2 /FiO 2 < <PaO with 2 /FiO 2 <200 PaO 2 /FiO2<100 PEEP or CPAP with with 5 cmh 2 O c PEEP 5 cmh 2 O PEEP 5 cmh 2 O a Chest X-ray or CT Scan b If altitude higher than 1000m,correction factor should be made as follows: PaO 2 /FiO 2 x (barometric pressure/760) c This may be delivered non-invasively in the Mild ARDS group
4 Increasing Intensity of Intervention Ferguson N et al ICM 2012 ECMO ECCO 2 -R NIV Low Moderate PEEP Higher PEEP HFO Neuromuscular Blockade Prone Positioning Low Tidal Volume Ventilation Increasing Severity of Lung Injury Mild ARDS Moderate ARDS Severe ARDS PaO 2 /FiO 2
5 Why is spontaneous breathing desirable? Preserve Respiratory Muscle Function (avoid VIDD) Improve VA/Q and Regional Ventilation Levine S et al. N Engl J Med 2008;358:
6 PNO 4% vs 12% Papazian L. NEJM 2010
7 Modes of ventilation Controlled MV Assist Control? Bilevel Pressure Ventilation? Pressure Support ventilation?
8 Volume Assist-Control Flow (L/sec) Paw (cm H 2 O) Pes (cm H 2 O) Akouniamaki E et al CHEST in press
9 Presure Assist-Control Paw (cm H2O) Flow (L/sec) EAdi (µv) Akouniamaki E et al CHEST in press
10 Entrainment: reverse triggering Akouniamaki E et al CHEST in press
11 Spontaneous Breathing (CPAP) Not BiPap!! PCV
12
13 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
14
15 High and low Paw with APRV/BIPAP (white squares) and ACV (black circles). Daily ratio of PaO2 to FiO2 (grey columns cases and white columns controls)
16 Outcomes of patients included in the matched-case study Gonzales ICM 2010
17 Pressure-Preset Modes No i-synchronization APRV Partial i-synchronization BIPAP, DuoPAP, BiVent, Bilevel, etc. Full i-synchronization BIPAPassist,, BiPAP PS Assist Pressure controlled, etc. Akoumianaki E et al. ESICM 2012
18 VT (ml) VT (ml) VT (ml) VT change in the presence of spontaneous breaths according to i-synchronization 6ml/kg/IBW No spontaneous breaths time (sec) 10 ml/kg/ibw 6 ml/kg/ibw Fully i-synchronized modes 10 ml/kg/ibw 6 ml/kg/ibw 4 ml/kg/ibw Non Non i-synchronized i-synchronized modes modes
19 METHODS: settings Artificial lung settings C Rrs : 30ml/cmH 2 O R Rrs : 5 cmh 2 O/lt/min P mus : -10 cmh 2 O RR: 20, 30 br/min Ti: 0.8 sec Ventilator settings PAW insp : 30 cmh 2 O PEEP : 15 cmh 2 O RR: 15/min I:E ratios: 1:3 and 3:1
20 Tidal volume (ml) Coefficient of variation (%) RESULTS: I:E 1/3, RR No i-synchronization Partial i- Synchronization PS 0 Partial i- Synchronization PS 15 Full i-synchronization Tidal volume Coefficient of variation
21 Tidal volume (ml) Coefficient of variation (%) RESULTS: I/E 3:1, RR No i-synchronization Partial i-synchronization PS 0 Partial i-synchronization PS 15 Full i-synchronization 0 Tidal volume Coefficient of variation
22 Bench study: preliminary conclusions In the presence of spontaneous breathing the same settings across different Pressure-Preset modes lead to different values of V T, Ptp and breathing variability As i-synchronization increases, VT and Ptp increase while variability decreases These effects of i-synchronization are less pronounced at higher I:E ratio Clinicians should be aware that i-synchronization may be harmful when high VT is undesirable (ARDS)
23 JAMA 2008
24 BIPAP APRV (EXPRESS) at H24: Target sedation based on (SB) as a %of total Vmn total Delta Pressure for Vt 6 ml/kg
25 Patient DATA Trends
26 The mode of ventilation allowing SB may depend on the stage/severity of ARDS Early: controlled with NMBA, (no entrainment?) At 48h: non synchronous pressure targeted ventilation («APRV») Later: synchronous pressure targeted ventilation («Assist Pressure Control, Pressure Support Ventilation»)
27 Thank you!
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ACUTELY DECOMPENSATED HEART FAILURE Role of Noninvasive Ventilation in the Management of Acutely Decompensated Heart Failure Edward A. Panacek, MD, MPH, J. Douglas Kirk, MD Division of Emergency Medicine,
Tests. Pulmonary Functions
Pulmonary Functions Tests Static lung functions volumes Dynamic lung functions volume and velocity Dynamic Tests Velocity dependent on Airway resistance Resistance of lung tissue to change in shape Dynamic