Is Diaphragmatic Function Important to YOUR Practice?

Transcription

1 Is Diaphragmatic Function Important to YOUR Practice?

2 OVERVIEW This presentation discusses neural ventilation and the advantages of accessing the patient s respiratory drive for improving patient care. Topics: Common ventilation/respiratory issues Introducing Edi (electrical diaphragmatic monitoring) and NAVA (Neurally Adjusted Ventilatory Assist) with SERVO-i ventilators Using NAVA or Edi for improved decision support Benefits of enhanced monitoring and synchrony MCV REVA

3 FIRST: HOW DO WE BREATHE? Health μv Disease μv μv Edi ml VT ml ml

4 CONCERNS WITH MECHANICAL VENTILATION Results: Ventilator Associated Pneumonia Complications associated with Sedation Increased work of breathing (>WOB) Increased Length of Intubation (>LOI) Increased risk of pneumothorax Ventilator-induced diaphragm dysfunction (VIDD) Delirium Patient / Ventilator Asynchrony Diaphragm Atrophy/Dysfunction

5 SYNCHRONY Synchrony is a simultaneous occurrence or motion Triggering Synchrony - Inspiratory Trigger Tidal Synchrony - Size of Breath I:E Ratio Synchrony Start/Stop Cycle

6 OTHER CAUSES OF ASYNCHRONY Variable leaks, which could result in: Lung Hyperinflation Increased incidence of pneumothoracies Asynchronous ventilatory support Triggering Tidal asynchrony Breath termination asynchrony Ventilator induced lung injury Patient / Ventilator Asynchrony MCV REVA

7 HIGH RESPIRATORY LOAD Caused by: Elevated elastic and resistive properties Decreased surfactant Unstable chest wall properties Atelectasis Increased caloric consumption Resulting in: Changes to metabolic activity, which can cause: increased breathing rate loss of body heat increased consumption of calories High Respiratory Load MCV REVA

8 SO HOW DO WELL HANDLE IT CURRENTLY? When in doubt, we KNOCK EM OUT! Don t wait, let s SEDATE! WE WILL, WE WILL ROC-uronium YOU!

9 COMPLICATIONS ASSOCIATED WITH SEDATION Source: Lancet 2008;371: Complications associated with Sedation

10 RESULTS OF ABC TRIAL Paired spontaneous awakening and spontaneous breathing improve ventilator free days - 3 Days Decreased time in coma Decrease time in the ICU and Hospital Complications associated with Sedation

11 VENTILATOR INDUCED DIAPHRAGM DYSFUNCTION Loss of diaphragmatic force generating capacity that is specifically related to the use of mechanical ventilation Do wasted efforts contribute to VIDD? Source: Vassilakopoulos T, Retrof BJ. Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med. 2004;169: Diaphragm Atrophy/Dysfunction MCV REVA

12 NEW ENGLAND JOURNAL OF MEDICINE Increase in oxidative stress Activation of degradation pathways proteolysis 50% reduction in muscle fiber cross sectional area Source: Levine S, Nguyen T, Taylor N, et al. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans. New Eng Jrnl Med. 2008;358(13): MCV REVA

13 DIAGNOSING DIAPHRAGM DYSFUNCTION VIDD is a diagnosis of exclusion based on an appropriate hx of having undergone a period of controlled mechanical ventilation. Other causes have been sought and ruled out. Typical scenario in which to suspect VIDD is a patient who fails to wean after a period of CMV. Source: Vassilakopoulos T, Retrof BJ. Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med. 2004;169: Diaphragm Atrophy/Dysfunction

14 IS DIAPHRAGMATIC ACTIVITY IMPORTANT IN YOUR PRACTICE? What is a potential cause of continually failed spontaneous breathing trial? Ventilator Induced Diaphragmatic Dysfunction Loss of diaphragmatic force generating capacity that is specifically related to the use of mechanical ventilation Source: Vassilakopoulos T, Retrof BJ. Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med. 2004;169: Diaphragm Atrophy/Dysfunction

15 ICU COSTS MECHANICAL VENTILATION Initial 2 days were most expensive requiring mechanical ventilation ($10,794 on Day 1 and $ 4,796 on Day 2). Average incremental cost of mechanical ventilation in the ICU is $1,522/PER DAY What the data shows: 1. ICU costs are highest during the first 2 days of admission and lower thereafter 2. Mechanical ventilation is associated with significantly higher daily costs 3. 70% of ICU Mortality occurred in Mechanically Ventilated Patients Dasta, et.al., Critical Care Med 2005 Vol. 33, No. 6 MCV REVA

16 ICU Costs (cont d) ICU patients requiring > 3 weeks of Mechanical Ventilation 50% of ICU Costs Cohen et al. Prolonged ICU stays and Mechanical Ventilation > risk of nosocomial infection and death. MCV REVA

17 IDEAL VENTILATORY MONITORING Ideally, inspiratory efforts should be identified by respiratory center output, phrenic nerve activity, or diaphragm activation. Attempts to monitor diaphragm activation in the clinical setting using electromyography (EMG) have suffered from lack of standardization and frequent signal contamination. 15 years ago monitoring the diaphragm was not practical but today Source: Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M. Patient-Ventilator Trigger Asynchrony in Prolonged Mechanical Ventilation. Chest. 1997;112(6):

18 EDI, NAVA, AND SERVO-i Definitions: NAVA (Neurally Adjusted Edi catheter: nasal or oralventilatory tube that Assist): SERVO-i ventilation uses sensors to measure diaphragm mode thatactivity uses an catheter to electrical at Edi all times during conduct thecontraction diaphragm s electrical diaphragm and at resting activity state to the SERVO-i ventilator (requires software and hardware module) Edi catheter NAVA mode MCV REVA

19 EDI AND NAVA TECHNOLOGY Measuring Edi in the NICU: Edi Catheter MCV REVA

20 EDI SIGNAL A NEW PERSPECTIVE ON RESPIRATORY RATE Components: Edi Peak Pressure Peak Edi Peak Maximum diaphragmatic load generated to inflate the lung (muscle contracted) Edi Min (Minimum) Minimum diaphragmatic load with lung at rest (muscle relaxed) PEEP Pressure Edi Min Edi Signal Indicator for alveolar derecruitment MCV REVA

21 EASY EDI CATHETER POSITIONING The SERVO-i screen provides guidance for catheter placement: 10 Edi sensors measure activity and aid placement ECG (P-waves & QRS) Blue indicator: (Lead II & III) Shows correct positioning Edi signal waveform present (during expiratory hold, positive Edi deflection coincides with negative pressure deflection) MCV REVA

22 EDI ELECTRONIC DIAPHRAGMATIC SIGNAL Respiratory drive revealed: Breath Edi min. peak Termination (Indicator trigger (cycle on) (depth (cycle of derecruitment) off) of inspiration) MCV REVA

23 EDI Monitor Edi during: NAVA Weaning Post-extubation ventilation evaluation Conventional modes MCV REVA

24 EDI V E N IC E E D Information that is helpful in forming a conclusion or judgment Asynchrony? I E I E N X N X S P S P P I P I I R I R R A R A A T A T T I T I I O I O O N O N N N MCV REVA

25 IMPROVED SYNCHRONY BASED ON PATIENT DEMAND Improved synchrony (presence of leaks) Support based on Patient Demand Decision support of diaphragm workload Patient and ventilator working in harmony. MCV REVA

26 NAVA PREVIEW Asynchrony is now measurable: Practical bedside diagnosis of asynchrony NAVA Preview displays measurable asynchrony in any mode of ventilation MCV REVA

27 NEW DIMENSION TO THE RESPIRATORY VITAL SIGN Confirmation of respiratory drive and sedation effects Evaluation of tonic activity indicator of alveolar derecruitment Improved synchrony trigger, breath delivery, breath termination MCV REVA

28 ATROPHY? DYSFUNCTION? OVERASSIST? OVERSEDATION? MAQUET MCV REVA

29 EDI AND NAVA ENHANCED MONITORING AND SYNCHRONY Synchrony Less PIP Less need for oxygen spontaneous breathing; V/Q matching Improved sleep quality Benefits of spontaneous breathing Confirmation of respiratory drive and load Sedative effects on respiratory drive Minimize diaphragm atrophy/dysfunction Continuous apnea monitoring Lung protective spontaneous mode MCV REVA

30 ISSUES WITH TRADITIONAL MECHANICAL VENTILATION NAVA positive triad in mechanical ventilation: Improved Patient / Ventilator Asynchrony Evaluation and Management of Apnea RESULT: Potentially Reduced Length of Intubation Variable Assist Based on Patient Demand MCV REVA