Year in review: mechanical ventilation
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1 Year in review: mechanical ventilation Leo Heunks, MD, PhD Pulmonary and Critical Care Physician Dept of Critical Care Intensivisten dagen 2013
2 Disclosures Maquet (NAVA catheters, travel fee, speakers fee) Covedien (advisory board) Orion Pharma (research support)
3 Year in Review 2012 Feb feb 2013 My selection bias
4 Topics covered ECCO2R in ARDS & COPD HFOV Noninvasive ventilation Weaning from mechanical ventilation Patient - ventilator asynchrony
5 Year in Review (1)
6 What you should know Prolonged mechanical ventilation: > 21 d MV Small group of patients High percentage of total ventilator days High costs
7 What you should know Best methods for weaning? PSV SBT
8 What they did LTACH setting (90 bed center) MV > 21 d & tracheotomized Ready to be weaned Respiratory distress < 5 days of unassisted breathing!
9 What they did Trach collar group PSV group Day 1 Max 12 h SBT Initial PSV target RR 30 / min Day 2 Max 12 h SBT Reduce PS level 2 cmh2o thrice a day Day 3 Max 24 h SBT / 24 h Tolerate 6 cmh2o for 12h: SBT trials Fail: resume ACV for rest of day Fail: Increase PS by 2 cmh2o every 3 min until comfortable ACV TV: 8 ml/kg, RR 4-6 < patient RR
10 What they did Stratification: Early versus late failure Postop, COPD, ARDS, NMD Primary outcome: successful weaning (5 days unassisted breathing)
11 What they did
12 What they did
13 What they found Proportion of patients ventilator dependent
14 What they found PS TC P weaning duration, d 19 (12-31) 15 (8-25) 0,004 deaths during study, % ,23 death 6 mo, % ,41 death 12 mo, % ,24
15 What they found PS TC P = % Successfully weaned
16 How I interpret these findings 1. SBT-strategy superior to PSV for weaning Prolonged weaning patient, LTACH Single centre Mortality is high in prolonged weaning patients 3. The ICU is not an ideal weaning environment
17
18 Year in Review (2)
19 What you should know ARDS high mortality VILI due to high tidal volume / low PEEP
20 What you should know HFOV Tidal volume 1-2 ml/kg High respiratory rate: 3-15 / sec Small studies suggest benefit Tends to be used earlier in ARDS
21 What you should know Sud, BMJ 2010
22 What they did (Oscillate) Multicenter worldwide Pulmonary symptomes < 2 weeks P / F < 200 mmhg, Diagnosis ARDS less 72 h Primary outcome: in-hospital mortality
23 What they did (Oscillate) Stop HFOV if MAP < 25 cmh2o, but could be resumed
24 What they did (Oscillate)
25 What they found Early termination N = 500 analysis (planned 1200) HFOV median 3 days [IQR 2-8]
26 What they found
27 What they found 71% 60%
28 What they found HFOV Control % * In hospital death Barotrauma refractory hypoxemia death after RH *
29 What they found HFOV Control % * In hospital death Barotrauma refractory hypoxemia death after RH *
30 What they found HFOV Control % * No subgroups with benefits from HFOV In hospital death Barotrauma refractory hypoxemia death after RH *
31 What you they found
32 What they found HFOV Control % Vasporessor NMBA Day 1
33 What they did (Oscar) Multicentre UK P / F < 200 mmhg, ARDS criteria Inclusion within 7 days of MV Protocol mosly as oscillate trial Primary outcome: vital status at 30 days
34 What they found N ± 400 / group
35 What they found (Oscar) HFOV more NMBA More sedation No effect total duration of mechanical ventilation
36 How I interpret these data 1. No role for HFOV in ARDS 2. New modes / devices should be studied before widespread implementation 3. Another wrong meta-analysis
37 Year in Review (3)
38 What you know
39 What you know Acute hypoxemic failure (cardiac + pulmonary) Ferrer, AJRCCM, 2003
40 What you know Acute hypoxemic failure (cardiac + pulmonary) Ferrer, AJRCCM, 2003
41 What they did Multicentre, randomized controlled NIV vs venturi mask + O2 ALI patients P / F mmhg No left haert failure (Echo / PAC) NIV < 24 h fullfilling inclusion
42 What they did NIV (BiPAP Vision) PEEP titration as tolerated Fi,o2 target Spo % PS titrate TV to > 6 ml/kg (?) Venturi Adjust o2 flow: Sp,o % Intubation criteria (P/F < distress)
43 What they did Primary endpoint Number of patients meeting ETI criteria and number of patients intubtaed
44 What they found Early termination!
45 What they found
46 What they found NIV Control 40 p = 0.02 ETI for development ARDS p = 0.02 % Need ETI 5 ETI
47 What they found NIV Control NIV Control 40 p = p = p = % % NS Need ETI 5 ETI Dead ICU 8 6 LOS ICU
48 What they found
49 How I interpret these data 1. NIV is safe in mild ARDS 2. NIV might prevent intubation in mild ARDS 3. Highly skilled team necessary
50 YiR (2)
51 What you know Slutsky,, NEJM, 2010
52 What you know Conventional Low TV ,8 p = % 25 31, ml/kg 0 Mortality P,plat: Conventional: 33 cmh2o Low tidal volume: 25 cmh2o ARDSNet NEJM, 2000 Terragni, Am J Respir Crit Care Med, 2007
53 What you know ARDS, 28 Pplat 30 cmh2o, with TV 6 ml/kg n = 10, with DECAP Terragni, Anesthesiology, 2009
54 What you know 10 kpa 6.6 kpa Terragni, Anesthesiology, 2009
55 What you know
56 What they did Hypothesis TV 3 ml/kg + ECCO2R more lung protective and better clinical outcome compared to TV 6 ml/kg Primary outcome: Proportion of days w/o assist
57 What they did Multicenter (D + A), Patients: ARDS, P / F < 200 mmhg Pplat > 25 cmh2o, TV 6 ml/kg
58 What they did ECCO2R group Pumpless device, AV cannulation TV 3 ml/kg, ARDSNet high PEEP table Criteria for ECCO2R weaning Control group 6 ml/kg ph > 7,2. (buffer (TRIS) allowed)
59 What they found
60 What they found All P / F < 150 mmhg ECCO2R Control ECCO2R Control p = VFD 0 28 VFD N = 10 and N = 20
61 What they found ECCO2R Control ECCO2R Control % NS 15 days 40 NS Hospital mortality 0 LOS - ICU
62 What they found
63 What they found TNF-a IL-6 IL pg/ml pg/ml * * * ng/ml ECCO2R Control
64 What they found 6A 5A inter-group: p= intra-group: p<0.001 control avecco 2 -R 5B 6B inter-group: p= intra-group: p< days days Figure 6!
65 How I interpret these data 1. ECCO2R is feasible in ARDS 2. Negatie study 3. Role for ECCO2R in ARDS is unknown
66 Year in Review (1) Burki and Moerer
67 What you know NIV in for AE-COPD in ICU Need for intubation, % In hospital mortality, % P< P< N = 42 / group FEV1 ~ 28% pred Pa,co2 ~ 8.9 kpa ph ~ 7.28 Standard NIV Brochard, NEJM, 1995
68 What they did Aim Evaluate safety and efficacy of ECCO2R in hypercapnic respiratory failure
69 What they did VV-ECCO2R Low flow system
70 What they did Group 1 (n=7): AE-COPD + NIV with high likelyhood ETI Group 2 (n=2): AE-COPD + failed weaning NIV, not to be intubated Group 3 (n=11): Hypercapnic failure, failed weaning IMV >1 time or failed once and did not want further IMV
71 What they did Group 1 (n=7): AE-COPD + NIV with high likelyhood ETI COPD GOLD stage III/IV
72 What they found Group 1: AE-COPD + NIV
73 What they found Group 1: AE-COPD + NIV
74 What they found Patients Number (n= 7) Time on NIV before ECCO2R, d 5 Time on ECCO2R, h 90 Outcome day 30 ETI NIV Dead 0 3 4
75 What they found T = 0 T = 48h ,2 P< ,6 0 Dyspnea score
76 What they found Complications Number (n= 20) Thrombocytopenia Transfusion needed Dead due to catheter placement Leg thrombosis Pneumothorax Significant bleeding (RBC)
77 How I interpret these results 1. ECCO2R feasible in AE-COPD 2. Use only in scientfic studies 3. New indications may arise
78 Year in Review (4)
79 (1) Asynchrony
80 (1) Asynchrony
81 (1) Asynchrony
82 (2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
83 (2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
84 (2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
85 (2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
86 (2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
87 What they did Pes / Edi in AC ventilated patients (previous studies) Identify respiratory entrainment Inspiratory efforts over a specific and repetitive phase of the ventilator cycle
88 What they did angle = dp Ttotmech *360
89 What they did Reverse triggering angle = dp Ttotmech *360
90 What they did ARDS, N = 8 PAC or VAC, deep sedation (RASS -4 / -5)
91 What they found
92 What they found Neural efforts before cycling off
93 What they found Reverse triggering affected by vent settings
94 What they found angle = dp Ttotmech *360
95 How I interpret this study 1. Patient ventilator interaction is very complex 2. Reverse triggering new type of P-V asynchrony 3. Difficult to detect from flow - pressure curve 4. May induce lung injury
96 How I interpret this study 1. Patient ventilator interaction is very complex 2. Reverse triggering new type of P-V asynchrony 3. Difficult to detect from flow - pressure curve 4. May induce lung injury
97 Mechanical ventilation Severe (H1N1) ARDS = ECMO center 2. Volutrauma, lagere P,plat 3. P-V asynchrony is unrecognized 4. NIV helps weaning in COPD 5. Respiratory muscles dislike by CMV 6. IMT improves weaning outcome
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