Acuut hypoxemisch falen

Acuut hypoxemisch falen Masterclass IC verpleegkundigen 2016 Leo Heunks longarts - intensivist 4 februari 2016

Casus Patient 58 jaar, opname 10.12 ivm trauma Ter plaatse intubatie bij onrust. Drain bij verdenking PTx SEH hypotensief 80/40 mmhg Trauma screening: Rib # re (1-7, 11), collum #, os pubis #; contusie long CT- C: geen afwijkingen Bloeding in nier Coiling bloeding nier; opname IC postoperatief Herstel neurologie 14.12: extubatie bij EMVmax, overplaatsing MC

CXR opname

Casus vervolg 18.12 AHF 32/min, Spo 2 91% (10 L O 2 /min via NRM) ph 7.37; Pco 2 4.5kPa (34); Po 2 8.5kPa (64); HCO 3-22mM; Fio 2 0.6-0.7 P/F ratio: 91-106 mmhg

CXR 18 januari

Casus vervolg 18.12 AHF 32/min, Spo 2 91% (10 L O 2 /min via NRM) ph 7.37; Pco 2 4.5; Po 2 8.5; HCO - 3 22; Spo 2 91% Fio 2 ± 0.7; P/F ratio: (8.5 * 7.5)/0.7 = 91-106 mmhg Volgende stap?: a.increase oxygen flow on NRM b.hfno c. NIV d.eti

Hypothesis Early NIV compared to O 2 alone on 28 day mortality in immunocompromised patients with acute hypoxemic failure

NIV and hypoxemia Inclusion Immunocompromised pts with acute hypoxemic failure Pao 2 < 60 mmhg (8.0 kpa) on RA RR > 30/min Exclusion: Hypercapnia, cardiac origin hypoxemia Need for ETI

NIV and hypoxemia Noninvasive ventilation PS to obtain TV 7-10 ml/kg PBW 60 min session every 4 hours for at least 2 days Oxygen group O 2 modality at clinicians discretion (including HFNO)

NIV and hypoxemia O 2 (n=183) NIV (n=191) Underlying condition, % (Hemato) cancer Immunosuppr. drugs 85 15 85 15 O 2 flow, L/min 9 (6-15) 9 (5-15) Pao 2 / Fio 2, mmhg 130 (86-205) 156 (95-248) Causes, % Pneumonia 65 67

NIV and hypoxemia Hours 10 8 6 4 (4-11) 8 (4-8) 6 (3-7) 5 First 24 h Day 2 Day 3 % 50 40 30 20 44 P=0.01 31 O2 NIV 2 10 0 gme on NIV 0 HFNC

NIV and hypoxemia: survival 76% 73%

NIV and hypoxemia: intubation 45% 38% All secondary endpoints negative

Conclusies: NIV bij ARDS Redelijk bij P/F ratio > 200 mmhg Terughoudend indien P/F <200 mmhg, Multiorgaan falen Dan trial gedurende 1 uur beoordelen of verbetering P/F

Oxygen administration Venturi mask / NRM Low flow = mix with ambient air Frequent displacement Dry air reduces comfort

Oxygen administration High flow nasal cannula (HFNC) Humidified O 2 up to 60 L/min Low level of PEEP Reduce dead space O 2 reservoir in upper airway

HFNC in acute hypoxemia Aim: Determine whether HFNO or NIV as compared with standard O 2 treatment, could reduce rate of endotracheal intubation Design Multicentre (23) RCT, acute hypoxemic ICU patients P/F < 300 mmhg (>75% pneumonia) Paco 2 < 45 mmhg

HFNC in acute hypoxemia NRM Nonrebreather face mask 10 L O 2 /min to maintain SpO 2 > 92% Until recovery or ETI HFNO Flow rate 50 L/min O 2 adjusted to maintain SpO 2 > 92% 2 days; switch to standard O 2 therapy NIV TV 7-10 ml/kg Adjust PEEP and Fio 2 to maintain Spo 2 > 92% 8 h / day, for at least 2 days; between sessions high flow O 2 (HFNC)

HFNC and intubation: all patients 50% 47% 38% All patients ± N=100/group

HFNC and intubation: P/F < 200mmHg 58% 53% 35% Pao 2 /Fio 2 <200 mmhg

Survival 88% 77% 72%

Conclusion HFNO in acute hypoxemia HFNO does not reduce ETI (whole group) Subgroup (P/F < 200 mmhg): HFNO reduces risk ETI May decreases mortality (mechanism?) But high TV in NIV: 9.2 ± 3 ml/kg @ PS 8 ± 3 cmh 2 O

Aim Assess TV during NIV for AHRF Relationship between TV and NIV failure

High TV during NIV >12 10-12 8-10 In only ±50% of pts TV < 10ml/Kg 6-8 N=62 Pneumonia: 81% NIV failure 52%

High TV during NIV High TV independent risk factor for NIV failure

Conclusions NIV and hypoxemia High TV (>9.5 ml/kg) associated with adverse outcome on NIV Due to VILI or marker of severity of disease? but TV risk factor after correction for severity of disease Do not accept high TV during NIV in hypoxemic failure

Continue case Start NIV (no HFNO available) PEEP 6 cmh 2 O; Fio 2 0.50; PS 6 cmh 2 O AHF 30; TVe ± 600 ml (11 ml/kg PBW) Cannot handle NIV: NRM - NIV

CXR

Case Readmitted to ICU due to progressive hypoxemic failure CXR ARDS?

CXR

ARDS Berlin definition

Lung- protective ventilation in ARDS Low Pplat? Low TV Appropriate PEEP

Initial ventilator settings? Slutsky NEJM, 2010 & 2013

Lung- protective ventilation Low Pplat? Low TV Appropriate PEEP

Pplateau protective? Ptp = Palv - Ppleural Ptp = Pplat - Peso Pplateau: 1. pressure to expand lung (transpulmonary pressure) 2. pressure to expand chest wall (transthoracic pressure)

Pplateau protective?

Lungprotective ventilation Low Pplat Low TV? Appropriate PEEP

What you should know: TV protective? Patient A: ARDS PBW 70 Kg TV 420 ml Patient A: ARDS PBW 70 Kg TV 420 ml

What you should know: TV protective? Not very useful to titrate TV to ml/kg PBW Titrate to available lung tissue: respiratory compliance

Respiratory compliance CRS = V P ml / cmh2o Controlled mechanical ventilation TV C RS = ml ml/cmh 2 O = cmh 2O = driving pressure ( P)

Driving pressure Hypothesis: Driving pressure provides better predictor of outcome in patients with ARDS than TV alone Retrospective analysis of ARDS RCT s (N ± 2400)

Driving pressure at same PEEP Increasing driving pressure increases mortality Mortality corrected for: trial, age, SAPS / APACHE, ph, P/F ratio

Same pressure at higher PEEP Increasing Pplat, by increasing PEEP, but similar P, does not affect mortality Thus Pplat is not a predictor of mortality, if P is not affected

Same Pplat at higher PEEP Increasing PEEP, but maintain Pplat by reducing P, reduces mortality. Thus high PEEP only affects mortality if P is reduced

Tidal volume

Conclusion driving pressure In ARDS reduction in mortality depends on reducing P, not TV But. Retrospective analysis P still a surrogate for transpulmonary pressure To be confirmed in prospective trials

Case Endotracheal intubation TV 5.8 ml/kg pbw PEEP 12 cmh 2 O; Fio 2 0.8 P/F 100 mmhg Next step?

Proning in ARDS

Primary outcome ARDS Pao 2 / Fio 2 < 150 mmhg 16% 33% Proseva, NEJM 2013

Prone better for every P/F studied 40 39 35 Mortality 28 d, % 30 20 24 28 17 30 15 10 7 0 45-87 87-105 105-124 124-150 Proseva, NEJM 2013

Vraag Is het bij ARDS veilig een ondersteunende beademingsvorm te gebruiken? A. Ja B. Ja, indien respiratoire drive niet te hoog is C. Ja, indien teugvolume ongeveer 6 ml/kg is D. Nee

Vraag 1 Bij deze pagënt is het veilig een ondersteunende beademingsvorm te gebruiken A. Ja B. Ja, indien respiratoire drive niet te hoog is C. Ja, indien teugvolume ongeveer 6 ml/kg is D. Nee

Benefits assisted ventilation?

Benefits assisted ventilation 1. Prevent muscle atrophy 2. Improve oxygenation 3. Improve hemodynamics 4. Less sedation / physiological breathing pattern

Benefits assisted ventilation 1. Prevent muscle atrophy 2. Improve oxygenation 3. Improve hemodynamics 4. Less sedation / physiological breathing pattern RISK OF EXCESSIVE TIDAL VOLUME & LUNG DISTENDING PRESSURE

Assisted ventilation in ARDS PCV PSV NAVA 30 min / mode Randomized order N=12 P/F 140 mmhg PEEP 14 cmh 2 O [10-18] Fio 2 0.55 [0.40-0.80] Submitted, 2014

Assisted ventilation in ARDS

Assisted ventilation in ARDS

Assisted ventilation in ARDS ph 7,14

In acute phase of ARDS (low ph) ARDS (P/F < 150 mmhg): NMBA or placebo first 48 h

In very acute phase of ARDS (low ph) 9.6% 31.6% 40.7%

In very acute phase of ARDS (low ph)

Case Recovering from ARDS. To be continued

Take home messages part 1 1. Beperkte rol voor NIV bij hypoxemisch falen (TV) 2. Long- protectieve beademing: geïndividualiseerd (fysiologie) 3. Buikligging is geen rescue therapie 4. Geassisteerde modus alleen indien normalisatie ph @NExCOB NExCOB.nl