Year in review: mechanical ventilation Leo Heunks, MD, PhD Pulmonary and Critical Care Physician Dept of Critical Care Intensivisten dagen 2013
Disclosures Maquet (NAVA catheters, travel fee, speakers fee) Covedien (advisory board) Orion Pharma (research support)
Year in Review 2012 Feb 2012 - feb 2013 My selection bias
Topics covered ECCO2R in ARDS & COPD HFOV Noninvasive ventilation Weaning from mechanical ventilation Patient - ventilator asynchrony
Year in Review (1)
What you should know Prolonged mechanical ventilation: > 21 d MV Small group of patients High percentage of total ventilator days High costs
What you should know Best methods for weaning? PSV SBT
What they did LTACH setting (90 bed center) MV > 21 d & tracheotomized Ready to be weaned Respiratory distress < 5 days of unassisted breathing!
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
What they did Stratification: Early versus late failure Postop, COPD, ARDS, NMD Primary outcome: successful weaning (5 days unassisted breathing)
What they did
What they did
What they found Proportion of patients ventilator dependent
What they found PS TC P weaning duration, d 19 (12-31) 15 (8-25) 0,004 deaths during study, % 15 10 0,23 death 6 mo, % 56 51 0,41 death 12 mo, % 66 60 0,24
What they found PS TC 60 50 P = 0.14 53 % 40 30 20 10 0 45 Successfully weaned
How I interpret these findings 1. SBT-strategy superior to PSV for weaning Prolonged weaning patient, LTACH Single centre... 2. Mortality is high in prolonged weaning patients 3. The ICU is not an ideal weaning environment
Year in Review (2)
What you should know ARDS high mortality VILI due to high tidal volume / low PEEP
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
What you should know Sud, BMJ 2010
What they did (Oscillate) Multicenter worldwide Pulmonary symptomes < 2 weeks P / F < 200 mmhg, Diagnosis ARDS less 72 h Primary outcome: in-hospital mortality
What they did (Oscillate) Stop HFOV if MAP < 25 cmh2o, but could be resumed
What they did (Oscillate)
What they found Early termination N = 500 analysis (planned 1200) HFOV median 3 days [IQR 2-8]
What they found
What they found 71% 60%
What they found HFOV Control 80 79 % 64 66 48 32 47 * 35 16 0 18 13 14 7 In hospital death Barotrauma refractory hypoxemia death after RH *
What they found HFOV Control 80 79 % 64 66 48 32 47 * 35 16 0 18 13 14 7 In hospital death Barotrauma refractory hypoxemia death after RH *
What they found HFOV Control % 80 64 48 32 16 0 47 * 35 18 No subgroups with benefits from HFOV 13 14 7 79 66 In hospital death Barotrauma refractory hypoxemia death after RH *
What you they found
What they found HFOV Control 80 78 60 58 % 40 46 20 26 0 Vasporessor NMBA Day 1
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
What they found N ± 400 / group
What they found (Oscar) HFOV more NMBA More sedation No effect total duration of mechanical ventilation
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
Year in Review (3)
What you know
What you know Acute hypoxemic failure (cardiac + pulmonary) Ferrer, AJRCCM, 2003
What you know Acute hypoxemic failure (cardiac + pulmonary) Ferrer, AJRCCM, 2003
What they did Multicentre, randomized controlled NIV vs venturi mask + O2 ALI patients P / F 200-300 mmhg No left haert failure (Echo / PAC) NIV < 24 h fullfilling inclusion
What they did NIV (BiPAP Vision) PEEP titration as tolerated Fi,o2 target Spo2 92-96% PS titrate TV to > 6 ml/kg (?) Venturi Adjust o2 flow: Sp,o2 92-96% Intubation criteria (P/F < 200 + distress)
What they did Primary endpoint Number of patients meeting ETI criteria and number of patients intubtaed
What they found Early termination!
What they found
What they found NIV Control 40 p = 0.02 ETI for development ARDS 37 30 p = 0.02 % 20 21 10 0 5 Need ETI 5 ETI
What they found NIV Control NIV Control 40 p = 0.02 30 p = 0.09 30 37 p = 0.02 23 26 % % 20 21 15 NS 10 0 5 Need ETI 5 ETI 8 0 5 Dead ICU 8 6 LOS ICU
What they found
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
YiR (2)
What you know Slutsky,, NEJM, 2010
What you know Conventional Low TV 50 38 39,8 p = 0.0007 % 25 31,0 13 6 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
What you know ARDS, 28 Pplat 30 cmh2o, with TV 6 ml/kg n = 10, with DECAP Terragni, Anesthesiology, 2009
What you know 10 kpa 6.6 kpa Terragni, Anesthesiology, 2009
What you know
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
What they did Multicenter (D + A), 2007-2010 Patients: ARDS, P / F < 200 mmhg Pplat > 25 cmh2o, TV 6 ml/kg
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)
What they found
What they found All P / F < 150 mmhg ECCO2R Control ECCO2R Control 20 20 15 15 p = 0.03 10 10 9 10 11 5 5 5 0 28 VFD 0 28 VFD N = 10 and N = 20
What they found ECCO2R Control ECCO2R Control 20 60 % 15 10 18 NS 15 days 40 NS 5 20 0 Hospital mortality 0 LOS - ICU
What they found
What they found TNF-a IL-6 IL-8 40 32 200 160 100 80 pg/ml 24 16 pg/ml 120 80 * * * ng/ml 60 40 8 40 20 0 0 24 48 72 0 0 24 48 72 0 0 24 48 72 ECCO2R Control
What they found 6A 5A inter-group: p=0.2429 intra-group: p<0.001 control avecco 2 -R 5B 6B inter-group: p=0.0001 intra-group: p<0.5722 days days Figure 6!
How I interpret these data 1. ECCO2R is feasible in ARDS 2. Negatie study 3. Role for ECCO2R in ARDS is unknown
Year in Review (1) Burki and Moerer
What you know NIV in for AE-COPD in ICU Need for intubation, % In hospital mortality, % 80 60 74 30 23 29 40 P<0.001 15 P<0.02 20 26 8 9 0 0 N = 42 / group FEV1 ~ 28% pred Pa,co2 ~ 8.9 kpa ph ~ 7.28 Standard NIV Brochard, NEJM, 1995
What they did Aim Evaluate safety and efficacy of ECCO2R in hypercapnic respiratory failure
What they did VV-ECCO2R Low flow system
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
What they did Group 1 (n=7): AE-COPD + NIV with high likelyhood ETI COPD GOLD stage III/IV
What they found Group 1: AE-COPD + NIV
What they found Group 1: AE-COPD + NIV
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
What they found T = 0 T = 48h 10 8 7,2 P<0.03 5 3 3,6 0 Dyspnea score
What they found Complications Number (n= 20) Thrombocytopenia Transfusion needed Dead due to catheter placement Leg thrombosis Pneumothorax Significant bleeding (RBC) 8 1 1 1 1 3
How I interpret these results 1. ECCO2R feasible in AE-COPD 2. Use only in scientfic studies 3. New indications may arise
Year in Review (4)
(1) Asynchrony
(1) Asynchrony
(1) Asynchrony
(2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
(2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
(2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
(2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
(2) Dyssynchrony Early cycling on Late cycling on Early cycling off Late cycling off Evidence for clinical relevance emerging
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
What they did angle = dp Ttotmech *360
What they did Reverse triggering angle = dp Ttotmech *360
What they did ARDS, N = 8 PAC or VAC, deep sedation (RASS -4 / -5)
What they found
What they found Neural efforts before cycling off
What they found Reverse triggering affected by vent settings
What they found angle = dp Ttotmech *360
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
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
Mechanical ventilation 2012 1. 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