Lung Protective Mechanical

Ventilation

ARDS – Diagnosis and

Prevention

CCCF

October 29, 2012

09:30 – 09:50

SHERATON CENTRE TORONTO HOTEL

MJ|Schultz

Academic Medical Center, Amsterdam, The Netherlands

MJ|Schultz

Laboratory of Experimental Intensive Care and Anesthesiology

MJ|Schultz

Disclosures

• advisor of Hamilton, Maquet and

Novalung (cont.)

• speakers fee from Maquet and

Novalung (paid to institution)

• restricted research grant from Hamilton

(2006)

MJ|Schultz

Mechanical Ventilation – a Double–edged Sword?

MJ|Schultz

That’s the Way We Always Did it (and it Can not be Wrong?)

Agenda

• why lung–protective MV–strategies?

• lower tidal volumes

• are automatic modes safe?

• oxygen

• prevent ventilation?

MJ|Schultz

Animal Studies of MV

• ex vivo

• in vivo

Webb & Tierney. Am. Rev. Respir. Dis. 1974;110:556

Cytokine Responses of Healthy

Lungs Subjected to ex vivo MV

Meier T. Anesth Analg 2008; 107:1265

Animal Studies of MV

• ex vivo

• in vivo

Volutrauma in Healthy Lungs

Subjected to in vivo MV

Dreyfuss D. Am Rev Resp Dis 1988; 137:1159

Moderate VT Increases Lung Injury

Challenged with LPS

Altemeier WA. Am J Physiol 2004; 287:L533

Cytokine Responses and Cellular

Influx in Lungs to in vivo MV

Wolthuis EK. Crit Care 2009; 13:R1

control lower (L)VT higher (H)VT

Agenda

• why lung–protective MV–strategies?

• lower tidal volumes

• are automatic modes safe?

• oxygen

• prevent ventilation?

MJ|Schultz

Use of Lower Tidal Volumes

Benefits Patients with ARDS

ARDS Network. N Engl J Med. 2000; 342:1301

That’s the Way We Always Did it (and it Can not be Wrong?)

Results are not Relevant (???)

Also in Patients with Severe and

Persistent ARDS …

Villar J. Crit Care Med 2006; 34:1311

Hager DN. AJRCCM 2005; 172:1241

And in Patients with Mild ARDS …

Protective Ventilation Strategies in

ALI – Hospital Mortality

Putensen C. Annals of Internal Med 2009; 151:566

NoLow VT at

similar PEEP

High VT at

similar PEEPOdds ratio

Brochard 116 – –

Brower 52 13/26 12/26 1.17 [0.39 – 3.47]

Brower 861 134/342 171/429 0.68 [0.51 – 0.90]

Stewart 120 30/60 28/60 1.14 [0.56 – 2.34]

Summary 0.75 [0.58 – 0.96]

NoLow VT +

high PEEP

High VT +

low PEEPOdds ratio

Amato 53 13/29 17/24 0.33 [0.11 – 1.05]

Villars 95 17/50 24/45 0.41 [0.18 – 0.94]

Summary 0.38 [0.20 – 0.75]

Critically Ill Patients without

ARDS at Onset of MV

Gajic O. Crit Care Med 2004; 32:1817

Critically Ill Patients without

ARDS at Onset of MV

Determann RM. Crit Care 2010; 14:R1

Lower Tidal Volume and Risk

of Lung Injury and Mortality

Serpa Neto A. JAMA 2012; 308:1651

Lower Tidal Volume and Risk

of Lung Injury and Mortality

MJ|Schultz

Mechanical Ventilation as a

Mediator of MOF in ARDS

Ranieri VM. JAMA 2000; 284:43

Higher Tidal Volumes and Organ

Dysfunction after Cardiac Surgery

Lellouche F. Anesthesiology 2012; 116:1072

That’s the Way We Always Did it (and it Can not be Wrong?)

Agenda

• why lung–protective MV–strategies?

• lower tidal volumes

• are automatic modes safe?

• oxygen

• prevent ventilation?

MJ|Schultz

COPD

asthma

emphysema

ARDS, fibrosis, pneumonia

Tidal Volumes with ASV in a

Typical ICU–population

Arnal JM. Intensive Care Medicine 2008; 34:75

Tidal Volumes with ASV in Post–

cardiac surgery Patients

Dongelmans D. Anesthesia & Analgesia 2010; 107:932

Tidal Volumes with ASV in a

Bench–study

Dongelmans D. Int J Artif Org 2010; 33:302

Tidal Volumes with ASV using

Open Lung Approach

Dongelmans D, Anesthesiology 2011; 114:1138

Agenda

• why lung–protective MV–strategies?

• lower tidal volumes

• are automatic modes safe?

• oxygen

• prevent ventilation?

MJ|Schultz

Clinicians’ Response to Hyperoxia

in Ventilated Patients

de Graaff A. Intensive Care Medicine 2011; 37:46

PaO2

category

% of

samples

PaO2

[mean ± SD]

FiO2

[median, IQR]

PEEP

[median, IQR]

< 8 kPa 3.6 7.3 ± 0.7 0.5 [0.4 – 0.6] 10 [7 – 12]

8 – 10 kPa 16.8 9.2 ± 0.6 0.45 [0.4 – 0.5] 9 [5 – 12]

10 – 13 kPa 35.9 11.5 ± 0.8 0.4 [0.4 – 0.5] 8 [5 – 10]

13 – 16 kPa 21.4 14.4 ± 0.9 0.4 [0.4 – 0.42] 5 [5 – 10]

> 16 kPa 22.3 20.7 ± 6.0 0.4 [0.4 – 0.45] 5 [5 – 10]

Clinicians’ Response to Hyperoxia

in Ventilated Patients

FiO2 No change in

FiO2 (%)

change in

PEEP (%)

no

change

0.21 – 0.40 18287 6 17 78

0.41 – 0.6 8451 57 21 35

0.61 – 0.8 866 83 20 15

0.81 – 1.0 618 81 17 18

de Graaff A. Intensive Care Medicine 2011; 37:46

Association between Oxygen

Levels, FiO2 and Outcome

de Jonge E. Crit Care 2008; 12:R156

Hyperoxia and Outcome in

Patients after OHCA

Kilgannon J. JAMA 2010; 303:2165

Hyperoxia Causes a Decline in

Coronary Blood Flow

Farquhar H, Am Heart J 2009; 158:371

Oxygen Therapy for Patients with

Ischemic Stroke

Cornet A, Arch Int Med 2012; 172:289

N oxygen effect

Padma 2010 N = 40 10 L/min no differences in

outcome

Rønning 1999 N = 292 3 L/min increased mortality in a

subgroup of patients

with severe CVA (OR,

0.45; 95% CI, 0.23 –

0.90)

Unpublished

2009

N = 85 30–45 L/min study stopped because

of increased mortality in

oxygen–group

High PaO2–targets

Harmful?

• direct (toxicity)

• indirect (strategies)

That’s the Way We Always Did it (and it Can not be Wrong?)

Agenda

• why lung–protective MV–strategies?

• lower tidal volumes

• are automatic modes safe?

• oxygen

• prevent ventilation?

MJ|Schultz

HYPERINFLATION

DERECRUITMENT

66% not ventilated

33% ventilated

= 18 ml/kg

Hyperinflation Occurs in One–

third of Patients

Terragni PP. AJRCCM. 2007; 175:160

MV–induced Diaphragm Atrophy

Long term ventilation Short term ventilation

Levine S. NEJM. 2008; 358:13

Mortality of ARDS in the Era of

Lung Protective MV

Villar J. Intensive Care Med. 2011; 37:1932

Protective MV?

• do no harm

• VT < 6 ml/kg IBW and/or P < 30 cmH2O

• low FiO2

• PEEP to avoid collapse

• prone positioning?

• recruitment maneuvers?

• consider ‘rescue’ strategies (…, ECMO)

Protective MV?

• do no harm

• consider ‘rescue’ strategies (…, ECMO)

• VT < 6 ml/kg IBW and/or P < 30 cmH2O

• low FiO2

• PEEP to avoid collapse

• prone positioning?

• recruitment maneuvers?

Terminology of Extra–corporeal

SystemsExtra–corporeal

Lung Assist (ECLA)

Extra–corporeal

Life Support (ECLS)

Pumpless

A–V

+ Pump

V–V

+ Pump

V–A

Bein T. Crit Care Med. 2006; 34:1372

Extra–corporeal CO2–removal in

90 ARDS–patients

Zimmerman M. Crit Care. 2009; 13:R10

Extra–corporeal CO2–removal in

51 ARDS–patients

Fast CO2–removal by ECLA Allows

for More Protective MV

Terragni PP. Anesthesiology 2009; 111:826

CESAR trial – ECMO Centers

versus non–ECMO Centers

Peek G. Lancet 2009; 374:1351

Avoiding Intubation in Patients

with Acute Hypercapnic Failure

Kluge S. Intensive Care Medicine 2012; 38:1632

Kluge S. Intensive Care Medicine 2012; 38:1632

Avoiding Intubation in Patients

with Acute Hypercapnic Failure

ECLA to Avoid Intubation –

Risk/Benefit Assessment

Marcus Schultz

That’s the Way We Always Did it (and it Can not be Wrong?)

PaO2 =

PaCO2 =

PaO2 ↓

PaCO2 ↑↑

VA ↓

Primary

Ventilatory

Failure

Absolute

Respiratory

Failure

PaO2 ↓↓

PaCO2 ↑

PaO2 ↓

PaCO2 =

VA/Q ↓ VA ↑

Gas

Exchange

DisturbanceRR ↑↑

Partial

Respiratory

Failure

PaO2 ↓↓

PaCO2 ↑↑

VA ↓

Secondary

Ventilatory

Failure

Absolute

Respiratory

Failure

COPD, Neuromuscular diseases:

ECMO may reduce WOB and may

even prevent MV

COPD, Pneumonia, ARDS, Cardiogenic edema:

ECMO may improve gas exchange

and may allow lung–protective MV

NIV?

Conclusions

• lower tidal volumes, for all ventilated

patients

• cautious with automatic modes safe

• accept lower PaO2

• prevent ventilation