Mechanical VentilationStrategies in Anesthesia
PAOLO PELOSI, MD, FERS
Department of Surgical Sciences and Integrated Diagnostics (DISC), San
Martino Policlinico Hospital– IRCCS for Oncology, University of Genoa, Italy
Conflicts of interest
I declareNO conflicts of interest
Pelosi P for the PROVE Network (www.provenet.eu)
http://www.provenet.eu/
To performLarge multicenter clinicalstudies, randomizedcontrolled trials, and
meta‐analyses
PROtective VEntilation NETWORK
Pelosi P for the PROVE Network (www.provenet.eu)
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
ERAS ReccomendationsNo place for Intra-op Protective MV !
Pelosi P for the PROVE Network (www.provenet.eu)
Pelosi P for the PROVE Network (www.provenet.eu)
Anesthesiology. 2016 Dec;125(6):1079-1082
Pelosi P for the PROVE Network (www.provenet.eu)
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Awake Anesthesia, spontaneous breathing
Anesthesia, and paralysis Spontaneous breathing 48 hrs postop
Strandberg et al Acta Anaesthesiol Scand. 1986 Feb;30(2):154-81
Atelectasis, Anesthesia and Post-Operative period
Pelosi P for the PROVE Network (www.provenet.eu)
Atelectasis and General Anesthesia
0
5
10
15
20
25Number of Patients
Atelectasis [% lung tissue]
Lundquist H. et al. (1995) Acta Radiologica 36; 626-632
(n = 109)
Brismar B. et al. Anesthesiology 1985 Apr;62(4):422-8
Pelosi P for the PROVE Network (www.provenet.eu)
Atelectasis and lung function in the postoperative period
Lindberg P et al. Acta Anaesthesiol Scand 1992: 36: 546-553
Pelosi P for the PROVE Network (www.provenet.eu)
Post-Op. Atelectasis: Myth or Reality ? Güldner A. et al. Anesthesiology 2015 June 29 [Epub Ahead of Print]
Pelosi P for the PROVE Network (www.provenet.eu)
Agenda
• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone
abdominal or thoracic surgerySerpa Neto A. et al. Lancet Respir Med. 2014 Dec; 2(12):1007-15.
25.2% 39.4%
Mortality
1.4%
PulmonaryComplications• ARISCAT 6.2%• Periscope 8.0%• Las Vegas 10.0%
Pelosi P for the PROVE Network (www.provenet.eu)
Epidemiology, Practice of Ventilation and Outcome for Patients at Increased Risk of PPCs
(LAS VEGAS) – an Observational Study in 29 Countries
Pelosi P for the PROVE Network (www.provenet.eu)
• 146 hospitals across 29 countries
• 9,864 patients
• Patients at increased risk - 28.4%
ARISCAT>=26ARISCAT<26
The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
Pelosi P for the PROVE Network (www.provenet.eu)
Epidemiology, Practice of Ventilation and Outcome for Patients at Increased Risk of PPCs
(LAS VEGAS) – an Observational Study in 29 CountriesThe LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
To Predict the Risk of PPCs: “ARISCAT” Score
13 % (score 26-44) – 54 % (score >45) risk to develop PPCs
Canet J. et al. for ARISCAT, Anesthesiology. 2010; 113(6):1338-50.
11
Mazo V. et al. Anesthesiology. 2014 Aug;121(2):219-31
Pelosi P for the PROVE Network (www.provenet.eu)
Post-operative atelectasis and Post-operative SatO2
Ball L, Bluth T, Guldner A et al. 2016 (in preparation)
sensitivity 92%, specificity 62%.
Pelosi P for the PROVE Network (www.provenet.eu)
Post-operative atelectasis and Post-operative SatO2
Ball L, Bluth T, Guldner A et al. 2016 (in preparation)
sensitivity 92%, specificity 62%.
Pelosi P for the PROVE Network (www.provenet.eu)
0
5
10
15
20
25
30
<90% >90-92 >92-94 >94-96 >96-98 >98%
PPC and Preoperative SpO2
SpO2
PPCs & preoperative SpO2Mazo V. et al. Anesthesiology. 2014 Aug;121(2):219-31
Canet J. et al. Eur J Anaesthesiol. 2015 Jul;32(7):458-70
Pelosi P for the PROVE Network (www.provenet.eu)
The accuracy of postoperative, noninvasiveAir-Test to diagnose atelectasis in healthy
patients after surgeryFerrando C et al. BMJ Open 2017;7:e015560
The presence of atelectasis was confirmed by CT scans inall patients (30/30) with positive and in 5 patients (17%)
with negative Air-Test results
Based on the Air-Test, postop atelectasis (CT>2%)
was present in 36% of the patients
Pelosi P for the PROVE Network (www.provenet.eu)
How to early recognize sepsis: qSOFA?Singer M et al. JAMA. 2016;315(8):801-810
1) Respiratory rate ≥22 breaths/min2) Altered mentation3) Systolic blood pressure ≤100 mmHg4) Sat O2 in air < 94%
Quick SOFA (qSOFA)Seymour CW et al. JAMA. 2016;315(8):762-774
- additional tests to evaluate organ function- prompt intervention - increased surveillance / transfer to ICU?
THAM = Tachypnea, Hypotension, Altered Mentation
In ED and ward settings
Pelosi P for the PROVE Network (www.provenet.eu)
Pelosi P for the PROVE Network (www.provenet.eu)
National Early Warning Score ( NEWS)To assess the acute-illness severity
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Ann Transl Med 2016;4(1):17Pelosi P for the PROVE Network (www.provenet.eu)
Vidal Melo M.F., Eikermann M. Anesthesiology 2013; 118:1254-7Brismar B. et al. Anesthesiology. 1985 Apr;62(4):422-8
Awake
MV & ZEEP
MV & PEEP
Duggan M, Kavanagh BP, Anesthesiology 2005; 102: 838-54.
Ball L et al. Minerva Anestesiol. 2017 May 19. (Epub ahead of print)
Pelosi P for the PROVE Network (www.provenet.eu)
British Journal of Anaesthesia, 2016 Mar;116(3):438-9.
Pelosi P for the PROVE Network (www.provenet.eu)
Ball L. and Pelosi P. Minerva Anestesiol. 2016 Mar;82(3):265-7MV & Postoperative Respiratory Disorders
Ball L., Battaglini D, Pelosi P. Curr Opin Crit Care 2016, 22:379–385Ball L et al. Minerva Anestesiol. 2017 May 19. (Epub ahead of print)
Pelosi P for the PROVE Network (www.provenet.eu)
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Dose–Response Relationship Between PPCs and VT during Surgery
Serpa-Neto A. et al. Anesthesiology. 2015 Jul;123(1):66-78
LOWER VTREDUCES PPCs (2,127 patients)
Pelosi P for the PROVE Network (www.provenet.eu)
• international observational study
• 8,241 patients• 8.1 [7.2–9.1] mL/kg
PBW• VT > 8 ml/Kg in
40% of patients
LAS VEGAS – Practice of Ventilation in ORs Worldwide
Pelosi P for the PROVE Network (www.provenet.eu)
The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
PEEP
Pelosi P for the PROVE Network (www.provenet.eu)
0
5
10
15
20
25
30 27.5 %
10.5 %
Low VT/High PEEPGroup (n=200)
P<0.001
Num
ber
of e
vent
s (%
)
High VT/Low PEEPGroup (n=200)
Futier E. et al. N Engl J Med 2013;369:428-37
Protective Mechanical Ventilation during Surgery: RCTs
- VT 10-12 ml/Kg PBW – PEEP 0 cmH2O - VT 6-8 ml/Kg PBW – PEEP 6-8 cmH2ORM 30 cmH2O – 30 s – every 30 min
PEEP/RM no PEEP/RM
0
10
20
30
40
50P = 0.84
Post
oper
ativ
e Pu
lmon
ary
Com
plic
atio
ns (%
)Group (n=449)Group (n=445)
PROVEnet investigators. The Lancet2014; Aug 9;384:495-503
- VT 7 ml/Kg PBW - PEEP =< 2 cmH2O- VT 7 ml/Kg PBW - PEEP 12 cmH2ORM 30 cmH2O 3 times
Pelosi P for the PROVE Network (www.provenet.eu)
Dose–Response Relationship Between PPCs and PEEP during Surgery
PEEP DOES NOT REDUCE PPCs (2,127 patients)
Serpa-Neto A. et al. Anesthesiology. 2015 Jul;123(1):66-78
Pelosi P for the PROVE Network (www.provenet.eu)
Intraoperative protective mechanical ventilationand risk of postoperative respiratory
complications: hospital based registry studyLadha K et al. BMJ 2015;351:h3646
Pos
tope
rativ
eP
ulm
onar
yC
ompl
icat
ions
Pelosi P for the PROVE Network (www.provenet.eu)
Higher PEEPN= 445
Lower PEEPN=449
P
Rescue for
de–saturation
2 (11/442) 8 (34/445) < 0·0008
Hypotension 46 (205/441) 36 (162/449) 0·0016
Vasoactive drugs 62 (274/444) 51 (228/445) 0·0016
New arrhythmias 3 (12/442) 1 (5/445) 0·09
Organ perforation 1 (4/444) 1(4/444) 1
Intraoperative Complications (%, n/N)The PROVE Network investigators. The Lancet 2014 Aug 9;384(9942):495‐503
Pelosi P for the PROVE Network (www.provenet.eu)
Respiratory System Mechanics During Low Versus High Positive End-Expiratory Pressure in Open
Abdominal Surgery: A Substudy of PROVHILO RCTD’Antini D et al. Anesth Analg. 2017 Jun 19. (Epub Ahead of Print)
Pelosi P for the PROVE Network (www.provenet.eu)
Ventilation with High or Low PEEP does not affectpostop pulmonary functional tests (PROVHILO substudy)
Treschan TA et al. Eur J Anaesthesiol. 2017 Aug;34(8):534-543.
Effects of PEEP: 2 cmH2O vs 12 cmH2O
Pelosi P for the PROVE Network (www.provenet.eu)
Kinetics of plasma biomarkers for inflammation or lunginjury in surgical patients with and without post‐operative
pulmonary complications (PROVHILO substudy)Serpa-Neto A et al. Eur J Anaesthesiol. 2017 Apr;34(4):229-238
Pelosi P for the PROVE Network (www.provenet.eu)
PPCs vs no PPCs: INCREASED Lung injury biomarkers
open symbols, green box (no PPCs) closed symbols, red box (PPCs)
open symbols, green box (low PEEP) closed symbols, red box (high PEEP)
High PEEP vs Low PEEP: INCREASED Lung injury biomarkers
before after before afterintubation intraoperative extubation
before after before afterintubation intraoperative extubation
Individualized PEEP in obese patients
Bariatric surgery, N = 50 patientsVT = 8 mL/kg PBW
PEEP = 5 cmH2OPEEP according to EIT (18.5 ± 5.6 cmH2O)
Nestler C et al Br J Anaesth 2017 (Epub Ahead of Print)
Pelosi P for the PROVE Network (www.provenet.eu)
before after before afterintubation intraoperative extubation
before after before afterintubation intraoperative extubation
Individualized PEEP in obese patients
Bariatric surgery, N = 50 patientsVT = 8 mL/kg PBW
PEEP = 5 cmH2OPEEP according to EIT (18.5 ± 5.6 cmH2O)
Nestler C et al Br J Anaesth 2017 (Epub Ahead of Print)
Pelosi P for the PROVE Network (www.provenet.eu)
SUBPHENOTYPES IN PATIENTS UNDERGOING GENERAL ANESTHESIA FOR OPEN ABDOMINAL SURGERY: An unbiased cluster analysis from the PROVHILO trial
Subphenotype 1(n = 170)
Subphenotype 2(n = 40)
Subphenotype 3(n = 10) p value
PPC 105 / 168 (62.5) 17 / 38 (44.7) 1 / 10 (10.0) 0.001
Severe PPC 79 / 168 (47.0) 10 / 38 (26.3) 1 / 10 (10.0) 0.007
EPC 101 / 168 (60.1) 21 / 38 (55.3) 1 / 10 (10.0) 0.007
Hospital LOS in survivors, days
15 (11 – 28) 12 (9 – 18) 8 (8 – 14) 0.001
In-hospital mortality 3 / 157 (1.9) 1 / 38 (2.6) 0 / 10 (0.0) 0.659
Association between subphenotypes assignment and clinical outcomes
Serpa-Neto A et al. for the PROVE Network Investigators (submitted)
Pelosi P for the PROVE Network (www.provenet.eu)
• international study• 8,241 patients• PEEP 4.0 [0–5] cm H2O • PEEP 0 and 5 cm H2O
most frequently used
LAS VEGAS – Practice of Ventilation in ORs Worldwide
Pelosi P for the PROVE Network (www.provenet.eu)
The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
Future RCTs on Intraoperative Ventilation
• PROBESE trial (obese patients): high vs. low PEEP, during lower VTventilation
• PROTHOR trial (OLV): high vs. low PEEP, during lower VT ventilation
http://www.provenet.eu/
Pelosi P for the PROVE Network (www.provenet.eu)
Rationale and study design for an individualizedperioperative open lung ventilatory strategy
(iPROVE): study protocol for a RCTFerrando et al. Trials (2015) 16:193
Pelosi P for the PROVE Network (www.provenet.eu)
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Intraoperative protective mechanical ventilationand risk of postoperative respiratory
complications: hospital based registry studyLadha K et al. BMJ 2015;351:h3646
Pos
tope
rativ
eP
ulm
onar
yC
ompl
icat
ions
Pelosi P for the PROVE Network (www.provenet.eu)
• international study• 8,241 patients• Pplat 15.5 [13.0-18.5]
cm H2O• Ppeak 17.5 [15.0-21.0]
cm H2O • Ppeak > 20 cm H2O
(Pplat > 18 cmH2O) in 25-30% of patients
LAS VEGAS – Practice of Ventilation in ORs Worldwide
Pelosi P for the PROVE Network (www.provenet.eu)
The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Pre
ssur
e( c
mH
2O )
Marini JJ. Clinics in Chest Medicine: Recent Advances in MV. 1996
DRIVING PRESSURE: DEFINITION
0
0
Time
PA
ΔP
Zero Flow
Pre
ssur
e( c
mH
2O )
Flow
(L
/se
c)
VSET
Bluth T et al. Curr Opin Anaesthesiol. 2016 Jun;29(3):421-9.
∆P = Pplat,rs – PEEP = VT/Cst = VT/EELV
Pelosi P for the PROVE Network (www.provenet.eu)
Driving Pressure (∆P,rs) & PPCs
HIGHER DRIVING PRESSURES INCREASE THE RISK OF PPCs2.679 patients from 15 RCTs
Neto AS et al. Lancet Respir Med. 2016 Apr;4(4):272-80.
Pelosi P for the PROVE Network (www.provenet.eu)
∆P,rs > 12 cmH2O Higher risk of PPCS
Driving Pressure (∆P,rs) & PPCs
HIGHER DRIVING PRESSURES (> 12 cmH2O) INCREASE THE RISK OF PPCs
69.265 patients from observational trial
Pelosi P for the PROVE Network (www.provenet.eu)*Adjusting for patient body mass index, age, gender, ASA
Ladha K et al. BMJ 2015;351:h3646
• international study• 8,241 patients• P 12.0 [10.0-15.0]
cm H2O• P > 12 cm H2O
in 50% of patients
LAS VEGAS – Practice of Ventilation in ORs Worldwide
Pelosi P for the PROVE Network (www.provenet.eu)
The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Recruitment maneuvre during anesthesiaGüldner A. et al. Anesthesiology. 2015 Sep;123(3):692-713
Reinius H et al. Anesthesiology 2009; 111:979-987
Pelosi P for the PROVE Network (www.provenet.eu)
Manual Recruitment with/without CPAP
Sustained Inflation Manoeuvre (single step)
Recruitment (multi-step)
PEEP 5 cmH2O
PEEP max20 cmH2O
Pinsp max35 cmH2O
P8 cm
H 2O
Resp@Maxn° breathsat PEEPmax
Resp/Passon° breaths
at increasing PEEP
PEEP step increase2 cmH2O
Lumb AB et al. British Journal of Anaesthesia 104 (5): 643–7 (2010)
Lung recruitment and positive airway pressure before extubation does not improve oxygenation
in the post-anaesthesia care unit: a RCT
PEEP 10 cmH2O + RM ( 40 cm H2O for 40 seconds)Pelosi P for the PROVE Network (www.provenet.eu)
Routine Bag – Squeezing RMs are associated with higher incidenceof Unplanned O2 and Severe PPCs
NotRecruited
RoutineVentilator
RoutineBag Squeezing
UnplannedVentilator
UnplannedBag Squeezing
0
20
40
60
80
100
Observed Events (%)
Unplanned O2
Severe PPC1
No1
***
§§
Ball L et al for PROVEnet and LAS VEGAS-ESA investigators
LAS VEGAS –Recruitment in obese patients
Pelosi P for the PROVE Network (www.provenet.eu)
2012 morbidly obese patients
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Oxygen concentration and characteristics of progressive atelectasis formation during
anaesthesiaEdmark L et al. Acta Anaesthesiol Scand 2011; 55: 75–81
Pelosi P for the PROVE Network (www.provenet.eu)
Post-operative atelectasis – a randomised trialinvestigating a ventilatory strategy and low
oxygenfraction during recoveryEdmark L et al. Acta Anaesthesiol Scand 2014; 58: 681–688
No significant effect of FiO2 (with PEEP) before extubationPelosi P for the PROVE Network (www.provenet.eu)
The effects of high perioperative inspiratory oxygen fraction for adult surgical patients
Wetterslev J et al. Cochrane Database Syst Rev. 2015 Jun 25;(6):CD008884.
Pelosi P for the PROVE Network (www.provenet.eu)
No effects on mortality of higher or lower perioperative FiO2
No effects on surgical infections of higher or lower perioperative FiO2
Agenda
• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Anesthesiology. 2015 Sep;123(3):501-3
Pelosi P for the PROVE Network (www.provenet.eu)
A ventilation strategy during general anaesthesia to reduce postoperative atelectasis
Edmark L et al. Upsala Journal of Medical Sciences. 2014; 119: 242–250
No significant effect of FiO2 and PEEP before extubationNo significant effect of FiO2 and PEEP after extubation
Pelosi P for the PROVE Network (www.provenet.eu)
Effect of early postextubation high-flow nasal cannula vs conventional oxygen therapy on hypoxemia in patients after major abdominal
surgery (OPERA): a multicentre RCTFutier E et al. Intensive Care Med. 2016 Dec;42(12):1888-1898
Edmark L et al. Ups J Med Sci 2014 Aug;119(3):242-50
Pelosi P for the PROVE Network (www.provenet.eu)
Agenda
• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
Practice of Ventilation in ORs
Pelosi P for the PROVE Network (www.provenet.eu)
The LAS VEGAS Investigators - Eur J Anaesthesiol 2017; 34:492–507
Agenda• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP psot extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
MechanicalVentilation
SpontaneousBreathing
Pelosi P for the PROVE Network (www.provenet.eu)
Pelosi P for the PROVE Network (www.provenet.eu)
Smart Ventilation Control (SVC)
Pelosi P for the PROVE Network (www.provenet.eu)
How does SVC operate? Course of a SVC session
Intubation Extubation
Ventilation Management Recovery PhaseAdaptationPhase
Controlled*
* SVC is usingthe target rangesof “Controlled”during adaptationphase
Pelosi P for the PROVE Network (www.provenet.eu)
What is Smart Ventilation Control? Main Idea
Rethink Ventilation …
Ventilation goal RR, Pinsp, I:E,…
etCO2, VT
• Select “ventilation goal” depending on procedure• Check target ranges for tidal volume and etCO2• Smart Ventilation Control will continuously monitor and adjust
the ventilationPelosi P for the PROVE Network (www.provenet.eu)
How does Smart Volume Control work? Ventilation Goals: Definition
Ventilation Goal
Explanation “OldWorld”
Controlled Applicable if no spontaneous breathing is desired
PC (BIPAP)
Augmented Applicable ifspontaneous breathing is OK, but should not be encouraged
PC (BIPAP)+ PS
Encourage SB Applicable if spontaneous breathing is desired
PS
Spont. Breathing100%
0%
Controlled Augmented Encourage SB
Ventilation Goal
Spon. Breathing
Pelosi P for the PROVE Network (www.provenet.eu)
SVC – A simple and patient oriented way to achieve spontaneous breathing
Pelosi P for the PROVE Network (www.provenet.eu)
Smart Ventilation Control: User InterfaceMain Parameters
Ventilation goal:main parameter to control theventilation through whole procedure
PEEP:The PEEP is the only parameter not adjusted by Smart Ventilation Control
Height: Needed for IBW as Smart Ventilation Controloperates with VT in ml/kg
Target Ranges:VT in ml/kg and etCO2Ranges predefined fornormal patients.Need only to be adapted for special patients (e.g. COPD)Default settings can be chosen by hospital.There are different target ranges for each ventilation goal.
Pelosi P for the PROVE Network (www.provenet.eu)
Smart Ventilation Control: User InterfaceMain Parameters
etCO2 Waveform:In the standard etCO2 waveform the target range for etCO2 will be shown
The range will always be shown if SVC is active
Pelosi P for the PROVE Network (www.provenet.eu)
Agenda
• Introduction• Lung changes during anesthesia• Postoperative pulmonary complications• Rationale of protective ventilation• Tidal volume • PEEP• Plateau pressure • Driving pressure • Recruitment• FiO2• PEEP post extubation• Interactions between VT and PEEP – Pplat - P – RR• Assisted ventilation during surgery• Conclusions
Pelosi P for the PROVE Network (www.provenet.eu)
“Permissive Atelectasis” during General AnesthesiaPelosi P, Rocco PRM, de Abreu MG (Crit Care 2018 – in press)
InspirationExpiration
Pelosi P for the PROVE Network (www.provenet.eu)
PEEP1967…….
Restin
Peace
The Funeral for Positive End-ExpiratoryPressure …better known as PEEP
“It was a dream for generationsof anesthesiologists”
Conclusions Mechanical ventilation setting during surgery affects postoperative outcome
(in patients “at risk”)
VT 6-8 ml/Kg PBW/IBW
PEEP 2-5 cmH2O w/o RM, but not yielding increased ∆P
PEEP higher than 5 cmH2O;- Surgery longer than 3 hours- Laparoscopy in Trendelenburg position- BMI equal or higher than 35 kg/m2
Higher PEEP induces hemodynamic impairment and need of fluid overload
Pplat < 16 cmH2O and ∆P (Pplat-PEEP) < 13 cmH2O
FiO2 up to 80% does not affect post operative function
Controlled mechanical ventilation is often unnecesssary and may be harmful: think about spontaneous breathing and servo-controlled systems !
Protective MechanicalVentilation
During SurgeryTo Improve Postoperative Outcome
JUST DO IT !
Pelosi P for the PROVE Network (www.provenet.eu)