Lung Protective Strategies in Mechanical · PDF fileMechanical Ventilation Strategies John J...
Transcript of Lung Protective Strategies in Mechanical · PDF fileMechanical Ventilation Strategies John J...
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Mechanical Ventilation
Strategies
John J Gallagher MSN, RN, CCNS, CCRN, RRT Clinical Nurse Specialist/Trauma Program Coordinator
Division of Traumatology, Surgical Critical Care and Emergency Surgery
Hospital of the University of Pennsylvania
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Objectives Describe the differences in volume targeted and pressure
targeted ventilation modes, as well as the benefits of
modern spontaneous breathing modes
Describe the pathophysiologic pulmonary changes in ARDS
that limit the effectiveness of conventional mechanical
ventilation and necessitate alternative ventilation strategy
Describe the differences between lung protection and lung
recruitment strategies
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Evolution of Mechanical Ventilators
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Volume Control Pressure Control
PEEP
A/C
SIMV
A/C
SIMV
Support
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Volume Targeted
(Control)Ventilation (VCV)
Guaranteed tidal volume with each breath
Set flowrate
Pressure varies based on resistance and
compliance of the lung and chest wall
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Volume Targeted (Control)
Ventilation (VCV)
Pressure
Flow
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Pressure Targeted (Control) Ventilation (PCV)
Fixed inspiratory pressure but
Volume is variable
Inspiratory pressure & inspiratory time*
Airway resistance
Lung compliance
* Practitioner controlled
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Pressure Control Ventilation (PCV)
Pressure
Flow
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Case
40 y.o. male, URD involved in an MVC
– One hour extrication time & hypovolemic shock
– Injuries
» Multiple mesenteric bleeders
» Ruptured spleen
» Multiple liver lacerations
– Damage control laparotomy
– ICU for resuscitation
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Case continued…
48 hours later…….
Febrile
HR 142
Increasing oxygen requirement
– P/F ratio: 80 (PaO2 80 on 1.0 FIO2)
Rising peak inspiratory pressures
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Pathophysiology
Alveolar injury/ permeability
Changes in airway diameter/resistance
Pulmonary vasoconstriction/ vascular injury
Alterations in oxygen delivery,consumption
and extraction
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ARDS Continuum
ALI ARDS
Severe
ARDS
Mild
ARDS
Moderate
ARDS
PaO2/FiO2 Ratio
Mild Moderate Severe
200 – 300 100 - 200 < 100
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ARDS Definition
Acute onset (within 7 days)
Bilateral opacities (CXR or CT)
Alveolar edema is not fully explained by
cardiac failure or fluid overload
– Does not require normal PCWP
– Does not require absence of LA hypertension
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Ventilator Induced Lung Injury (VILI) “Volutrauma”
Caused by the over-expansion (over- distention)
of alveoli from ventilation with volumes in
excess of relative lung capacity
Correlated with transalveolar pressure > 30 cmH2O
(Static “plateau” pressures of > 30 cm H2O)
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Zone of
↑ Risk
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Spectrum of Regional Opening Pressures
(Supine Position)
Superimposed
Pressure Inflated 0
Alveolar Collapse
(Reabsorption) 20-60 cmH2O
Small Airway Collapse
10-20 cmH2O
Consolidation
(from Gattinoni)
Lung Units at Risk for Tidal
Opening & Closure =
Opening
Pressure
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Ventilator Induced Lung Injury
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Collapsed Alveoli
Inspiratory phase
Expiratory phase
End-tidal collapse/shearing force
“Milking” of surfactant from alveoli with repeat closure
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Inspiratory Hold: PIP and Plateau pressures
(VC)
Plateau
Peak Pressure
Inspiratory Hold
Proximal
airway
pressure
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PIP Elevated and Plateau Normal
Plateau
Peak Pressure
Inspiratory Hold
Proximal
airway
pressure
40 cm H2O
20 cm H2O
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Airway Pressures
Peak Inspiratory Pressure High and Plat unchanged:
(Greater than 10 cmH2O difference between)
– Tracheal tube obstruction
– Airway obstruction from secretions
– Acute bronchospasm
Rx: Suctioning and Bronchodilators
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PIP Elevated and Plateau Elevated
Plateau: 36 cmH2O
Peak Pressure: 40 cmH2O
Inspiratory Hold
Proximal
airway
pressure
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Airway Pressures
Pip and Plat are both increased
(less than 10 cm H2O difference)
– Pneumothorax
– Lobar atelectasis
– Acute pulmonary edema
– Worsening pneumonia
– ARDS
– COPD with tachypnea and Auto-PEEP
– Increased abdominal pressure (ACS)
– Asynchronous breathing
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Lung Protective Principles
Maintain safe transalveolar pressures
– Plateau pressure < 30 cm H20
Prevent end-tidal alveolar collapse
– PEEP
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Tidal Volume
Conventional Volumes
– 10 – 12 ml / kg predicted body weight (PBW)
Low Tidal Volume (LTV)
– 5 - 8 ml / kg predicted body weight (PBW)
Ideal Body Weight Calculation • Male PBW in lb: 106 + [6 x (height in inches – 60)]
• Female PBW in lb:105 + [5 x (height in inches – 60)]
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Acute Respiratory Distress Syndrome Network
ARDSNET
Comparison of “traditional” tidal volume (12 ml/kg)
versus “low” tidal volume (6 ml/kg)
861 patients at 30 centers
Low Tidal Volumes (432) Traditional Tidal Volumes (429)
25-30 cmH2O plateau 45-50 cmH2O plateau
ARDSNET (2000). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute
lung injury and the acute respiratory distress syndrome. NEJM, 342(8), 1301-1308.
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Acute Respiratory Distress Syndrome
Network ARDSNET
Low tidal Volume Ventilation
Lower mortality
Lower levels of IL-6 (lung inflammation)
Higher number of days without organ or system
failure
ARDSNET (2000). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute
lung injury and the acute respiratory distress syndrome. NEJM, 342(8), 1301-1308.
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Improving Oxygenation
Manipulation of FiO2
Manipulation of Mean Airway Pressure (Paw)
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Mean Airway Pressure ( Paw )
Airway pressure
Time Inspiration Expiration
Adapted from Pilbeam, 2006
Definition: the MAP is the area under the curve during
inspiration and expiration divided by the duration of the cycle
MAP = area under the pressure curve duration of the cycle
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Increase Mean Airway Pressure
PEEP
I:E Ratio Manipulation
– Inverse Ratio Ventilation (IRV)
– Respiratory Rate
Inspiratory Pause
Square Waveform
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Positive End Expiratory Pressure
(PEEP)
Maintains the alveoli open at the end of the breath
Reduces shear force injury to alveoli
Displacement of lung H2O
Insp.
Exp. PEEP
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Pulmonary Pitfalls of PEEP
Overdistension of normal alveoli
Alveolar Injury Deadspace Shunt
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Cardiovascular Pitfalls of PEEP
Increased Intra-thoracic Pressure
RV Afterload Venous Return
(RV filling)
Cardiac Output False Elevations of
CVP-PAP-PCOP
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Lung Protection is Not Enough
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Alveolar Recruitment Strategies
Recruitment Maneuvers (episodic)
Pressure Control Ventilation
Manipulation of I: E ratio
Airway Pressure Release Ventilation (APRV)
High Frequency Oscillation Ventilation (HFOV)
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Recruitment
OPEN – Overcome the Trans-alveolar Opening Pressure
MAINTAIN – Positive End Expiratory Pressure
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%
50
Paw [cmH2O] 0 5 10 15 20 25 30 35 40 45 50
0
10
20
30
40 Opening
pressure Closing
pressure
From Crotti et al
AJRCCM 2001.
High pressures may be needed to open some lung units, but once open, many units stay
open at lower pressure.
Opening and Closing Pressures in ARDS
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Recruitment Maneuver
Patient Selection
Early ALI/ARDS (<72 hrs) vs. Late ARDs
Intra-pulmonary vs. Extra-pulmonary lung
Injury
Hemodynamic stability
Absence of Contraindications
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Recruitment Strategies
Intermittent Recruitment Maneuver
Pressure Control Ventilation/PEEP
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Intermittent Recruitment Maneuver
Brief application of high inspiratory pressures to
recruit collapsed alveoli
Inspiratory pressure application
– CPAP 40- 50 cm H2O for 30 - 40 seconds
Optimal PEEP application to prevent collapse
Repeat maneuver after a ventilator disconnect
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Recruitment
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Decremental PEEP Trial
PEEP set at 20-25 cm H2O
PEEP decreased 2 cmH2O every 5-20 min – Monitoring oxygenation
– Compliance
Until Optimal PEEP is achieved – the lowest PEEP associated with the best
compliance/oxygenation
Recruitment maneuver repeated
PEEP set 2 cm H2O above the Optimal PEEP
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Decremental PEEP Trial with PCV
50
25
5
0
I-Time E-Time I-Time
Time
Pressure
40
I-Time E-Time
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Recruitment Maneuver Contraindications
Pulmonary blebs, bullae, existing barotrauma
Hemodynamic instability
– Hypovolemia
– Impaired RV function
Increased intracranial pressure (relative)
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Pressure Control Ventilation (PCV)
An inspiratory pressure limit, rather than
a tidal volume is set by the practitioner.
Inspiratory pressure & inspiratory time*
Airway resistance
Lung compliance
* Practitioner controlled
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Pressure Control Ventilation (PCV)
Pressure
Flow
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PCV Waveform Advantages
Controlled, constant inspiratory pressure
Better distribution of tidal volume to collapsed alveoli
Optimal increase in Paw
0
5
25
Paw
Time
Pressure
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Volume Control vs. Pressure Control
Waveform
PIP
Paw Paw
50
25
5
0
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Collateral Ventilation
Channels
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Pressure Control Inverse Ratio (PCIRV)
50
25
5
0
I-Time E-Time I-Time
Time
Pressure
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Auto-PEEP
50
25
5
0
I-Time E-Time I-Time
Time
Pressure
8
Set PEEP
Auto- PEEP
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P
F
Exp. Flow
50 - 80% of Peak
PCV PC-IRV
Auto PEEP
Measurement
Actual
PEEP
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Volume Assured Pressure Modes
Pressure Limited + Minimum Volume Guarantee
aka…
– Adaptive Pressure Control Modes
– “Dual Control” Modes
Machine adjusts to changing lung mechanics to
provide tidal volume within pressure limit
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Also known as……
Adaptive Pressure Control Modes
“Dual Control” Modes
Volume Assured Pressure Modes
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Pressure
Flow
Pressure Regulated Volume Control
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Volume Support
VS adjusts pressure level to maintain selected volume
This is a spontaneous mode
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Pressure Augmentation
Pressure Augmentation starts as a pressure breath but ends as a
volume breath if volume not reached
Spontaneous and control options available
•Tidal volume (Vt)
•Sensitivity
•FiO2
•PEEP
Control mode
•Rate (fx)
•Inspiratory time (Ti)
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Volume Assured Pressure Modes
PCV + Volume Target
•Pressure Regulated Volume Control (PRVC)
•Volume Support
•Volume Control Plus (VC+)
•Volume Support
•Pressure Control Volume Guarantee (PCVG)
•Volume Targeted Pressure Control (VTPC)
•Adaptive Pressure Ventilation
•Adaptive Support Ventilation
•Pressure Augmentation
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Control Mode Settings
Rate (fx)
Inspiratory time (Ti)
FiO2
PEEP
Support Mode Settings
Target tidal volume
FiO2
PEEP
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Points to Remember
Guaranteed minimum tidal volume but
not a constant tidal volume!!
Tidal volume may not be achieve if lung
compliance becomes low or pressure
limit is set too low
Excessive tidal volume if the patient
generates excessive inspiratory efforts
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Pressure Control
Spontaneous Breathing Modes
Provides ventilatory support while allowing the
patient to perform some work of breathing
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Benefits of Spontaneous Breathing
Improved ventilation/perfusion matching
Lower airway pressures
Reduced hemodynamic side effects
Improved organ perfusion
Less need for sedation/neuromuscular blockade
New pressure modes have exhalation valves and other
technology that allow for patient interaction throughout
the respiratory cycle.
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Diaphragm Excursion
Awake
spontaneous
Anesthetized
spontaneous
Paralyzed
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Active Exhalation Valve
40 PCIRC
cmH2O
INSP
L
min
EXP
30
20
10
0
10
-20
80
60
40
20
0
20
-80
40
60
V .
0 4 8 12s 2 6 10
Spontaneous Efforts Spontaneous Efforts
PCV W/O Active Valve PCV with Active Valve
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Pressure Support (PSV)
A mode of ventilation that augments or
supports a spontaneous inspiration with a
clinician-selected pressure level
Patient selection
– stable?
– reliable ventilatory drive
– ready to wean
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Bi-Level/Bi-Phasic Ventilation
Bi-level:
– is similar to pressure controlled ventilation ,
during which unrestricted spontaneous breathing
is possible in each phase of the respiratory
cycle.
APRV:
– allows spontaneous breathing on a preset CPAP
level and which is interrupted by a short (<1s)
release for expiration.
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Spontaneous Breaths
P
T
PEEPHI
PEEPLO
Biphasic Ventilation
Spontaneous Breaths
•Inspiratory Pressure Limit (PEEPHI)
•PEEP (PEEPLOW)
•Inspiratory time (Ti)
•Rate (fx)
•Pressure Support
• Biphasic
• Bi-level
• Bi-Vent
• BIPAP
• Duo
PAP
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APRV Characteristics High CPAP level with a short expiratory releases at set
intervals (rate).
APRV always implies an inverse I:E ratio
All spontaneous breathing is done at upper pressure level
PEEPHI
P
PEEPLO
T
* * * * * * * † † †
Synchronized Transition † Spontaneous Breaths *
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Spontaneous Breaths
P
T
PEEPHI
PEEPLO
Spontaneous Breaths
PEEPHI
P
PEEPLO
T
* * * * * * * † † †
Synchronized Transition † Spontaneous Breaths *
APRV
BiPhasic
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Airway Pressure Release Ventilation
Waveform
50
25
0
(Thi): 6 seconds
(Tlo): 0.8 seconds
Time
Pressure
(Phi):25 cm H20
(Plo): 0 cm H20
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Initiating APRV
Pressure High (PEEPhi): set at the level of the
measured plateau pressure
– 20-30 cmH20
Time High: 4 seconds increasing to 15
seconds
Pressure Low (PEEPlow)
– 0 cmH20
Time Low: 0.5 - 1.0 seconds (0.8 average)
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Alveolar Volumetric Changes
Insp.
Exp.
Conventional APRV
Insp. Exp. ~ ~
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Managing Oxygenation APRV - Principle of Operation
P
F
Exp. Flow
50 - 80% of Peak
PCV APRV
AutoPEEP
Measurement
Actual
PEEP
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APRV Pressure and CO2 Adjustments
40 PCIRC
cmH2O
INSP
L
min
EXP
30
20
10
0
10
-20
80
60
40
20
0
20
-80
40
60
V .
0 4 8 12s 2 6 10
Increase the number of releases
0.8 sec
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Weaning APRV
“Drop and Stretch”
20cm
30cm
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Bi-level/APRV Considerations
Tidal volume changes with lung compliance
Over-sedation/NMB may reduce minute ventilation
Caution in patients requiring longer expiratory time (COPD, Asthma)
Elevated ICP in TBI
– Hypercapnea/ Cerebral venous congestion
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General Considerations
Avoid disconnection of the circuit
Closed system suctioning
Transport on the ventilator
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High Frequency Ventilation
Jet Ventilation
– Up to 600 bpm
Oscillation
– 300 to 3000 bpm
Small tidal volumes
Combined applied and intrinsic (Auto-
PEEP) to recruit alveoli
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3100B Oscillator
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Oscillator
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Alveolar Volumetric Changes During HFO
Insp.
Exp.
Conventional HFOV
Insp. Exp. ~ ~
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Volumetric Diffusive Respiration (VDR)
Images courtesy of Percussionaire Corporation
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VDR Waveform
Images courtesy of Percussionaire Corporation
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Summary Points
Protect the lung and support
oxygenation/ventilation
Recruit the lung
Know the mode you select!
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Bibliography
Kunugiyama, S.K. & Schulman, C.S. (2012) High-frequency percussive ventilation using the VDR-4 ventilator. AACN: Advanced Critical Care, 23(4):370-380.
Burns, S.M. (2008). Pressure modes of mechanical ventilation: The good, the bad and the ugly. AACN: Advanced Critical Care, 19(4):399-411.
Nichols, D.& Haranath, S. (2007). Pressure control ventilation. Critical Care Clinic, 23: 183-199.
Branson, R.D. & Chatburn, R.L. (2005). Should adaptive pressure control modes be utilized for virtually all patients receiving mechanical ventilation? Respiratory Care, 52(4): 478-485.
Habashi, N. (2005). Other approaches to airway pressure release ventilation: airway pressure release ventilation. Critical Care Medicine, 33(3): S228-240.