Mechanical Ventilation in Acute Respiratory Distress Syndrome · Papazian L, et al. Crit Care Med...
Transcript of Mechanical Ventilation in Acute Respiratory Distress Syndrome · Papazian L, et al. Crit Care Med...
Mechanical Ventilation
in Acute Respiratory Distress Syndrome
Case
Male / 65
Severe dyspnea, 3 days
High fever and purulent sputum
WBC: 23,000/mm3
2D-echo: EF 60%
Oxygenation under Mechanical ventilation
Mode: Controlled Mandatory Ventilation
FIO2: 80%
PEEP: 8 cmH2O
ABGA
pH 7.356
PaCO2 42.7 mmHg
PaO2 80.0 mmHg
HCO3- 29.7 mEq/L
SaO2 93.6%
Q1: Which of the following is a correct pathophysiology of hypoxemia
in this patient?
1. Decreased alveolar-capillary barrier permeability
2. Eosinophil dependent lung injury
3. A decrease in cytokines
4. Increased alveolar fluid removal
5. Heterogeneous acute lung inflammation
Summary of the Case
Acute onset of dyspnea, 3 days
Severe hypoxemia, PaO2/FIO2 = 80 / 0.8 = 100 mmHg
Bilateral opacities in a chest X-ray
Normal cardiac function
What Condition?
ARDS Acute Respiratory
Distress Syndrome
RECOMMENDED CRITERIA FOR ACUTE LUNG INJURY (ALI) AND
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Timing Oxygenation Chest Radiograph
Pulmonary Artery
Wedge Pressure
ALI criteria Acute onset PaO2/FIO2 300 mmHg
(regardless of
PEEP level)
Bilateral
infiltrates
seen on frontal
chest radiograph
18 mmHg when
measured or no
clinical evidence
of left atrial
hypertension
ARDS criteria Acute onset PaO2/FIO2 200 mmHg
(regardless of
PEEP level)
Bilateral
infiltrates
seen on frontal
chest radiograph
18 mmHg when
measured or no
clinical evidence
of left atrial
hypertension
www.wordle.net Bernard GR, et al. Am J Respir Crit Care Med 1994;149;818
Timing Within 1 week of a known clinical insult or new or worsening respiratory
symptoms
Chest
imaginga
Bilateral opacities—not fully explained by effusions, lobar/lung collapse,
or nodules
Origin
of edema
Respiratory failure not fully explained by cardiac failure or fluid overload
Need objective assessment (eg, echocardiography) to exclude hydrostatic
edema if no risk factor present
Oxygenationb
Mild 200 mmHg < PaO2/FIO2 300 mmHg with PEEP or CPAP 5 cmH2Oc
Moderate 100 mmHg < PaO2/FIO2 200 mmHg with PEEP 5 cmH2O
Severe PaO2/FIO2 100 mmHg with PEEP 5 cm H2O Abbreviations: CPAP, continuous positive airway pressure; FIO2, fraction of inspired oxygen; PaO2, partial pressure of arterial oxygen;
PEEP, positive end-expiratory pressure aChest radiograph or computed tomography scan. bIf altitude is higher than 1000 m, the correction factor should be calculated as follows: [PaO2/FIO2(barometric pressure/760)]. cThis may be delivered noninvasively in the mild acute respiratory distress syndrome group.
The New (Berlin) Definition of ARDS
ARDS Definition Task Force, et al. JAMA. 2012;;307:2526
Increased permeability of the alveolar-capillary barrier
Influx of protein-rich edema fluid into the air-space
Neutrophil dependent lung injury
Cytokines
Disrupt normal epithelial fluid transport, impairing the
removal of fluid
Abnormalities in the production, composition, and
function of surfactant
Abnormalities of the coagulation system
Ware LB, et al. N Engl J Med 2000;342:1334
Q1: Which of the following is a correct pathophysiology of hypoxemia
in this patient?
1. Decreased permeability of the alveolar-capillary barrier
2. Eosinophil dependent lung injury
3. Decrease in cytokines
4. Increased alveolar fluid removal
5. Heterogeneous acute lung inflammation
Expiration Inspiration
Mechanical Ventilation with traditional high tidal volume
and zero PEEP Physical stretch
Shearing force
Multiple Organ Dysfunction
Syndrome
1. Spillover
2. Translocation
Lung Protective Ventilation Strategies
Low Tidal Volume
6~8 mL/Kg of predicted body weight
Plateau Pr. < 30 cmH2O
High (adequate)
PEEP
Shearing force
Heterogeneity
Homogeneity
Prone Position Ventilation
Recruitment Maneuver
In a Narrow Sense
Lung protective ventilation strategy
Low tidal volume
High-PEEP
Prone position
Recruitment maneuver
In a Broad Sense
Q2: Which of the following mechanical ventilation strategies for ARDS
is a recommended therapy based on strong clinical evidence?
1. Low tidal volume
2. High-PEEP
3. Prone position
4. Recruitment maneuver
5. High frequency ventilation
A, recommended therapy based on strong clinical evidence from randomized clinical trials; B, recommended therapy based on
supportive but limited clinical data; C, indeterminate evidence: recommended only as alternative therapy; D, not recommended based
on clinical evidence against efficacy of therapy.
Low tidal
volume
High PEEP Prone position
ventilation
Recruitment
maneuvers
A
B
C
D
recommended therapy based on strong clinical
evidence from randomized clinical trials A
indeterminate evidence: recommended only
as alternative therapy C
Evidence based recommendations for LPV strategies
Q2: Which of the following mechanical ventilation strategies for ARDS
is a recommended therapy based on strong clinical evidence?
1. Low tidal volume
2. High-PEEP
3. Prone position
4. Recruitment maneuver
5. High frequency ventilation
Review of Evidence
Low Tidal Volume
Different ONLY in
Traditional
tidal volume
Lower
tidal volume
Tidal
volume 12 mL/Kg* 6 mL/Kg*
Plateau
pressure 50 cmH2O 30 cmH2O
*Kg of predicted body weight
ARDS Network Trial: Lower Tidal Volume vs. Traditional Tidal Volume
VARIABLE
GROUP
RECEIVING
LOWER TIDAL
VOLUMES
GROUP
RECEIVING
TRADITIONAL
TIDAL VOLUMES
P VALUE
DEATH before discharge home
and breathing without
assistance (%) 31.0 39.8 0.007
Breathing without assistance
by day 28 (%) 65.7 55.0 <0.001
No. of ventilator-free days,
days 1 to 28 1211 1011 0.007
No. of days without failure
of nonpulmonary organs
or systems*, days 1 to 28 1511 1211 0.006
Plasma interleukin-6** on day 3,
pg/mL 2.00.5 2.30.7 0.002 ** Interleukin-6, IL-6
: a representative
pro-inflammatory
cytokine
*without MODS
Main Outcomes of ARDS Network Trial
A, recommended therapy based on strong clinical evidence from randomized clinical trials; B, recommended therapy based on
supportive but limited clinical data; C, indeterminate evidence: recommended only as alternative therapy; D, not recommended based
on clinical evidence against efficacy of therapy.
Low tidal
volume
High PEEP Prone position
ventilation
Recruitment
maneuvers
A
B
C
D
recommended therapy based on strong clinical
evidence from randomized clinical trials A
Evidence based recommendations for LPV strategies
High PEEP
Clinical trials Mortality
p High PEEP Control
ALVEOLI ARDS network, USA
N Engl J Med 2004;351:327-36 27.5% 24.9% 0.48
Not
Significant
LOVS Canada, Australia,
and Saudi Arabia
JAMA 2008;299:637-45 36.4% 40.4% 0.19
EXPRESS France
JAMA 2008;299:646-55 27.8% 31.2% 0.31
Mortality in Large-scaled clinical trials
Oxygenation in Large-scaled clinical trials
Clinical trials PaO2/FIO2 at Day 7, mmHg
p High PEEP Control
ALVEOLI 218
> 181 <0.05
Significant LOVS 212.7 180.8 <0.001
EXPRESS 206 184 0.03
NO Effect on Mortality Gain
Only Improves Oxygenation
Prone Position Ventilation
Q3: Which is right among these descriptions
for prone position ventilation?
1. Increases heterogeneity of lung inflammation
2. Decreases mortality in all ARDS patients
3. Improves oxygenation
4. Decreases ventilation-perfusion match
5. Increases ventilator-induced lung injury
Supine
Changes from Supine to Prone Position
Prone
1
2
Homogeneity
End-expiratory lung
volume
Ventilation-perfusion
matching
Regional changes in
ventilation
Alterations in chest-wall
mechanics
Ventilator-induced
Lung Injury
Watanabe I, et al. Crit Care Med 2002;30:1799
Beuret P, et al. Intensive Care Med 2002;28:564
Guerin C, et al. JAMA 2004;292:2379
Curley MA, et al. JAMA 2005;294:229
Voggenreiter G, et al. J Trauma 2005;59:333
Papazian L, et al. Crit Care Med 2005;33:2162
Mancebo J, et al. Am J Respir Crit Care Med 2006;173:1233
Demory D, et al. Crit Care Med 2007;35:106
Chan MC, et al. J Formos Med Assoc 2007;106:708
Ibrahim TS, et al. J Med Sci 2007;7:390
Prone ventilation reduces mortality in patients with acute respiratory
failure and severe hypoxemia: sytematic review and meta-analysis
Sud S, et al. Intensive Care Med 2010;36:585
Systematic Review and Meta-analysis
Gattinoni L, et al.
N Engl J Med
2001;345:568
Taccone P, et al.
JAMA
2009;302:1977
Clinical Evidence
Oxygenation
Improves in
Prone Position
Prone Higher
Day 1
Day 2
Day 3
p=0.54
p=0.35
Mortalities in All Patients and PaO2/FIO2 100 mmHg subgroup
Not
Significant
p=0.01
Reduction
in Mortality
Mortality in Severe Hypoxemia, PaO2/FIO2 < 100 mmHg subgroup
Favors prone
Improves Oxygenation
Can reduce Mortality
in a severe subset of ARDS
by meta-analysis
1. Increases heterogeneity of lung inflammation
2. Decreases mortality in all ARDS patients
3. Improves oxygenation
4. Decreases ventilation-perfusion match
5. Increases ventilator-induced lung injury
Q3: Which is right among these descriptions
for prone position ventilation?
Recruitment Maneuver
CPAP
Extended Sigh
Recruitment maneuver
Similar with
Prone Position
Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006667
28 day mortality
ICU mortality
In hospital mortality
Not
Significant
Not
Significant
Not
Significant
A, recommended therapy based on strong clinical evidence from randomized clinical trials; B, recommended therapy based on
supportive but limited clinical data; C, indeterminate evidence: recommended only as alternative therapy; D, not recommended based
on clinical evidence against efficacy of therapy.
Low tidal
volume
High PEEP Prone position
ventilation
Recruitment
maneuvers
A
B
C
D
Evidence based recommendations for LPV strategies
indeterminate evidence: recommended only
as alternative therapy C
But, evidence is changing…..
A, recommended therapy based on strong clinical evidence from randomized clinical trials; B, recommended therapy based on
supportive but limited clinical data; C, indeterminate evidence: recommended only as alternative therapy; D, not recommended based
on clinical evidence against efficacy of therapy.
Low tidal
volume
High PEEP Prone position
ventilation
Recruitment
maneuvers
A
B
C
D
Insufficient Evidence
Recent
RCT Systematic
Review
Evidence is changing…..
Recent Feature Meta-analysis for High PEEP
Clinical trials
ALVEOLI ARDS network, USA
N Engl J Med 2004;351:327-36
LOVS Canada, Australia, and Saudi Arabia
JAMA 2008;299:637-45
EXPRESS France
JAMA 2008;299:646-55
Systematic Review
Meta-analysis
ALI non-ARDS
Hospital Mortality 0.049
ICU Mortality 0.001 <
Rescue Therapy < <
<.001
<.001
<
> 0.004
With ARDS
Days with
unassisted
breathing
Stratified by Presence of ARDS at Baseline
Can Improve Mortality
in Severe ARDS
Recent Feature Clinical Trial for Prone Position Ventilation
Prone Positioning in Severe Acute Respiratory Distress Syndrome
PROSEVA study
Guerin C, et al. N Engl J Med 2013;368:2159
Enroll Criteria Enroll Time
Very Severe ARDS
: a Pao2:Fio2 ratio of < 150 mmHg, with
an Fio2 of ≥ 60%
a PEEP of ≥ 5 cmH2O
Less than 36 hours
: earlier than in prior studies
Supine
Prone
At least
16 Hours/Day 28 days
Main Results : 28-day and 90-day mortalities
>
>
* *
* *
*
*
Significant
Significant
Main Results : Other outcomes
<
>
< <
*
*
* *
*
*
*
Significant
Significant
Significant
*
Reduces Mortality
in a Severe subset of ARDS
New evidence is emerging and
Clinical evidence grade of medical strategies are
continuously changing.
Conclusions
3 Always Keep Up With Changing Evidence
1 Essential MV strategy for
ARDS patients Low Tidal Volume
2 Should be considered in Selected
Clinical Conditions
esp. Severe ARDS patients
High PEEP
Prone Position Ventilation
Recruitment Maneuver
Thank You For Your Attention