Mechanical Ventilation Strategies in Anesthesia · 2017-10-17 · Mechanical Ventilation Strategies...

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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


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


ERAS ReccomendationsNo place for Intra-op Protective MV !


Anesthesiology. 2016 Dec;125(6):1079-1082


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


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


Atelectasis and lung function in the postoperative period

Lindberg P et al. Acta Anaesthesiol Scand 1992: 36: 546-553


Post-Op. Atelectasis: Myth or Reality ? Güldner A. et al. Anesthesiology 2015 June 29 [Epub Ahead of Print]


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


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%


Epidemiology, Practice of Ventilation and Outcome for Patients at Increased Risk of PPCs

(LAS VEGAS) – an Observational Study in 29 Countries


• 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


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


Post-operative atelectasis and Post-operative SatO2

Ball L, Bluth T, Guldner A et al. 2016 (in preparation)

sensitivity 92%, specificity 62%.


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


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


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



National Early Warning Score ( NEWS)To assess the acute-illness severity

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)


British Journal of Anaesthesia, 2016 Mar;116(3):438-9.


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)


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)


• 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



PEEP


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


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


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


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


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)


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


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


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)


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)


• international study• 8,241 patients• PEEP 4.0 [0–5] cm H2O • PEEP 0 and 5 cm H2O

most frequently used




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/


Rationale and study design for an individualizedperioperative open lung ventilatory strategy

(iPROVE): study protocol for a RCTFerrando et al. Trials (2015) 16:193


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


• 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




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


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.


∆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




Recruitment maneuvre during anesthesiaGüldner A. et al. Anesthesiology. 2015 Sep;123(3):692-713

Reinius H et al. Anesthesiology 2009; 111:979-987


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


2012 morbidly obese patients

Oxygen concentration and characteristics of progressive atelectasis formation during

anaesthesiaEdmark L et al. Acta Anaesthesiol Scand 2011; 55: 75–81


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.


No effects on mortality of higher or lower perioperative FiO2

No effects on surgical infections of higher or lower perioperative FiO2

Agenda



Anesthesiology. 2015 Sep;123(3):501-3


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


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


Agenda



Practice of Ventilation in ORs



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


MechanicalVentilation

SpontaneousBreathing


Smart Ventilation Control (SVC)


How does SVC operate? Course of a SVC session

Intubation Extubation

Ventilation Management Recovery PhaseAdaptationPhase

Controlled*

* SVC is usingthe target rangesof “Controlled”during adaptationphase


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


SVC – A simple and patient oriented way to achieve spontaneous breathing


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.


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


Agenda



“Permissive Atelectasis” during General AnesthesiaPelosi P, Rocco PRM, de Abreu MG (Crit Care 2018 – in press)

InspirationExpiration


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 !


Mechanical Ventilation Strategies in Anesthesia · 2017-10-17 · Mechanical Ventilation Strategies...

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Transcript of Mechanical Ventilation Strategies in Anesthesia · 2017-10-17 · Mechanical Ventilation Strategies...