Mechanical Ventilation in Patients with Sepsis

mechanical ventilation in patients with sepsis

Armin Kalenka, MD, Ph.D. head of anaesthesia/intensive care med [email protected]

2 conflict of interest consultant, travel expenses, lecture fees

3 What is your focus for a patient on the ventilator?

• Oxygenation

• CO2 Elimination • Lung protection

4 Best practice in mechanical ventilation?

• VT: 6 ml/kg pbw for all patients? • NEJM 2000 • PEEP: ARDS network table based on Oxygenation? • NEJM 2000 or NEJM 2004 • High PEEP: for severe ARDS • JAMA 2010 • Prone: for severe ARDS • NEJM 2013 • NMB: for severe ARDS • NEJM 2010 • No NIV for severe ARDS • AJRCCM 2017

5 6 ARDS and Sepsis

ARDS Sepsis

7 ARDS and Sepsis

Sepsis

ARDS

8 ARDS and Sepsis

ARDS Sepsis

9 How often is ARDS in severe sepsis?

Shock; 2013:40: 375-382 10 Fluids, Sepsis and ARDS LIPS: adult patients with one or more ARDS risk factors admitted to the hospital through the Emergency Department or admitted for high-risk elective surgery.

Ann Intensive Care 2017; 7: 11 11 Best practice in mechanical ventilation?

? 12 Normalisation because of unknown size of the „baby“ lung

the driving pressure: ΔP = VT/Comp

13 tidal volume should not longer be the target!

14 goal partial pressure of oxygen in arterial blood range of 55–80 mm Hg

fiO2 of 0.5 = 0

increasing deaths with higher oxygenation in all groups of ARDS severity

Crit Care Med 2017; DOI: 10.1097/CCM.0000000000002886 15 n = 861 Oxygenation should not be the 6 ml∙kg-1: n = 432 key parameter 12 ml∙kg-1: n = 429 for the ventilator settings !

Mortality [%] paO2/fiO2 190 50 * * *

40 180

30 170

20 160

10 150

0 0 6 ml∙kg-1 12 ml∙kg-1 1 2 7 days

16 alveolar stability is unrelated to arterial oxygenation

Andrews et al. Intensive Care Medicine Experimental (2015) 3:16 17 Odds Ratio to hospital discharge rise in CO2 of 1 mmHg

with a 3% increase in odds of survival

Crit Care Med 2017; DOI: 10.1097/CCM.0000000000002918 18 19 The Rivers protocol

1. stratify according to severity

2. measure relevant parameter

3. individualize therapy

20 Niemann et al Intensive Care 21 Expr. 2017; 5:8 1. End-expiratory lung volume (EELV) at a given PEEP

2. Transpulmonary pressure gradient

(Pplat - Poes/EI) - (PEEP - Peos/EE)

Cortes and Marini Critical Care 2013, 17:219 22 23 baby lung size ≈ EELV

Male 188 cm Male 188 cm

24 Why oxygenation is not a good target

Kalenka et al, unpublished data 25 26 27 Tidal volume of 420 ml based on kg iBW at different FRC (EELV)

0,7

0,525 n i

a 0,35 r t S

0,175

0 0 650 1300 1950 2600 3250 EELV

dynamic strain = VT/EELV

28 dynamic strain = VT/EELV aim for dynamic strain < 0.25

29 Courtesy of Antonio Pesenti 30 31 32 Strain: „the driving pressure“

VT/EELV ≠ VT/ml/iKG Stress:

PTP ≠ PAW

Stress = k * Strain k = Specific Elastance (EL,s) = Stress/Strain Specific Elastance = 13 – 15 cmH2O

33 Individualized titration of PEEP and VT

Ppulm. = Palv – Ppl ~ Poes

34 optimize PEEP and VT with measurement of esophageal pressure and transpulmonary pressure gradient

1. PEEP > endexspiratory esophageal pressure

2. VT max = transpulmonary pressure gradient < 10 (20)

(Pplat - Poes/EI) - (PEEP - Peos/EE)

35 VT and PEEP ? male 172 cm 86 kg EF 20% respiratory distress high dose vasopressor fiO2 0.9 spO2 88 %

36 400/2000=0.2 400/1600=0.25

37 38 TPP = (35-26)-(20-18) = 9-2=7

39 SOP

„Friday night“ Minerva Anestesiologica 2014; 80: 1046

40 BiLevel-VG

Moderate Recruitment decremental PEEP InView Ann Emerg Med. 2017;70:406-418. 42 43 Résumé