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Invasive Ventilation No Conflict of Interest 21/09/2018 Invasive Ventilation Is lung protection necessary in the ED? Helen Askitopoulou MD, PhD, FRCA, DA Professor Emeritus, University of Crete No Conflict of Interest 1 21/09/2018 Invasive Positive Pressure Ventilation Is lung protection necessary in the ED? • Invasive ventilation in the ED: the facts? • Ventilator Lung Injury: Why? How soon? • Is it necessary to protect the lungs from IPPV in the ED? Invasive Positive Pressure Ventilation in the ED What are the facts? 2 21/09/2018 2012;30;1183‐8 • approximately 240.000 patients per year are ventilated in US EDs, representing approximately 0.23% of all ED visits or 0.85 visits per year per 1000 US population • ¾ of ventilated patients stayed in the ED almost 2 hrs, • ¼ were present for more than 5 hrs • 24% in‐hospital mortality of mechanically ventilated pts pts mechanically ventilated in the ED • Many mechanically ventilated pts in the ED have protracted lengths of stay while awaiting ICU admission – Scand J Trauma Resusc Emerg Med 2012;20:30 – Crit Care Med 2007;35(6):1477‐83 • more than 20% of ED pts receiving ventilation develop pulmonary complications, such as ARDS and ventilator-associated conditions, which adversely affect outcome – Shock 2013;40:375‐381 – J Crit Care 2015;30:1163‐1168 3 21/09/2018 Emergency Department concerns about the quality of mechanical ventilation in the ED the portal of entry of the highest risk patients for ARDS • Lung protective ventilation was uncommon in the ED • Given – the frequency of ALI & ARDS in the ED, – the progression to ARDS shortly after ICU admission, – that ventilator‐induced lung injury (VILI) can develop within hours, and progression to ALI occurs early in the course of respiratory failure • The effect of ED‐based interventions to reduce the sequelae of ALI should be investigated further 4 21/09/2018 Key messages • higher tidal volumes are causal in the development of ARDS. • ARDS occurs early in the course of mechanical ventilation, • suggesting that ARDS‐PREVENTION trials should occur EARLY in the course of mechanical ventilation, • such as in the EMERGENCY DEPARTMENT. Protecting the lungs in the ED Ventilation Induced Lung Injury (VILI) Understanding the mechanisms of lung damage 5 21/09/2018 VentilaTOR‐Induced Lung Injury VILI ventilatory setting VentilaTION‐Induced Lung Injury forces acting on lung parenchyma how mechanical ventilation injures the lungs wide series of lung damages VILI from edema to gross pneumothorax Gattinoni et al. Crit Care Clin 34 (2018) 343–35 One GATTINONI ΗΙΤ MODEL Volu‐ Strain trauma stress risers stress Atelec‐ VILI trauma Baro‐ trauma Bio‐trauma 6 21/09/2018 physical forces may cause release of various intracellular Biotrauma mediators either directly or indirectly ⇒ Biotrauma Slutsky AS, Ranieri M. Ventilator induced lung injury. NEJM 2013;369:2126 “Biotrauma Hypothesis” One Hit OR Multiple HITS? • Strong form: – mechanical ventilaTION induced inflammation may suffice to injure the lungs much stronger than explained by the mechanical forces alone (one hit model) • Weak form: – ventilaTOR‐induced inflammation contributes to the mortality of ARDS patients in conjunction with other factors (multiple hits model) Anesthesiology 2017; 126:909‐22 7 21/09/2018 Multiple ΗΙΤ MODEL direct lung indirect insult lung insult ARDS potentially Sepsis Pneumonia Trauma Aspiration iatrogenic Pancreatitis Toxic inhalation disease Post arrest syndrome Lung injury Transfusions multiple Lung vasculitis Serious burns Harmful mechanical ventilation leading to VILI in healthy lungs Intensive Care Med 2013;39:6–15 protective strategies to reduce lung damage during mechanical ventilation ↓ VT /EELV ↓ strain ↓ Ptp or respiratory ↓ rate ↓ Pplateau mechanic ↓ stress VILI↓ al power ↓ Ppeak stress PEEP ↓risers recruitment 8 21/09/2018 volutrauma ↓strain lung protective ventilation: 1st Strategy focuses on Low‐tidal Volume Ventilation (< 6 ml/kg/PBW) to reduce lung strain from Volutrauma and over-distension of alveoli from large tidal volumes VT = 6 ml/kg/PBW safe for all patients?? 9 21/09/2018 the “baby lung” of ARDS areas with very low compliance make the functional lung inflated smaller than expected from small somatometric airway features collapse alveolar VT is directed to collapse alveoli with normal compliance causing Gattinoni L, et al. The ‘‘baby lung’’ became an OVERDISTENTION adult. Intensive Care Med 2016;42:663–673 Barotrauma ↓ stress lung protective ventilation: 2nd Strategy focuses on reducing lung stress & barotrauma by adjusting tidal volumes according to static compliance to lower driving pressure (VT/CRS) Ventilation even at low lung volumes can also cause injury 10 21/09/2018 Driving Pressure (ΔP) = Ptp(insp) –Ptp(exp) = Pplateau – PEEP Pplateau mean Paw Palv Intrinsic PEEP Ppl External PEEP Palv at zero flow = Pplateau Ppl is measured as Poesophageal … driving pressure as opposed to tidal volume and PEEP could further enhance lung protection by adjusting tidal volumes according to the size of the lung available for ventilation (reflected by the static compliance) ΔP = Pplateau – PEEP 15‐20 cmH2O CRS = VT / [Pplateau – PEEP] ΔP = VT / CRS 11 21/09/2018 higher Pplateau: not always protective higher PEEP: not always protective ΔP = driving pressure, S1‐S5 = five distinct subsamples of patients • lower survival rate among patients with higher ∆P and • higher survival among patients with lower ∆P • independent of concomitant variations in PEEP and plateau pressure 12 21/09/2018 Atelectrauma Stress ↓ risers lung protective ventilation: 3rd Strategy focuses on adjusting PEEP to stabilize the lung & minimize repeated opening and closing of alveolar units and open up the lung Atelectrauma / dynamic strain Ventilation that occurs at low lung volumes can also cause injury through multiple mechanisms, including repetitive opening and closing of airways and lung units, causing ⇒ Slutsky AS, Ranieri M. Ventilator induced lung injury. NEJM 2013;369:2126 13 21/09/2018 • “‘The best PEEP’ does not exist” – we may find a PEEP level that avoids intra‐ tidal recruitment–derecruitment, …, – without causing hyperinflation and affecting hemodynamics, – reflects a wishful dream that has nothing to do with the reality • we should use a ‘better PEEP’ approach • as a reasonable compromise among • oxygenation, hemodynamics status, intra‐tidal opening and closing – Higher PEEP in severe ARDS (range 15–20 cmH2O) – Lower PEEP in mild ARDS (range 5–10 cmH2O) – Intermediated in moderate ARDS paying attention to the Ecw and hemodynamic impairment 14 21/09/2018 mechan ical energy x power time lung protective ventilation: 4th Strategy focuses on respiratory rate energy and time define the mechanical power Crit Care Clin 2018;34:343–356 Mechanical power: a new way of looking at VILI • VILI is caused by the delivery of a critical amount of mechanical energy to the lung applied over time • energy and time are the 2 essential components of VILI • considered together, they define the mechanical power • every component of the mechanical ventilation: – VT, driving pressure, respiratory rate, flow, & PEEP • contribute, each one at a different extent, to the mechanical power delivered to the respiratory system (and to the lung) Critical Care Medicine 2017;45(3):e327–e328 Crit Care Clin 2018;34:343–356 15 21/09/2018 Lung‐Protective Ventilation to reduce the risk of VILI A Neglected Area in the ED that it is necessary to change EDITORIALS AJRCCM 2015;191(2):125‐126 HOW SOON? Clinicians should move to initiate low tidal volume ventilation as soon as possible in ARDS ... timely recognition of ARDS and timely adherence to low tidal volume ventilation is important for reducing mortality 16 21/09/2018 Which patients? healthy ARDS lungs lung homogeneity lung in‐ homogeneity Healthy Lungs Injured Lungs initial settings initial settings V = 6‐8 ml/Kg IBW T VT = 4‐6 ml/Kg IBW PEEP = 6‐8 cmH O 2 PEEP = 8‐15 cmH2O recruitment /30‐45 min recruitment selected pts goal ‐ monitoring goal ‐ monitoring Pplateau < 25 cmH2O Pplateau < 30 cmH2O ETCO2 > 35‐45 mmHg ETCO2 > 40‐55 mmHg SpO2 95 % pH = 7.30‐7.40 SpO2 92 % Anesthesiology 2014;121:400‐8 17 21/09/2018 Protecting the lungs in the ED In Summary Key challenges of IPPV in the ED: personalisation of mechanical ventilation • minimise STRAIN (volutrauma) – reduce VT (on driving pressure) = 6 mL/kg PBW • minimise STRESS (barotrauma) – reduce Pplateau (on driving pressure) • ARDS < 30 cm H2O • healthy lungs < 15‐20 cm H2O • maintain driving pressure ≤ 15‐20 cmH2O • minimise LUNG INHOMOGENEITY (atelectrauma) – personalise PEEP (on driving pressure ‐ dynamic compliance ‐ stress index) start 5 cmH2O – personalise recruitment manoeuvre • adjust RESPIRATORY FREQUENCY 18–22 breaths/min – personalise according to mechanical energy of ventilator 18 21/09/2018 Invasive Ventilation Is lung protection necessary in the ED? a lot of Data but still more questions than answers Thank you Transpulmonary Pressure (Ptp) ‐ Driving Pressure (ΔP) • Transpulmonary Pressure Ptp = Paw –Ppl separates the pressure delivered to the lung from the one acting on chest wall PEEP and abdomen – Paw = Palv at zero flow = Pplateau – Ppl is measured as Poesophageal • Driving Pressure (ΔP) ΔP = Ptp(insp) –Ptp(exp) = Pplateau – PEEP reflects the distending pressure taken by the lungs when VT is delivered stands for the VT‐induced lung stress 19 21/09/2018 Impact of PEEP on lung hemodynamics – ICP ICP ‐ CPP ΡΕΕΡ Preexisting cardiovascular conditions VR ‐ CO PVR ‐ RV afterload LV afterload ‐ CO (M. Vardas, et al. PEEP Role in ICU and Operating Room Scientific World J 2014) 20.
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