Poster Discussion Room E104-106 - 10:45-12:45 MONDAY,SEPTEMBER 26TH 2011

245. Mechanical ventilation and lung injury: new advances

P1985 Late-breaking abstract: High flow oxygen therapy decreases endotracheal intubation requirement in patients with ALI or ARDS Guillaume Schnell1,2, Claire Andrejak1, Bouchra Lamia2, Bénédicte Toublanc1, Jean-François Muir2, Antoine Cuvelier2, Vincent Jounieaux1. 1Pulmonary and Respiratory Intensive Care Unit, Amiens Teaching Hospital, Amiens, France; 2Pulmonary and Respiratory Intensive Care Unit, Rouen University Hospital & UPRES EA 3830, University of Rouen, Rouen, France

High flow oxygen (HFO) therapy is able to deliver up to 60L/min of a heated and humidified air-oxygen mixture through nasal cannulae and to provide small amount of positive end-expiratory pressure. Our objective was to assess the out- come of patients admitted for acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) who were treated by HFO and to determine if HFO could decrease endotracheal intubation rate. We retrospectively selected 38 consecutive patients (median age 57 yrs) admitted in ICU for ALI (n=5, 13%) or ARDS (n=33, 87%) and who underwent HFO (Optiflow®, Fisher & Paykel, France) at admission (PaO2 = 65 mmHg, PaO2/FiO2

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= 110±71 mmHg). Most of our population (26/38 patients, 68%) resolved their P1988 acute episode with HFO. In this group, invasive ventilation was not required and High-frequency oscillatory ventilation – A safe procedure for COPD patients? this decision was not stated on EOL care (success group). PaO2/FiO2 at admission Sven Pulletz1, Ute Achtzehn2, Andreas Pechmann2,ErnstSchmidt2, was found higher in the success group (126 vs. 76 mmHg, p=0.04). Failure pa- Michael Quintel3, Norbert Weiler1, Inéz Frerichs1. 1Department of tients (12/38, 32%) exhibited more comorbidities (Charlson’s score = 4.5 vs. 2.5, Anaesthesiology and Intensive Care Medicine, University Medical Center p=0.034) and appeared more severe at admission (SAPS2 = 45 vs. 31, p=0.0054). Schleswig-Holstein, Campus Kiel, Kiel, Germany; 2Department of Internal After 24 hours, the %FiO2 under HFO was significantly lower in the success group Medicine IV, Medical Center Chemnitz, Chemnitz, Germany; 3Department of (50% vs. 70%, p=0.004). The hospitalization length was similar in both groups Anaesthesiology, Emergency and Intensive Care Medicine, University Medical (p=0.28). Hospital mortality rate was significantly higher in the failure group than Center Göttingen, Göttingen, Germany in the success group ((92% vs. 4%, p<0.0001) as was the 28-days mortality rate (respectively: 83% and 4%, p<0.0001). Introduction: High-frequency oscillatory ventilation (HFOV) is an alternative In conclusion, HFO may avoid endotracheal intubation during ALI/ARDS and its type of mechanical ventilation. HFOV is usually considered as not indicated in usefulness in hypoxemic respiratory failure needs further investigations. patients with obstructive lung disease because of the theoretical risk of air trapping and hyperinflation. Aim and objectives: Intention of this study was to establish if HFOV can safely P1986 be applied in patients with exacerbation of chronic obstructive pulmonary disease In vitro performance of an improved collapsible holding chamber (CHC) for and hypercapnic respiratory failure. the delivery of bronchodilators to patients receiving mechanical ventilation Methods: Ten patients with acutely exacerbated chronic obstructive pulmonary Mark Nagel, Valentina Avvakoumova, Rubina Ali, Cathy Doyle, Jolyon Mitchell. disease (GOLD stages II-IV) requiring intensive care treatment who failed on non- Medical Aerosol Laboratory, Trudell Medical International, London, ON, Canada invasive ventilation were studied. After initial conventional mechanical ventilation (CMV) of less than 72 hours all patients were transferred to HFOV for 24 hours Bronchodilator delivery by pressurized metered-dose inhaler (pMDI) to patients and then back to CMV. on mechanical ventilation is best achieved without breaking the breathing circuit. Main results: Regional lung aeration and ventilation were assessed by electrical We describe an evaluation of an improved CHC (AeroVent Plus*, Trudell Medical impedance tomography. HFOV was tolerated well, no adverse effects were ob- International, London, Canada (n=5 devices, 1 measurement/device)), in which served. Effective CO2 elimination and oxygenation were achieved. Arterial partial the pMDI canister receptacle is offset from the CHC axis to reduce internal im- pressure of CO2 was 52±13 mmHg (mean ± SD) during CMV before transition paction, and can also accept GSK pMDI canisters having a dose counter. Delivery to HFOV and 47±9 mmHg by the end of the 24-hour period of HFOV. Ventilation of 3-actuations of salbutamol (HFA-Ventolin*, GSK (Canada); 100-μg/actuation) was more homogeneously distributed during HFOV than during initial CMV. was assessed with the expanded CHC inserted in the inspiratory limb of an adult No signs of hyperinflation induced by HFOV were identified. Higher respiratory breathing circuit equipped with a 7-mm diameter endotracheal tube (ETT). An system compliance and tidal volume were found during CMV after 24 hours of adult test lung (Michigan Instruments) was used to simulate the patient. The circuit HFOV than before. was humidified near to body conditions (T = 36°C, 100%RH), and tidal breathing Conclusions: Contrary to present recommendations on the use of HFOV in adult (600-mL, duty cycle = 33%, 10 breaths/min) was simulated by a servo ventilator patients our pilot study indicates that this type of mechanical ventilation can safely (Siemens, model 900C). A filter was located between the distal end of the ETT and be used in patients with chronic obstructive lung disease. test lung to collect the aerosol. Total mass (TM) of salbutamol after 6 respiratory cycles was determined by HPLC-UV spectrophotometry. Similar measurements were undertaken with a Spirale* CHC (Armstrong Medical), providing benchmark P1989 data from a European marketed CHC having the pMDI receptacle in-line with Efficacy of a ventilator bundle for the prevention of the ventilator-associated the axis of the device. TM (mean ± S.D.) from the AeroVent Plus and Spirale pneumonia CHCs was 22.7±3.1 and 4.7±0.7 μg/actuation respectively. Clinicians using these Felipe Chertcoff1, Miguel Blasco1, Carolina Giuffre2, Lorena Maldonado1, devices should be aware of the implications of the difference in drug output Sergio Verbanaz2, Elias Soloaga1, Emiliano Descotte1, Ernesto Efron2. between these apparently similar devices. 1Respiratory and Critical Care Medicine, British Hospital, Buenos Aires, Argentina; 2Infectology, British Hospital, Buenos Aires, Argentina

P1987 Introduction: Several specific and general strategies have proven effectiveness for Comparisons of predictive performance of breathing pattern variabilities prevention of ventilator-associated pneumonia (VAP). measured during T-piece, automatic tube compensation and pressure support Objective: To evaluate the impact of a ventilator bundle and the control of process ventilation for weaning ICU patients from mechanical ventilation measures on the rate of VAP in our Intensive Care Unit. Mauo-Ying Bien1,2,3,YuRuKou4,5, You Shui Lin6, You-Lan Yang1, Methods: A prospectively ventilator bundle have applied to every patient who Chung-Hung Shih1,2. 1School of Respiratory Therapy, College of Medicine, received mechanical ventilation (MV). Daily control of the application of venti- Taipei Medical University, Taipei, Taiwan; 2Division of Pulmonary Medicine, lator bundle was registered and weekly control of ventilator bundle compliance Department of Internal Medicine, Taipei Medical University Hospital, Taipei, was registered. We compare the VAP rate of two periods, 25 months before the Taiwan; 3Division of Pulmonary Medicine, Department of Internal Medicine, implementation of the bundle and 11 months after. The Poisson regression test was Wan Fang Hospital, Taipei, Taiwan; 4Institute of Physiology, National Yang-Ming used. The methodology of the NHSN (National Healthcare Safety Network) was University, Taipei, Taiwan; 5Institute of Emergency and Critical Care Medicine, used for infection surveillance and the methodology of IHI (Institute of Healthcare National Yang-Ming University, Taipei, Taiwan; 6Department of Physiology, Improvement) was used for compliance control. College of Medicine, Taipei Medical University, Taipei, Taiwan Results: The MV use rate was (ventilator day/patients day) higher during the bundle period compare to the previous period (1381/2253 = 0.61 vs. 2840/5262 = Objective: To compare the influence of different ventilatory supports on the 0.54 p<0.0001), the MV average days was also higher during the bundle period predictive performance of breathing pattern variabilities (BPV) for extubation (8.52±2.07 vs. 7.03±1.61 p<0.0001). The VAP rate was lower during the bundle outcomes in ICU patients. period compare with the previous one (3.62‰ MV days vs. 12.32‰ MV days Methods: 68 ready-for-weaning patients were divided into success (n=45; ES) and p=0.001) with a reduction of the VAP of 70.61%. The compliance to the ventilator failure (n=23; EF) groups based on their extubation outcomes. Breath-to-breath bundle was 97.91% and the fulfillment of the ventilator bundle was 90.13%. analyses of peak inspiratory flow (PIF), total breath duration, tidal volume and Conclusion: The application of a ventilator bundle and control of ventilator bundle rapid shallow breathing index (BB-RSBI) were performed for three 30-min periods compliance was associated with a diminishment of the VAP rate. while patients randomly received T-piece, 100% inspiratory automatic tube com- pensation with 5 cmH2O PEEP (ATC) and 5 cmH2O pressure support ventilation with5cmH2O PEEP (PSV) trials. Coefficient of variations (CV) and SD1 and P1990 SD2 of the Poincaré plot were analyzed to serve as BPV indices. Effects of N-acetylcysteine in lipopolysaccharide-induced acute lung injury in Results: Under all three trials, BPV in EF patients were smaller than in ES patients. the rat: Treatment after acute lung injury ATC and PSV decreased the ability of certain BPV indices to discriminate ES from Jae Sung Choi, Ho Sung Lee, Ki Hyun Seo, Ju Ock Na, Yong Hoon Kim. EF than T-piece trial. The areas under the ROC curve of these BPV indices were: Division of Pulmonary and Critical Care Medicine, Soonchunhyang University T-piece > ATC > PSV. Analysis of the classification and regression tree indicated Cheonan Hospital, Cheonan, Republic of Korea that during the T-piece trial, a SD1 of PIF > 3.36 L/min defined a group including all ES patients and the combination of a SD1 of PIF ≤ 3.36 L/min and a CV of Introduction: As it has been known that N-Acetylcysteine (NAC) which is a free BB-RSBI ≤ 0.23 defined a group of all EF patients. The decision strategies using radical scavenger and antioxidant reduces acute lung injury of rats stimulated by SD1 of PIF and CV of BB-RSBI measured during ATC and PSV trials achieved a endotoxin, studies on NAC are being executed recently as a way of treatments of less clear separation of EF from ES. lung injuries. This study was to elucidate effect of NAC in LPS-induced acute lung Conclusions: BPV measurement during the T-piece trial is the best choice for injury in rats. predicting extubation outcome in ICU patients. Methods: Six weeks old SD rats were divided into 4 groups (group 1: saline, 2: NAC, group 3: LPS, group 4: LPS+NAC). LPS was intravenously injected at the rate of 5mg/kg. NAC of 20mg/kg was injected into abdominal cavity 3, 6 and 12 hours after the injection of LPS. BAL fluids and lung tissues were obtained from individual rats. Using 100mg of lung tissues, the levels of NF-kB and lipid peroxidation (LPO) were measured.

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Results: Neutrophilic inflammations of the lung tissues and BAL fluids were the ratio and a smaller compliance than well inflated tissue changes in compliance most severe in the LPS group. The amounts of NF-kB in the group 3 (0.32±0.23 may not be used to estimate lung recruitment at bedside. ng/μl) showed statistically significant differences compared with the group 1 Reference: (0.16±0.12 ng/μl), 2 (0.16±0.12 ng/μl) (p<0.001) and 4 (0.25±0.19 ng/μl) [1] Gattinoni, L. et al. N Engl J Med 2006; 354:1775-1786. (p<0.05). The amounts of LPO in the group 3 (15.29±3.76 nmol/ml) showed sta- tistically significant differences compared with the group 1 (4.35±4.27 nmol/ml), 2 (4.99±5.06 nmol/ml) (p<0.001) and 4 (7.65±6.24 nmol/ml) (p<0.01). P1993 Conclusion: N-Acetylcysteine has a protective effect to reduce acute lung injury Lactate and lactate clearance were associated with higher mortality in stimulated by endotoxin and it is considered that the mechanism appears in relation patients with septic shock to neutrophils that are mainly involved in lung injuries. Prapun Kittivoravitkul, Anan Wattanathum, Adisorn Wongsa. Pulmonary and Critical Care Division, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand P1991 C-reactive protein as a predictor of mortality in patients with severe sepsis in Introduction: An elevated lactate level is associated with higher mortality in intensive care unit patients with severe sepsis. Also, lactate clearance is a surrogate for magnitude Zuhal Karakurt, Ozlem Yazicioglu Mocin, Ozkan Devran, Nalan Adiguzel, and duration of global tissue hypoxia. However, the utility of the lactate clearance Gokay Gungor, Merih Kalamanoglu Balci, Ece Oz, Adnan Yilmaz. Intensive after ICU admission as an indicator of outcome in patients with septic shock is Care Unit, Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital, still limited. Istanbul, Turkey Objectives: The purpose of study is to evaluate the advantage of lactate level and clearance in predicting mortality of patients with septic shock. Objective: We aimed to research whether initial and/or third day of C- reactive Methods: We prospectively enrolled 38 patients with septic shock in ICU at Phra- protein (CRP) values can be good predictors of mortality as other well known mongkutklao hospital. Measurements of venous lactate and ScvO2 were obtained complex predictors of mortality (ie, SOFA scores) for patients with severe sepsis at 0, 2, 6, 24, 48, and 72 hours after ICU admission. Lactate clearance was defined requiring ICU. as the percent change in lactate levels after 2 or 6 hours from the baseline value. Methods: Observational cohort study was done in a 20 beds respiratory ICU in The primary outcome was 28-day mortality rate. chest diseases center in January 2009- March 2010. Patients with severe sepsis Results: The 28-day mortality rate was 55.3%. There was no significant differ- due to respiratory diseases (pneumonia, acute exacerbation of chronic obstructive ences in 28-day mortality rate between normal ScvO2 (≥ 70%) group and low pulmonary diseases, bronchiectasis) were enrolled in this study. Patients with ScvO2 (< 70%) group at initial presentation. Using cut off value of 3 mmol/L, rheumatic diseases and cancer were excluded from study. SOFA scores and CRP higher initial lactate level was significantly associated with higher 28-d mortality values on admission, third day and mortality rate were recorded. The receiver (p = 0.017). There was, also, significant association between lactate non-clearance operator characteristic (ROC) method and area under curve (AUC) were used to (lactate clearance < 10%) at 2 and 6 hrs and higher 28-d mortality (p = 0.029 and compare SOFA scores, CRP values. 0.014). Results: In study period 814 patients were admitted to ICU and eligible 314 Conclusions: Early lactate clearance may indicate a resolution of global tissue patients had severe sepsis were included. Sepsis related mortality rate was 14.2% hypoxia and is associated with decreased mortality. Patients with higher lactate (n=45). AUC of CRP values and SOFA scores on admission and 3rd day were clearance after 2 and 6 hrs of ICU admission have improved outcome compared calculated AUC: 0,57 (CI:0.48-0,66); 0,72 (CI: 0,63-0,80); 0,72 (CI: 0,64-0,81); with those with lower lactate clearance. Also, initial lactate level was independently 0,76 (CI: 0,67-0,86), respectively. Sepsis due to nosocomial infection, on 3rd associated with 28-day mortality rate. day CRP >100mg/L, higher 3rd day SOFA scores were found as risk factors for mortality (odds ratio [OR]: Confidence Interval [CI]; OR: 3.76, CI: 1.68-8.40 p<0.001 and OR: 2.70, CI 1.41-2.01, p<0.013 OR: 1.68, CI: 1.41-2.01 p<0.0001 respectively). Conclusion: Third day CRP values especially >100mg/L are better mortality predictor than first day CRP and as valuable as SOFA scores in patients with severe sepsis in ICU.

P1992 Mechanical properties of ALI/ARDS lung may be heterogenous Massimo Cressoni1, Daniela Febres1, Chiara Chiurazzi1, Gallazzi Elisabetta1, Antonella Marino1, Federica Ylenia Romano1, Matteo Brioni1, Eleonora Carlesso1, Davide Chiumello2, Luciano Gattinoni1,2. 1Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Università degli Studi di Milano, Milan, Italy; 2Dipartimento di Anestesia, Rianimazione, Terapia del Dolore, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy

Introduction: ARDS is characterized by lung collapse which is partly reversible by the application of PEEP; it is common belief that recruited lung units resume normal gas/tissue ratio and mechanical properties so that optimal PEEP can be set according to EELV and compliance changes. Methods: We retrospectively analyzed 68 ALI/ARDS patients CT scans performed at 5 and 15 cmH2O PEEP [1]. Assuming that lung expansion while increasing PEEP is homogeneous, we divided each lung along the transverse, sagittal and coronal axes in oreder to obtain 125 parallelepiped compartments with an average weight of 5 g and we estimated a surrogate compliance per gram of tissue as: ( Volume of gas/ PEEP)/gram of tissue. Each lung compartment was classified according to its gas/tissue ratio as shown in Table 1. Results: In Table 1 we summarize the surrogate compliances as median [interquar- tile range]. As shown the median compliance of the well inflated tissue was almost double the compliance of the poorly inflated tissue while the surrogate compliance of the recruited lung units was between the surrogate compliance of well inflated and poorly inflated tissue.

Table 1. Specific lung tissue compliances

Surrogate compliance 5-15 Not inflated (g/t < 0.1) 0.00 [0.00 to 0.00] Recruited 5-15 0.040 [0.02 to 0.10] Poorly inflated (g/t < 1) 0.033 [0.00 to 0.08] Well inflated (1 < g/t <9) 0.061 [0.00 to 0.15] Over inflated (g/t > 9) 0.132 [–0.11 to 0.18]

Conclusions: As recruited regions while increasing PEEP reach a lower gas tissue

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