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PVtoolandlungrecruitmentChengdumechanicalventilationtraining.Sept.2011DrJean-MichelArnalIntensiveCareUnit.HôpitalFontPréToulonFrancejean-michel@PVtoolandlungrecruitmentCh1Atelectraumaresultingfromrepeatedalveolarrecruitment/derecruitmentBarotraumaand/orvolutraumaresultingfromlungoverdistensionMechanismsofVentilatorInducedLungInjuriesMechanicalInjuryBiotrauma:alveolarinflammationInflammatoryInjuryAtelectraumaresultingfromre2PreventionofVILIReducedtidalvolumeandairwaypressurelimitationstrategyRecruitmentstrategy:recruitmentmaneuver+PEEPtoavoidderecruitmentPreventionofVILIReducedtida3WhatdoweknowaboutARDS?LowertidalvolumeandairwaypressurelimitationdecreasesmortalityNoeffectofPEEPonmortalityARDSnetwork.NEnglJMed2000ALVEOLI.Brower.NEnglJMed2004EXPRESS.MercatJAMA2008LOVS.Meade.JAMA2008WhatdoweknowaboutARDS?Low4EffectofPEEPonmortalityinARDSALVEOLI.Brower.NEnglJMed2000PEEP=8,3±3,2cmH2O13,2±3,5cmH2On=549EffectofPEEPonmortalityin5EffectofPEEPonmortalityinARDSBriel.JAMA2010EffectofPEEPonmortalityin6WhatdoweknowaboutPEEP?PEEPdoesnotrecruitorjustalittleCollapse/re-expansionoccursduringtidalvolumeRecruitmentofpreviouslycollapsedlungwitharecruitmentmaneuverPEEPmayavoidcollapseandderecruitmentinalungpreviouslyexpanded/recruitedDon’tsetPEEPwithoutrecruitingthelung!WhatdoweknowaboutPEEP?PEE7RecruitmentCollapsedcompliantairways/alveoliFluidocclusionofnoncollapsedairwaysRecruitmentCollapsedcompliant8AmJRespirCritCareMed2006AmJRespirCritCareMed200924sur26patientsAmJRespirCritCareMed200624sur26patientsAmJRespir10n=68
n=6811RecruitabilitydependsonTypeofARDSTimefromthebeginningofthediseasePressureChestwallcomplianceRecruitabilitydependsonType12TypeofARDSMechanism:extrapulmonary>pulmonaryLocalization:diffuse>lobarEtiology:aspirationpneumonia>CAPRiva.CritCareMed2008Puybasset.IntensiveCareMed2000TypeofARDSMechanism:extrap13TimefromthebeginningofthediseaseEarlyphaseProteinrichedemafluidsandpolyneutrophilsLatephaseFibrosingalveolitisTimefromthebeginningofthe1424on26patientsPressureBorges.AmJRespCritCareMed200624on26patientsPressureBorge15Chestwallcompliance
Chestwallcompliance
16Chestwallcompliance
AirwaypressureisaroughestimateoftranspulmonarypressureTalmor.CritCareMed2006Chestwallcompliance
Airwayp17AssessmentofrecruitabilityEarlyinthemanagementofARDSWhenhemodynamicconditioniscontrolled
LowflowinflationanddeflationPVcurvefrom0to40cmH2OAssessmentofrecruitabilityEa18AssessmentofrecruitabilityAssessmentofrecruitability19Assessmentofrecruitability
ShapeofthecurveGrasso.AJRCCM2005Assessmentofrecruitability
S20Assessmentofrecruitability
LinearcomplianceMaggiore.AJRCCM2001Assessmentofrecruitability
L21CLIN=37mL/cmH2OCLIN=83mL/cmH2OAssessmentofrecruitability
LinearcomplianceCLIN=37mL/cmH2OCLIN=83mL22Assessmentofrecruitability
HysteresisDemory.IntensiveCareMed2008Assessmentofrecruitability
H236798cmH2O.ml25115cmH2O.mlDemory.IntensiveCareMed2008Assessmentofrecruitability
Hysteresis6798cmH2O.ml25115cmH2O.mlD24Assessmentofrecruitability
Hysteresisandvolumedifferenceat20cmH2ODemory.IntensiveCareMed2008r2=0.97Assessmentofrecruitability
H25Assessmentofrecruitability
300200100Assessmentofrecruitability
326Assessmentofrecruitability
CLIN=20cmH2O/mLCLIN=60cmH2O/mLHMAX=50mLHMAX=200mLClinicalcase
Assessmentofrecruitability
C27Clinicalcase
Mr.BeM,63yearsoldLeukemiatreatedbysteroidsAcuterespiratoryfailureCommunityacquiredpneumoniaMrs.LeD,72yearsoldLymphomatreatedbychemotherapyAcuterespiratoryfailureCommunityacquiredpneumoniaClinicalcase
Mr.BeM,63yea28Clinicalcase
Mr.BeM,63yearsoldMrs.LeD,72yearsoldClinicalcase
Mr.BeM,63yea29DecisionatthebedsideLowpotentialofrecruitabilityHighpotentialofrecruitabilityLowerinflectionpointNonePresentLinearcomplianceLowHighHysteresisLowHighDecisionatthebedsideLowpot30DecisionatthebedsideLowpotentialofrecruitabilityHighpotentialofrecruitabilityLowerinflectionpointNonePresentLinearcomplianceLowHighHysteresisLowHigh1/3ofpatientsNorecruitmentmaneuverLowPEEP:5–10cmH2O2/3ofpatientsRecruitmentmaneuverHighPEEP:>10cmH2ODecisionatthebedsideLowpot31DefinitionofarecruitmentmaneuverUseofatransientincreaseintranspulmonarypressuretoreopenpreviouslycollapsedornonaeratedlungunits.Definitionofarecruitmentma32JustificationandgoalforRMARDSischaracterizedbyanaturaltendencyforlungcollapse:lungedema,surfactantdysfunction,lowVT,highFiO2,repeatedtrachealsuctioning…Goal:keepthelungopenandpreventVILIJustificationandgoalforRMA33MethodforRMCPAPmethod:increasePEEPto40cmH2Ofor40sSighs:periodicallyincreaseVTorPINSPProgressiveincreaseinPEEPPronepositioningGrasso.Anesthesiology2002Pelosi.AJRCCM1999.BarbasAJRCCM2001Albert.AJRCCM2000Borges.AJRCCM2006Timeconsuming,nodirectmonitoringMethodforRMCPAPmethod:incr34VolumerecruiteddependsonPreviousrecruitmentTranspulmonaryinflationpressureDurationPEEPsettingaftertheRMVolumerecruiteddependsonPre35PressureandtimeAlbert.JApplPhysiol2009PressureandtimeAlbert.36TimeRothen.BJA199912anaesthetizedpatientswithhealthylung=2,6sTimeRothen.12anaesthetizedpa37OptimaldurationoftherecruitmentmaneuverArnal.IntensiveCareMed2011=2,3±1,3sn=50Optimaldurationoftherecrui38OptimaldurationoftherecruitmentmaneuverRecruitmentmaneuver****Arnal.IntensiveCareMed2011n=50Optimaldurationoftherecrui39SustainedinflationrecruitmentmaneuverQuick,safewithvolumerecruitedassessmentSustainedinflationrecruitmen40InspiratoryExpiratory=40cmH2O
pneumotachographPawVolumeincreaseduringasustainedinflationrecruitmentmaneuverInspiratoryExpiratory=40cmH41VolumeincreaseduringasustainedinflationrecruitmentmaneuverVolumeincreaseduringasusta42VRM=100mLVRM=240mLVolumeincreaseduringasustainedinflationrecruitmentmaneuverVRM=100mLVRM=240mLVolumei43Clinicalcase
Mr.BeM,63yearsoldMrs.LeD,72yearsoldVRM=30mLVRM=220mLClinicalcase
Mr.BeM,63yea44Recruitmentmaneuveratthebedside
ConditionsPassivepatient:deepsedation±paralysisStablehemodynamiccondition:ΔPP<13%CuffoverinflatedtoavoidleaksNocontraindicationsRecruitmentmaneuveratthebe45Recruitmentmaneuveratthebedside
ContraindicationsHighintracranialpressureEmphysemaBronchopleuralfistulaPregnancyRightheartfailureRecruitmentmaneuveratthebe46Recruitmentmaneuveratthebedside
SettingsRecruitmentmaneuveratthebe47HowtosetPEEPafterrecruitmentmaneuver?LowinflectionpointonPVcurveDeflectionpointonPVcurveMaximumPEEPwhilelimitingPplataround28cmH2OPEEPsettingguidedbyesophagealmeasurementPEEPsettingguidedbySpO2Hickling.AJRCCM1998Talmor.NEnglJMed2009Hickling.AJRCCM2001Lapinski.IntensiveCareMed1999EXPRESS.MercatJAMA2008HowtosetPEEPafterrecruitm48SettingPEEPaccordingtoinflationPVcurveHickling.AJRCCM1998SettingPEEPaccordingtoinfl49Hickling.AJRCCM2001SettingPEEPaccordingtodeflationPVcurveHickling.SettingPEEPaccordi50PEEPsettingguidedbyesophagealpressureRandomizedcontrolledtrial61ARDSpatientsControl:ARDSnetPEEP/FiO2tableIntervention:PEEPend-expirationPpulm0-10cmH2OTalmor.NEnglJMed2009PEEPsettingguidedbyesophag51PEEPsettingguidedbyesophagealpressureVT=400PEEP=14FiO2=90%Talmor.NEnglJMed2009Ppulmins=4Ppulmexp=-6PEEPsettingguidedbyesophag52PEEPsettingguidedbyesophagealpressureTalmor.NEnglJMed2009VT=400PEEP=12FiO2=60%Ppulmins=3Ppulmexp=-6PEEPsettingguidedbyesophag53PEEPsettingguidedbyesophagealpressureTalmor.NEnglJMed2009VT=320PEEP=24FiO2=60%Ppulmins=12Ppulmexp=4PEEPsettingguidedbyesophag54PEEPsettingguidedbyesophagealpressureTalmor.NEnglJMed2009PEEPsettingguidedbyesophag55PEEPsettingguidedbyesophagealpressureTalmor.NEnglJMed2009PEEPsettingguidedbyesophag56PEEPsettingguidedbyesophagealpressureTalmor.NEnglJMed2009PEEPsettingguidedbyesophag57Clinicalcase
Mr.BeM,63yearsoldMrs.LeD,72yearsoldPTP
insp=20cmH2OPTP
insp=8cmH2OPTP
exp=2cmH2OPTP
exp=-1cmH2OPEEP=10cmH2OClinicalcase
Mr.BeM,63yea58Clinicalcase
Mr.BeM,63yearsoldMrs.LeD,72yearsoldPTP
insp=13cmH2OPTP
insp=8cmH2OPTP
exp=0.5cmH2OPTP
exp=2cmH2OPEEP=8cmH2OPEEP=12cmH2OClinicalcase
Mr.BeM,63yea59Lapinski.IntensiveCareMed1999n=14PEEPsettingguidedbySpO2Lapinski.IntensiveCareMed160Lapinski.IntensiveCareMed1999PEEPsettingguidedbySpO2Lapinski.IntensiveCareMed161ConclusionsRecruitmentstrategyispartofprotectiveventilationinARDSPEEPdoesnotrecruitAssessingrecruitabilityisapre-requisiteforarationalsettingofPEEP:lowflowPVtoolHighpotentialofrecruitabilitypatients:RecruitmentstrategyRecruitmentmaneuver:40cmH2O(upto60)for10sPEEP>10cmH20(upto25)guidedbyPoesoorSpO2RecruitmentshouldbeanearlygoalinthemanagementofARDS.Thankyou…ConclusionsRecruitmentstrate62PVtoolandlungrecruitmentChengdumechanicalventilationtraining.Sept.2011DrJean-MichelArnalIntensiveCareUnit.HôpitalFontPréToulonFrancejean-michel@PVtoolandlungrecruitmentCh63Atelectraumaresultingfromrepeatedalveolarrecruitment/derecruitmentBarotraumaand/orvolutraumaresultingfromlungoverdistensionMechanismsofVentilatorInducedLungInjuriesMechanicalInjuryBiotrauma:alveolarinflammationInflammatoryInjuryAtelectraumaresultingfromre64PreventionofVILIReducedtidalvolumeandairwaypressurelimitationstrategyRecruitmentstrategy:recruitmentmaneuver+PEEPtoavoidderecruitmentPreventionofVILIReducedtida65WhatdoweknowaboutARDS?LowertidalvolumeandairwaypressurelimitationdecreasesmortalityNoeffectofPEEPonmortalityARDSnetwork.NEnglJMed2000ALVEOLI.Brower.NEnglJMed2004EXPRESS.MercatJAMA2008LOVS.Meade.JAMA2008WhatdoweknowaboutARDS?Low66EffectofPEEPonmortalityinARDSALVEOLI.Brower.NEnglJMed2000PEEP=8,3±3,2cmH2O13,2±3,5cmH2On=549EffectofPEEPonmortalityin67EffectofPEEPonmortalityinARDSBriel.JAMA2010EffectofPEEPonmortalityin68WhatdoweknowaboutPEEP?PEEPdoesnotrecruitorjustalittleCollapse/re-expansionoccursduringtidalvolumeRecruitmentofpreviouslycollapsedlungwitharecruitmentmaneuverPEEPmayavoidcollapseandderecruitmentinalungpreviouslyexpanded/recruitedDon’tsetPEEPwithoutrecruitingthelung!WhatdoweknowaboutPEEP?PEE69RecruitmentCollapsedcompliantairways/alveoliFluidocclusionofnoncollapsedairwaysRecruitmentCollapsedcompliant70AmJRespirCritCareMed2006AmJRespirCritCareMed2007124sur26patientsAmJRespirCritCareMed200624sur26patientsAmJRespir72n=68
n=6873RecruitabilitydependsonTypeofARDSTimefromthebeginningofthediseasePressureChestwallcomplianceRecruitabilitydependsonType74TypeofARDSMechanism:extrapulmonary>pulmonaryLocalization:diffuse>lobarEtiology:aspirationpneumonia>CAPRiva.CritCareMed2008Puybasset.IntensiveCareMed2000TypeofARDSMechanism:extrap75TimefromthebeginningofthediseaseEarlyphaseProteinrichedemafluidsandpolyneutrophilsLatephaseFibrosingalveolitisTimefromthebeginningofthe7624on26patientsPressureBorges.AmJRespCritCareMed200624on26patientsPressureBorge77Chestwallcompliance
Chestwallcompliance
78Chestwallcompliance
AirwaypressureisaroughestimateoftranspulmonarypressureTalmor.CritCareMed2006Chestwallcompliance
Airwayp79AssessmentofrecruitabilityEarlyinthemanagementofARDSWhenhemodynamicconditioniscontrolled
LowflowinflationanddeflationPVcurvefrom0to40cmH2OAssessmentofrecruitabilityEa80AssessmentofrecruitabilityAssessmentofrecruitability81Assessmentofrecruitability
ShapeofthecurveGrasso.AJRCCM2005Assessmentofrecruitability
S82Assessmentofrecruitability
LinearcomplianceMaggiore.AJRCCM2001Assessmentofrecruitability
L83CLIN=37mL/cmH2OCLIN=83mL/cmH2OAssessmentofrecruitability
LinearcomplianceCLIN=37mL/cmH2OCLIN=83mL84Assessmentofrecruitability
HysteresisDemory.IntensiveCareMed2008Assessmentofrecruitability
H856798cmH2O.ml25115cmH2O.mlDemory.IntensiveCareMed2008Assessmentofrecruitability
Hysteresis6798cmH2O.ml25115cmH2O.mlD86Assessmentofrecruitability
Hysteresisandvolumedifferenceat20cmH2ODemory.IntensiveCareMed2008r2=0.97Assessmentofrecruitability
H87Assessmentofrecruitability
300200100Assessmentofrecruitability
388Assessmentofrecruitability
CLIN=20cmH2O/mLCLIN=60cmH2O/mLHMAX=50mLHMAX=200mLClinicalcase
Assessmentofrecruitability
C89Clinicalcase
Mr.BeM,63yearsoldLeukemiatreatedbysteroidsAcuterespiratoryfailureCommunityacquiredpneumoniaMrs.LeD,72yearsoldLymphomatreatedbychemotherapyAcuterespiratoryfailureCommunityacquiredpneumoniaClinicalcase
Mr.BeM,63yea90Clinicalcase
Mr.BeM,63yearsoldMrs.LeD,72yearsoldClinicalcase
Mr.BeM,63yea91DecisionatthebedsideLowpotentialofrecruitabilityHighpotentialofrecruitabilityLowerinflectionpointNonePresentLinearcomplianceLowHighHysteresisLowHighDecisionatthebedsideLowpot92DecisionatthebedsideLowpotentialofrecruitabilityHighpotentialofrecruitabilityLowerinflectionpointNonePresentLinearcomplianceLowHighHysteresisLowHigh1/3ofpatientsNorecruitmentmaneuverLowPEEP:5–10cmH2O2/3ofpatientsRecruitmentmaneuverHighPEEP:>10cmH2ODecisionatthebedsideLowpot93DefinitionofarecruitmentmaneuverUseofatransientincreaseintranspulmonarypressuretoreopenpreviouslycollapsedornonaeratedlungunits.Definitionofarecruitmentma94JustificationandgoalforRMARDSischaracterizedbyanaturaltendencyforlungcollapse:lungedema,surfactantdysfunction,lowVT,highFiO2,repeatedtrachealsuctioning…Goal:keepthelungopenandpreventVILIJustificationandgoalforRMA95MethodforRMCPAPmethod:increasePEEPto40cmH2Ofor40sSighs:periodicallyincreaseVTorPINSPProgressiveincreaseinPEEPPronepositioningGrasso.Anesthesiology2002Pelosi.AJRCCM1999.BarbasAJRCCM2001Albert.AJRCCM2000Borges.AJRCCM2006Timeconsuming,nodirectmonitoringMethodforRMCPAPmethod:incr96VolumerecruiteddependsonPreviousrecruitmentTranspulmonaryinflationpressureDurationPEEPsettingaftertheRMVolumerecruiteddependsonPre97PressureandtimeAlbert.JApplPhysiol2009PressureandtimeAlbert.98TimeRothen.BJA199912anaesthetizedpatientswithhealthylung=2,6sTimeRothen.12anaesthetizedpa99OptimaldurationoftherecruitmentmaneuverArnal.IntensiveCareMed2011=2,3±1,3sn=50Optimaldurationoftherecrui100OptimaldurationoftherecruitmentmaneuverRecruitmentmaneuver****Arnal.IntensiveCareMed2011n=50Optimaldurationoftherecrui101SustainedinflationrecruitmentmaneuverQuick,safewithvolumerecruitedassessmentSustainedinflationrecruitmen102InspiratoryExpiratory=40cmH2O
pneumotachographPawVolumeincreaseduringasustainedinflationrecruitmentmaneuverInspiratoryExpiratory=40cmH103VolumeincreaseduringasustainedinflationrecruitmentmaneuverVolumeincreaseduringasusta104VRM=100mLVRM=240mLVolumeincreaseduringasustainedinflationrecruitmentmaneuverVRM=100mLVRM=240mLVolumei105Clinicalcase
Mr.BeM,63yearsoldMrs.LeD,72yearsoldVRM=30mLVRM=220mLClinicalcase
Mr.BeM,63yea106Recruitmentmaneuveratthebedside
ConditionsPassivepatient:deepsedation±paralysisStablehemodynamiccondition:ΔPP<13%CuffoverinflatedtoavoidleaksNocontraindicationsRecruitmentmaneuveratthebe107Recruitmentmaneuveratthebedside
ContraindicationsHighintracranialpressureEmphysemaBronchopleuralfistulaPregnancyRightheartfailureRecruitmentmaneuveratthebe108Recruitmentmaneuveratthebedside
SettingsRecruitmentmaneuveratthebe109HowtosetPEEPafterrecruitmentmaneuver?LowinflectionpointonPVcurveDeflectionpointonPVcurveMaximumPEEPwhilelimitingPplataround28cmH2OPEEPsettingguidedbyesophagealmeasurementPEEPsettingguidedbySpO2Hickling.AJRCCM1998Talmor.NEnglJMed2009Hickling.AJRCCM2001Lapinski.IntensiveCareMed1999EXPRESS.MercatJAMA2008HowtosetPEEPafterrecruitm110SettingPEEPaccordingtoinflationPVcurveHickling.AJRCCM1998SettingPEEPaccordingtoinfl111Hickling.AJRCCM2001SettingPEEPaccordingtodeflationPVcurveHickling.SettingPEEPaccordi112PEEPsettingguidedbyesophagealpressureRandomizedcontrolledtrial61ARDSpatientsControl:ARDSnetPEEP/FiO2tableIntervention:PEEPend-expiratio
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