2) concepts of lung protective ventilation

8/19/2019 2) Concepts of Lung Protective Ventilation

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Rational for and strategies oflung protective ventilation (including

the Open Lung Concept)

Prof. Peter C. Rimensberger, MD Service of Neonatology and Pediatric Intensive Care

Department of Pediatrics

University Hospital of Geneva

Geneva, Switzerland

The postnatal pulmonary injury sequence

The choices: 1) Try to avoid mechanical ventilation2) Use gentle lung protective

mechanical ventilation

Problem No 1 = Atelectasis: --> Open the lung

T --> Surfactant

Surfactant as a recruitment agent

PEEP PIP PEEP PIP

pre post

V o l u m e

Pressure

Kelly E Pediatr Pulmonol 1993;15:225-30

Soll RF (Cochrane Database) 2002

mortality

bronchopulmonary dysplasia

Morris S MJM 2006 9:95-101

Group 2: after introduction

of surfactant

Group 3: ten years later

Group 1: before introduction

of surfactant

a retrospective chart review of twoepochs, 1990-1991 and 1999-2000:

Effects of surfactant

and changes inventilator strategies

over time


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Morris S MJM 2006 9:95-101

Group 3: + lower PIP

Group 2: + surfactant

Group 1: no surfactant

Group 3: + lower PIP

?

Group 2: + surfactant

Problem No 1 = Atelectasis: --> Open the lung

T --> Surfactant

P --> positivepressure:

- CPAP

- CMV / HFO

% onmechanicalventilation

% onCPAP

Inborn infants GA


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SUPPORT- Trial

NEJM 2010: 362;1970-9

Need for mechanicalventilation (duration)

Survival w/o need formechanical ventilation

Postnatal steroidstherapy for BPD

intubation andsurfactant treatment

(within 1 hour after

birth) or to CPAPtreatment initiated inthe delivery room

From CPAP group83 % intubated later

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* reduced intubation rate (37% vs 51%; P=0.04)** requirement for intubation, postnatal use of corticosteroids for BPD, days of mechanical

ventilation, and mechanical ventilation by day

NCPAP used early or prophylactically for respiratory distress

Levels of Evidence

Level I Systematic review of randomized controlled trials

Level II Randomized controlled trial

Level I I I Cohort s tudy

Level IV Case-control studyLevel V Case series or historical controls

Level VI Animal or mechanical model study

Adapted form SE Courtney in Neonatal and Pediatric Mechanical Ventilation:From Basics to Clinical Practice, ed. Rimensberger, Springer (2015)

7 but no difference for death or BPD (at 36 wks)

Derecruitment (poor oxygenation and ventilation ) with „shallow“ tidalvolumes

Recruitment (good oxygenation and ventilation) with large tidal volumes

Bendixen NEJM 1963; 269:991-996

40 years ago

Parker JC et al. Crit Care Med 1993;21:131-143

Barotrauma is notonly gross airleak

Ventilator induced lung injury:

Experimental data

PIP 45cmH2O

for 5min

PIP 45cmH2Ofor 20

min

Nonventilated lung

Dreyfuss D AJRCCM 1998;157:294-323

Effect of ventilation at peak airway pressures of 45 cmH2O on:

Pulmonary edema Permeability Albumin distribution

Dreyfuss D et al. ARRD 1985;132:880-884


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HVZP40 ml/kg0 cm H2O

Biotrauma:

cytokines

Tremblay L J Clin Invest 1997; 99:944-952

ControlVt 7 ml/kgPEEP 3 cm H2O

MVZP15 ml/kg0 cm H2O

MVHP15 ml/kg10 cm H2O


Ito Y AJRCCM 1997; 155:493-499

Surfactant conversion from large to small aggregates

surfactant inactivation

1) high Vt (15 ml/kg)/ PEEP 3.52) normal Vt (10 ml/kg) / PEEP 3.53) low Vt (5 ml/kg)/ PEEP 3.5

Bjorklund LJ Ped Research 1997; 42:348-55

Manual ventilation with a few large breath

The classical inflation breaths in the labor room

Surfactant before first breath Bagging before surfactant

Small Vt-Ventilation or

Peak Pressure Limitation

(Permissive Hypercapnia)

• 15 infants (2000 - 4800 g/bw); PPHN and severe respiratory failure

(FiO2 1.0)

• PaCO2 allowed to increase to 60 mmHg

•

maximum PIP 25 to 35 cmH2O (increased ventilatory rates);

no paralysis

• --> all survived, 1 infant with CLD

1984: Controlled hypoventilation in status asthmaticus

Wung J-T Pediatrics 1985;76:488-494

1985: Management of infants with severe respiratory failure

Darioli R, Perret C. Am Rev Respir Dis 1983; 129:385-387

1994: Low mortality rate in adult respiratory distresssyndrome using low-volume, pressure-limited

ventilation with permissive hypercapnia

Hickling KG. Crit Care Med 1994;22:1568-1578

Permissive hypercapnia in preterm infants

Mariani G, Cifuentes J, Carlo WA Pediatrics 1999;104:1082-1088

p = 0.002 Log rank test

Duration of MV (hours)0 12 24 36 48 60 72 84 96

I n f a n t s o n M V ( % )

0

20

40

60

80

100

NormocapniaPermissive hypercapnia

RESPIRATORY OUTCOMES

Hypercapnia Normocapnia

Days on MV 2.5 (1.5 - 11) 9.2 (2 - 22)

Days on O2 15 (4 - 53) 32 (17 - 50) O2 at 28 days (%) 43 64

O2 at 36 weeks (%) 10 9

Reintubation (%) 67 54

Air leaks (%) 8 16

Steroids (%) 12 24

all differences between groups did not reach significance

Birth weight 601-1250 gm

RDS requiring ventilation

Postnatal age less than 24 hours

PaCO2 pH(mmHg)

Permissivehypercapnia 45 - 55 > 7.20

Normocapnia 35 - 45 > 7.25


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Carlo W et al. J Pediatr 2002;141:370-5

Minimal ventilationto prevent BPD

Carlo W et al. J Pediatr 2002;141:370-5

Minimal ventilationto prevent BPD

vs.

PCO2 target >52 mm Hg

PCO2 target


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Mechanism 2: Intratidal collapse

and decollapse

(opening)

PEEP and lung function

assessment

to prevent VILI

during small Vt

ventilation

Pinf (LIP)

PEEP > Pinf Control

PEEP = 0

Muscedere AJRCCM 1994;149:1317-1334

PEEP = 4


Biotrauma:

Protection

by PEEP


ControlVt 7 ml/kgPEEP 3 cm H2O

MVZP15 ml/kg0 cm H2O

MVHP15 ml/kg10 cm H2O

Effects of Ventilation with Different PEEP: on CytokineExpression in the Preterm Lamb Lung

Naik AS Am J Respir Crit Care Med 2001; 164:494–498

LA-pool size recovery

Michna J AJRCCM 1999;160:634–639

PEEP preserves surfactant function inpreterm lambs

surfactant alone

Atelectasis

Ventilator induced lung injury (VILI)

V o l u m e

0 3 6 9 12 15 18 21 24 27 30

transpulmonary pressure (cmH2O)

Atelectrauma: Concept of « high » PEEP


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QuickTime™etun décompresseurPhoto- JPEGsont requispour visualiser

cette image.

The combination of Low Vt + High PEEP

LIP


Biotrauma:

Combined

Vt and PEEPeffects

MVHP15 ml/kg

10 cm H2O

HVZP40 ml/kg

0 cm H2O

identicalend-inspiratory

distension

Tidal Breath

Recruitment

Tidal Breath

Recollapse

28’800 times/day 57’600 times/day

86’400 times/day

VILI

Tidal Breath

Overdistention

In heterogeneous lung injury inflation behavior is heterogeneous

Lung heterogeneity

Courtesy from Niemann G


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Lung protective mechancial ventilation:

Concept of low Vt or peak pressure limitation and

« high » PEEP

Froese ACrit Care Med 1997;25:906-8

How much istoo much or

how high is too

high ?

How low is toolow ?

Lung Opening:

Experience from

the adults

Radford: in Respiratory Physiology (eds. Rahn and Fenn)

Anatomical Recruitment

during increasing PEEP steps

P

t

Gattinoni L AJRCCM 2001; 164:1701–1711 Courtesy from Niemann G

Barbas C Crit Care Med 2003; 31[Suppl.]:S265–S271

Lung volumerecruitment

and

higher PEEP

CT-aeration

poorly areated

poorly areatednormal

normal

At ZEEP and

2 PEEP levels

= turning up

the PEEP

approach

Diffuse CT-attenuations

Focal CT-attenuations

Rouby JJ AJRCCM2002;165:1182-6


Behavior of the whole lung: Hysteresis

Lung opening and closing

Pressure


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Factors that influence the efficiency of RM

1) Recruiting pressure (CPAP, SI or Pplat)

Gattinoni L A JRCCM 2001; 164:1701–1711

Recruitment occurs over the whole PV-range

Rimensberger PC Crit Care Med 1999; 27:1946


PEEP is an end-expiratory phenomenon

It does not recruit

It does maintain

Optimal PEEP

Recruited vol


8

30

P r e s s i o n

small tidal volume ventilation (5 ml/kg)

Optimal PEEP

Recruited vol


8

30

P r e s s i o n


0

100

200

300

400

500

600

0 60 120 180 240

Time (min)

Postlavage

OxygenationGradient PaO2 /FiO2

Optimal PEEP

Recruited vol


8

30

P r e s s i o n


Rimensberger PCCrit Care Med 1999; 27:1940

A B


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Hickling KG et al. AJRCCM 2001; 163:69-78

Optimal = Maximum dynamic compliance andbest oxygenation at the least pressure required

Volume effect of various levels of PEEP(In- and decremental PEEP steps)

Courtesy from David Tingay, Melbourne

before RM after RM

Halter JM AJRCCM 2003, 167:1620-6

alveoli per field

inspiration expiration

I – E

Factors that

influence theefficiency of RM

PEEP after


CPAP-Recruiting Maneuver (Sustained Inflation)

Common RM-Techniques

CPAP to 40 – 60 cmH2Ofor 20 to 60 secondes

Lapinsky SE Intensive Care Med 1999; 25: 1297-1301

45/20

?

CPAP-Recruiting Maneuver (Sustained Inflation)

Common RM-Techniques

CPAP to 40 – 60 cmH2Ofor 20 to 60 secondes

Lapinsky SE Intensive Care Med 1999; 25: 1297-1301

Individuel PEEP level


Behavior of the whole lung: Hysteresis

Volumederecruitment

throughout

deflationUIPdefl

Pclosing

Alveolarrecruitment

throughout

inflation

LIP

UIPinfl

Lung opening and closingFrequency distribution of

opening and closing pressurein patients with ARDS

Crotti S AJRCCM 2001;164: 131–140

Use of dynamic

compliance for open

lung positive end-

expiratory pressure

titration in an

experimental study

F Suarez-SipmanCrit Care Med 2007; 35:214–221


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A Roncally S Carvalho et al. Critical Care 2006, 10:R122

Effects of descending positive end-expiratory pressure on lung

mechanics and aeration in healthy anaesthetized piglets

Volume controlled ventilation

end-inspiration end-expiration

PEEP 6 PEEP 24

PEEP 6

PEEP 18

PEEP 14

end-inspiration

end-expiration

PEEP 14 = level of bestcompliance

PEEP 10

F Suarez-SipmanCrit Care Med 2007; 35:214–221

PEEP 14

Volumedistribution

Frerichs I, Dargaville P, Rimensberge r PC Intensive Care Med 2003; 29:2312-6

Frerichs I et al. J Appl Physiol 2002; 93: 660–666

Get the lung as much homogeneous as possible Volumedistribution

Tidal volume

distribution

Frerichs I, Dargaville P, Rimensberger PC Intensive Care Med 2003

Dargaville P, Frerichs I, Rimensberger PC

right lung dependent region

normal lung

injured lung

post surfactant lung

Regional «homogeneity» on the deflation limb

right lung non-dependent region

normal lung

injured lung

post surfactant lung

median

ventral

dorsal

Delivered tidal volume(% of maximal Vt)

Regional ventilation (L)

Dargaville P, Rimensberger PC, Frerichs I Intensive Care Med 2010

Regional ventilation (R)


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C = 1

ARDS / RDS lung

(Heterogeneous)

C = 2

VT= 1ml/kg

= ==

32= /=

Vt=5ml/kg

AlveolarRupture!

C = 2

Vt=2.5ml/kg

Vt=2.5ml/kg

= ==

32= /=

Normal lung / recruited lung

at optimal lung volumes

Vt=5ml/kg

C = 2

Vt=4ml/kg

PEEP titration vs. recruitment maneuvers

Recruitment maneuvers:

Sustained inflation

Intermittentlyincreased PEEP

StepwisePEEP increase

Intermittentlyincreased VT

How high, and what afterwards ?

?

?

From the lab to the bedside: The principal concepts

Adapted from Suzuki H Acta Pediatr Japan 1992; 34:494-500

Lung Recruitment Using Oxygenation during OpenLung High-Frequency Ventilation in Preterm Infants

De Jaegere Ann et al. Am J Respir Crit Care Med 2006: 174; 639–645

Adapted from Suzuki H

Acta Pediatr Japan 1992

Lung Recruitment Using Oxygenation during Open

Lung High-Frequency Ventilation in Preterm Infants

De Jaegere Ann et al. Am J Respir Crit Care Med 2006: 174; 639–645

Adapted from Suzuki H Acta Pediatr Japan 1992

Lung Recruitment Using Oxygenation during Open

Lung High-Frequency Ventilation in Preterm Infants

De Jaegere Ann et al. AJRCCM 2006: 174; 639–645

before surfactant after surfactant


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Ventilation efficiency during optimal CDP finding

Alveolar Ventilation during HFV is defined as:

f x Vt 2 ( Vmineff or DCO2 )

Diffusion coefficient of CO2 (DCO2) = alveolar ventilation

RIP PV-curve inRSV pneumonitis

on HFOV

Optimal O2 = Paw 19Optimal Vt = Paw 10.5

Optimal CO2 = Paw 8

David Tingay,Melbourne, 2004

pO2

pCO2

Cdyn

pO2

pCO2

Cdyn

pO2

pCO2

Cdyn

CMV: Optimal = Maximum dynamic

compliance and best oxygenation at

the least pressure required

Optimal lung expansion (the mosthomogeneous one) adapted to the lung

pathology assures best oxygenation and

ventilation

pO2

pCO2

Vt (VCO2)

pO2

pCO2

Vt (VCO2)

pO2

pCO2

Vt (VCO2)

Optimal lung expansion (the mosthomogeneous one) adapted to the lung

pathology assures best oxygenation and

ventilation

HFOV: Optimal = Maximum DCO2(f x Vt2) and best oxygenation at the

least pressure required

Suzuki H Acta Pediatr Japan 1992; 34:494-500

Setting PEEP and lung volume recruitment

)3 = =2 3 1= =

( / / = /

//

= ==

= 3 3 = = 3=

/ 3 =3/ / 3 3 =2=

= 3 / //

2) concepts of lung protective ventilation

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