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Lung Protective Strategies:Lung Protective Strategies:The Effects of Vt, PEEP & The Effects of Vt, PEEP &

Alveolar RecruitmentAlveolar Recruitment

David Grooms BS, RRTDavid Grooms BS, RRTSentara Norfolk General, Sentara Norfolk General,

Leigh & Bayside Leigh & Bayside HospitalsHospitals

Understanding ARDS…….Understanding ARDS…….2 Types2 Types

Extrapulmonary Extrapulmonary ARDS (In-direct)ARDS (In-direct)

Pulmonary ARDS Pulmonary ARDS (Direct)(Direct)

Identifying ARDS…….2 Types?Identifying ARDS…….2 Types?

Pulmonary ARDS Pulmonary ARDS (Direct)(Direct)

Pneumonia: Bacterial Pneumonia: Bacterial or Viralor Viral

Inhalation of noxious Inhalation of noxious agentagent

Aspiration of Gastric Aspiration of Gastric ContentsContents

Isolated pulmonary Isolated pulmonary contusioncontusion

Fat Embolus syndromeFat Embolus syndrome

Extrapulmonary Extrapulmonary ARDS (In-direct)ARDS (In-direct)

Multi-system TraumaMulti-system Trauma Transfusion related ALITransfusion related ALI Acute pancreatitisAcute pancreatitis SepsisSepsis Post- CABG surgeryPost- CABG surgery Hemorrahagic shockHemorrahagic shock

Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4

Characteristics of Extrapulmonary ARDS Characteristics of Extrapulmonary ARDS (In-direct)(In-direct)

Viera et al. Am J Respir Crit Care Med 1998:158

Contrasts between 2 types of ARDSContrasts between 2 types of ARDS


MechanicsMechanics Extrapulmonary Extrapulmonary ARDSARDS

Pulmonary ARDSPulmonary ARDS

Chest Wall Chest Wall ComplianceCompliance

ReducedReduced NormalNormal

Lung Compl.Lung Compl. ReducedReduced Severely ReducedSeverely Reduced

Lower inflec. PtLower inflec. Pt >10 usually present>10 usually present

Risk of Risk of overdistentionoverdistention

Recruitment Recruitment PotentialPotential

Response to PEEPResponse to PEEP










LowLow


Response to PEEPResponse to PEEP










LowLow


HighHigh

Response to PEEPResponse to PEEP Excellent (10-20 cm)Excellent (10-20 cm)








Lower inflec. PtLower inflec. Pt >10 usually present>10 usually present <10 cm often absent<10 cm often absent


LowLow


HighHigh

Response to PEEPResponse to PEEP Excellent (10-20cm)Excellent (10-20cm)

Characteristics of Pulmonary ARDS (Direct)Characteristics of Pulmonary ARDS (Direct)











LowLow HighHigh


HighHigh


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-10 0 10

ARDS ARDS CT and PV Curve (slow inflation)CT and PV Curve (slow inflation)

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ARDS ARDS CT and PV Curve (slow inflationCT and PV Curve (slow inflation))

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LowLow HighHigh


HighHigh LowLow











LowLow HighHigh


HighHigh LowLow

Response to PEEPResponse to PEEP Excellent (10-20cm)Excellent (10-20cm) Good (8-12cm)Good (8-12cm)

Effects of Mechanical/Physical Stretch Effects of Mechanical/Physical Stretch on Rat Alveolar Epithelial Cellson Rat Alveolar Epithelial Cells

Tschumperlin, D et al. Am J Respir Crit Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000Care Med, Vol 162. pp 357-362, 2000

Excised Rat lungs Excised Rat lungs Placed Alveolar Epithelial Cells in a “cell-Placed Alveolar Epithelial Cells in a “cell-

stretching device”stretching device”

Tschumperlin, D et al. Am J Respir Crit Care Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000Med, Vol 162. pp 357-362, 2000


Both static and single deformations were significantly less injuriousthan cyclic deformations at each deformation level


Reducing the amplitude reduced cell death

Cell Death dependent on frequency

ARDS NetworkARDS Network

ARDS NetworkARDS Network Multicenter, Randomized trialMulticenter, Randomized trial 861 Patients recruited from March 1996 through March 861 Patients recruited from March 1996 through March

1999 at 10 university centers.1999 at 10 university centers. Patients enrolled if:Patients enrolled if:

1) They were receiving mechanical ventilation 1) They were receiving mechanical ventilation 2) Had acute decrease in the P/F ratio (<300)2) Had acute decrease in the P/F ratio (<300)3) Bilateral pulmonary infiltrates on a chest radiograph 3) Bilateral pulmonary infiltrates on a chest radiograph consistent with the presence of edemaconsistent with the presence of edema4) No clinical evidence of left atrial hypertension or if 4) No clinical evidence of left atrial hypertension or if measure a PCWP<18mmHgmeasure a PCWP<18mmHg..

ResultsResults

Trial was stopped after fourth interim analysis.Trial was stopped after fourth interim analysis. Mortality ratesMortality rates

12 cc/Kg VT group- 39.8%12 cc/Kg VT group- 39.8% 6cc/Kg Vt group- 31.0% 6cc/Kg Vt group- 31.0%

Mortality decreased by 22%Mortality decreased by 22% Vt & Plat were significantly lowerVt & Plat were significantly lower Question to you- Question to you- What group had better PaO2’s?What group had better PaO2’s? 12 & they died more often- so better PaO2 does 12 & they died more often- so better PaO2 does

not translate into better outcomesnot translate into better outcomes

What did we do then?What did we do then?

We were skeptical at the results. Didn’t We were skeptical at the results. Didn’t like it because Vt was so low. like it because Vt was so low.

Also questioned that mortality could have Also questioned that mortality could have been better if more PEEP was used or use been better if more PEEP was used or use of Recruitment Maneuvers.of Recruitment Maneuvers.

Did we interpret the results of the studies Did we interpret the results of the studies right???right???

Lower PEEP/Higher FiO2

FiO2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24

Higher PEEP/Lower FiO2

FiO2 .3 .3 .4 .4 .5 .5 .5-.8 .8 .9 1.0 PEEP 12 14 14 16 16 18 20 22 22 22-24

Recruitment Maneuver AttemptsRecruitment Maneuver Attempts

RM’s were performed on the first 80 patients RM’s were performed on the first 80 patients assigned to the higher PEEP group.assigned to the higher PEEP group.

1 or 2 manuevers per day @ 35-40cmH2O for 1 or 2 manuevers per day @ 35-40cmH2O for 30 seconds.30 seconds.

Mean increase in O2sat was “small & Mean increase in O2sat was “small & transient.” Therefore RM were DC’d for the transient.” Therefore RM were DC’d for the remainder of the trial.remainder of the trial.

ResultsResults

Trial stopped @ the 2Trial stopped @ the 2ndnd interim analysis after 549 interim analysis after 549 pts. Had been enrolled.pts. Had been enrolled.

Stopped based on the specified futility stopping Stopped based on the specified futility stopping rule.rule.

Surprising ResultsSurprising Results

Interpretation…..Interpretation….. PEEP does not improve PEEP does not improve

mortality of ARDS patients. mortality of ARDS patients. Added to our own confusionAdded to our own confusion Now what do we do if PEEP Now what do we do if PEEP

doesn’t help survivaldoesn’t help survival Instead of developing my Instead of developing my

own interpretation of the own interpretation of the results, I will wait around results, I will wait around until someone shows me until someone shows me the right way to do it.the right way to do it.

Do our dirty work for us!!!Do our dirty work for us!!!

So what can we do to try to do it So what can we do to try to do it right??right??

Question aspects of personal satisfaction vs. Question aspects of personal satisfaction vs. patient overall satisfactionpatient overall satisfaction

VS

I got the PaO2 up from 70-80 by turning the Vt up to 1200cc. You know I am

the man right?

Wow, awesome job, I will try to get it higher

than you did today! You are the man


Example: Patient with ALI/ARDSExample: Patient with ALI/ARDSSteps to take to minimize progression of Steps to take to minimize progression of

syndromesyndromeMinimize FIO2, make all attempts to Minimize FIO2, make all attempts to

decrease FIO2 decrease FIO2 <<60%. 60%.

Oxygen Dissociation CurveOxygen Dissociation CurveARDSnet Study

88-94%PaO2 55-80


Example: Patient with ALI/ARDSExample: Patient with ALI/ARDSSteps to minimize progression of Steps to minimize progression of

disease/syndromedisease/syndromeMinimize FIO2, make all attempts to Minimize FIO2, make all attempts to

decrease FIO2 decrease FIO2 <<60%. 60%. Management and consideration of VtManagement and consideration of Vt

Can mechanical ventilation actually Can mechanical ventilation actually produce lung injury?produce lung injury?

Webb & Tierney, 1974, Webb & Tierney, 1974, Am Rev Respir Dis 110:556-565Am Rev Respir Dis 110:556-565

Key Findings of the studyKey Findings of the study

1)1) Healthy Lungs with low PIP Healthy Lungs with low PIP does not cause lung injurydoes not cause lung injury

2)2) Ventilation with high PIP Ventilation with high PIP (30-45) & no PEEP (30-45) & no PEEP produces perivascular produces perivascular edema & leads to severe edema & leads to severe injury.injury.

3)3) PEEP provides protection PEEP provides protection from alveolar edema due to from alveolar edema due to high PIP.high PIP.

Webb & Tierney, 1974, Webb & Tierney, 1974, Am Rev Respir Dis Am Rev Respir Dis

110:556-565110:556-565

Overdistention/Increased Transalveolar Overdistention/Increased Transalveolar Pressure of Good alveoliPressure of Good alveoli Nieman, GNieman, G

Take HomeTake Home

Minimize Stretching of Healthy Alveoli by Minimize Stretching of Healthy Alveoli by reducing Vt or Plat pressure.reducing Vt or Plat pressure.

OK but what about patients that do not OK but what about patients that do not have ALI/ARDS??have ALI/ARDS??

Crit Care Med 2004 Vol. 32, No. 9

ResultsResults

VT’s above 9cc/Kg VT’s above 9cc/Kg cause VILI in non- cause VILI in non- ARDS patients.ARDS patients.

The incidence of The incidence of

VILI is higher in pts.VILI is higher in pts.

who get >9cc/Kgwho get >9cc/Kg

VT. & blood VT. & blood transfusions.transfusions.

What if I go too low on the Vt because I am trying to protect?

WOB & P0.1 comparison of pt. placed on low tidal volume strategy

0

1

2

3

4

5

6

7

8

1 101 201 301 401 501 601 701 801 901 1001 1101

# of Breaths

P0.1

(- v

alue

)

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

WOB

(J/L

)

P01 (cmH2O) Wob (J/L) Linear (Wob (J/L)) Linear (P01 (cmH2O))

Pt. SwitchedTo AVTS Mode. Maintained @

8-9cc’s/Kg

Pt. Placed on 6cc/Kg Vt

Pt. Placed on 8-9cc/Kg Vt

Pt. Placed on 6cc/Kg VtSNGH Burn/Trauma Unit


Example: Patient with ALI/ARDSExample: Patient with ALI/ARDSSteps to take to minimize progression of Steps to take to minimize progression of

syndromesyndromeMinimize FIO2, make all attempts to Minimize FIO2, make all attempts to

decrease FIO2 decrease FIO2 <<60%. 60%. Management and consideration of VtManagement and consideration of VtManagement of PEEPManagement of PEEP

How to set PEEP How to set PEEP

Use PEEP FIO2 table from ARDSnet Use PEEP FIO2 table from ARDSnet studystudy

FiO2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24

This table is designed to be appropriate for the average patient, but sometimes PEEP needs to be individualized

How to set PEEP How to set PEEP


Set PEEP based off Lower Inflection point Set PEEP based off Lower Inflection point (pflex)(pflex)

Rimensberger P et al. CCM 1999;27:1940-1945Rimensberger P et al. CCM 1999;27:1940-1945

Crit Care Med 2006 Vol. 34, No. 5

Villar, et al. Crit Care Med 2006 Vol. 34, No. 5

Amato, M. et al. 1998. NEJM

Minimizing AtelectatictraumaMinimizing Atelectatictrauma(repeated opening and closing)(repeated opening and closing)

Nieman, G.

How to manage PEEP How to manage PEEP


Set PEEP based off Lower Inflection point Set PEEP based off Lower Inflection point (pflex) +1-2cm(pflex) +1-2cm

Set PEEP based off Point of maximum Set PEEP based off Point of maximum Curvature or recruitable lung volume via Curvature or recruitable lung volume via deflation limb of PV curvedeflation limb of PV curve

The Effects of Recruitment on End-The Effects of Recruitment on End-expiratory Lung Volumeexpiratory Lung Volume

Barbas CSV Am J Respir Crit Care Med 2002;165:A218

APRV/HFOV puts pt. at this point

Figure 2

Pressure (cmH2O)

0 10 20 30 40 50 60

Vol

ume

(ml)

0

500

1000

1500

2000

2500

3000

Incremental PEEP10 cmH2O

IncrementalPEEP 20

IncrementalPEEP 25

DecrementalPEEP 15

DecrementalPEEP 10

DecrPEEP 5

Open-lung PEEP 18 cmH2O

Hickling K. AJRCCM 2001;163:69-78.

APRV/HFOV puts pt. at this point

Rimensberger P et al. CCM 1999;27:1940-1945Rimensberger P et al. CCM 1999;27:1940-1945

+350 cc’s

Maximizing a current modalityMaximizing a current modality

Not how much but HOW!Not how much but HOW!Pressure Modes: Use of Flow Time Pressure Modes: Use of Flow Time

pattern for adequate inspiratory phase to pattern for adequate inspiratory phase to improve gas distribution and minimize improve gas distribution and minimize level of pressure needed for ventilationlevel of pressure needed for ventilation

I-times in Pressure Modes for Full Flow deceleration improve gas distribution and

minimize PC level

F

T

P

T

MAP MAP

Vt Vt


minimize PC level

F

T

P

T

MAP

VtVt

F

T

P

T

MAP

Vt

Min.Insp. PressureAdjustments

Needed

Vt

Vt


minimize PC level

Maximizing a current or alternative Maximizing a current or alternative modalitymodality

Not how much but HOW!Not how much but HOW!Pressure Modes: Use of Flow Time Pressure Modes: Use of Flow Time

pattern for adequate inspiratory phase to pattern for adequate inspiratory phase to improve gas distribution and minimize improve gas distribution and minimize level of pressure needed for ventilationlevel of pressure needed for ventilation

Use of Airway Pressure Release Use of Airway Pressure Release Ventilation (APRV), HFOV, Jet VentilationVentilation (APRV), HFOV, Jet Ventilation

Normal Ventilation with Normal Normal Ventilation with Normal MAPMAP

P

Time

PEEP PEEP

Plat

PeakInsp

Mean InspPressure

Mean ExpPressure+ = MAP

5

20

15

Increase in Insp. PressureIncrease in Insp. PressureWhat will happen to MAP?What will happen to MAP?

P

Time

PEEP PEEP

Plat

PeakInsp

Mean InspPressure


5

20

15

25

Increase in Insp. PressureIncrease in Insp. PressureWhat will happen to What will happen to PlatPlat??

P

Time

PEEP PEEP

PlatPeakInsp

Mean InspPressure


5

20

15

25

Increase in PEEP, What will Increase in PEEP, What will happen to MAP & Plat?happen to MAP & Plat?

P

Time

PEEP PEEP

Plat

PeakInsp

Mean InspPressure


5

20

1510

APRV (Basically inverse Ratio with Spont. APRV (Basically inverse Ratio with Spont. Breathing during insp. Phase.) Can Increase Breathing during insp. Phase.) Can Increase

MAP and keep safe Plat. & spont. Breath.MAP and keep safe Plat. & spont. Breath.P

Time

PEEP PEEP

PlatPeak

Insp

Mean InspPressure


5

20

15

= If Flow isFully dec.

Spontaneous Breaths

SummarySummary Understand disease type, what is cause for Understand disease type, what is cause for

inflammation of the Lunginflammation of the Lung Manage FIO2 Manage FIO2 <<60% with PaO2 60% with PaO2 >>60mmHg & 60mmHg &

SpO2 SpO2 >>88%88% Manage Vt (4-8cc/KgIBW) & Plateau Pressure Manage Vt (4-8cc/KgIBW) & Plateau Pressure

<<30cmH2O to minimize stretch on good and bad 30cmH2O to minimize stretch on good and bad alveoli. >9cc/Kg IBW in non ARDS patients alveoli. >9cc/Kg IBW in non ARDS patients increases incidence of ALI developementincreases incidence of ALI developement

Commericial Vents actually incorporate an Commericial Vents actually incorporate an automatic Lung Protective Strategy (Hamilton automatic Lung Protective Strategy (Hamilton Galileo/ASV Mode & Drager Evita XL)Galileo/ASV Mode & Drager Evita XL)

SummarySummary

PEEP can be managed by multiple PEEP can be managed by multiple options, Goal is to prevent repeated options, Goal is to prevent repeated alveolar opening and closing, and proper alveolar opening and closing, and proper recruitment of dependent lung unitsrecruitment of dependent lung units

Alternative Modes can improve specific Alternative Modes can improve specific indices, but lack appropriate randomized indices, but lack appropriate randomized clinical trials for universal acceptanceclinical trials for universal acceptance

Optimize settings to improve gas Optimize settings to improve gas distribution on conventional modesdistribution on conventional modes

Thank Y’all for having

me!!

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