targets in ards management blood gases · targets in ards management blood gases antonio pesenti,...
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Targets in ARDS
management
Blood Gases
Antonio Pesenti, MDUniversità di Milano
Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico
Milan, Italy
CCCF 2017
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ACUTE RESPIRATORY
DISTRESS SYNDROME IN
ADULTS
By D.G. Ashbaugh et al. The Lancet, 1967.
“THE CLINICAL PATTERN, … INCLUDES
SEVERE DYSPNOEA, TACHYPNOEA,
CYANOSIS THAT IS REFRACTORY TO OXYGEN
THERAPY, LOSS OF LUNG COMPLIANCE, AND
DIFFUSE ALVEOLAR INFILTRATION SEEN ON
CHEST X-RAYS”
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At first it was :
try to get the best PaO2
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• Intermittent positive-pressure respiration.-
Patient 9 was ventilated with an
experimental volume-cycled respirator
incorporating deep breath at regular
intervals.
• Continuous positive-pressure respiration.
End-expiratory pressures were maintained
at 5-10 cm. water. All 5 patients
demonstrated a rise in P a02 or oxygen
saturation with the use of end-expiratory
pressure.
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1988
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Guerin C neJM 2013 368:2159
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ARDSNet NEJM 2000
Lung protective ventilation
vs. 12 ml/kg
6 ml/kg and/or
Pplat <30
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P/F 158±73 176±76 160±68 177±81 165±71 164±88
PaO2 76±23 77±19 74±22 76±23 73±17 75±21
DAY 1 DAY 3 DAY 7
Low VT High VT Low VT High VT Low VT High VT
Oxygenation in the ARMA trial
NEJM 342: 1341: 2000
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• A
At 1 hr
At 7 days
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Minerva Anestesiol 2010;76:1043
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Minerva Anestesiol 2010;76:1043
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Minerva Anestesiol 2010;76:1043
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Lung Safe Sp O2
• All 95% (94-95) 8.4 (8.3- 8.6)
• Mild 97% (97-98) 7.4 (7.2-7.6)
• Moderate 95% (95-96) 8.3 (8.1-8.5)
• Severe 90% (89-91) 10.1 (9.8-10.4)
Bellani G et al. JAMA. 2016;315(8):788-800.
SpO2% PEEP
15
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Permissive Hypoxemia
• How low can we tolerate a PaO2?
• 80% Sat?
• A wise compromise between what we get and what we pay
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Grocott et al : N Engl J Med 2009;360:140
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Grocott et al N Engl J Med 2009;360:140-9
ADAPTATION TO HYPOBARIC HYPOXEMIA
Large leftward shift of dissociation curve
Hyperventilation, bicarbonate loss, high pH
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Control 1
Control 2
ARDS 1
ARDS 2
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Mikkelsen et al 2012 AJRCCM
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Mikkelsen et al 2012 AJRCCM
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Hyperoxemia is bad:
• In cardiac arrest ( Kilgannon J JAMA 2010)
• In AMI (Stub D Circulation 2015)
• In Brain Injury (Helmerhorst H CCM 2015
• etc
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GIRARDIS M, JAMA 2016
94-98% 97- 100%
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Right oxemia
• How low/ High can we tolerate a PaO2?
• 87% - 97%Sat?
• No supranormal values ( Hb%!!!!!!)
• A wise compromise between what we get and what we pay
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Carbon Dioxide: an innocuous gas?
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PaO2 min PaCO2 max
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Courtesy of Dr Gilles Capellier
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Baseline Characteristics of Patients With ARDS
RR
VT
PEEP
PPLAT
VE
20.8
(21.5-21.2)
19.5
(19.0-19.9)
20.7
(20.3-21.1)
22.7
(21.5-23.8)
7.6
(7.5-7.7)
7.8
(7.6-7.9)
7.6
(7.5-7.7)
7.5
(7.3-7.6)
8.4
(8.3-8.6)
7.4
(7.2-7.6)
8.3
(8.1-8.5)
10.1
(9.8-10.4)
23.2
(22.6-23.7)
20.5
(19.8-21.3)
23.1
(22.6-23.7)
26.2
(25.2-27.1)
10.8
(10.6-11.0)
9.3
(9.1-9.6)
10.7
(10.5-11.0)
12.8
(12.3-13.3)
All
(N = 2377)
Mild
(N = 714)
Moderate
(N = 1106)
Severe
(N = 557)
Bellani G et al. JAMA. 2016;315(8):788-800.
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Baseline Characteristics of Patients With ARDS
PaO2/FIO2
FIO2
PaCO2
pH
161
(158-163)
246
(244-248)
149
(147-150)
75
(74-77)
0.65
(0.64-0.65)
0.48
(0.47-0.50)
0.62
(0.61-0.63)
0.90
(0.88-0.91)
PEEP8.4
(8.3-8.6)
7.4
(7.2-7.6)
8.3
(8.1-8.5)
10.1
(9.8-10.4)
46.0
(45.4-46.6)
41.5
(40.7-42.2)
45.8
(44.9-46.6)
52.2
(50.7-53.7)
7.33
(7.32-7.33)
7.36
(7.36-7.37)
7.33
(7.32-7.33)
7.27
(7.26-7.29)
Bellani G et al. JAMA. 2016;315(8):788-800.
All
(N = 2377)
Mild
(N = 714)
Moderate
(N = 1106)
Severe
(N = 557)
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NEJM 2002:346: 1281
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Is permissive Hypercapnia the best solution to
prevent VILI?
Hyperventilation of the “baby lung”80% Dead Space means that the baby lung is
severely hypoperfused.
The rest is ventilated 12 l/min i.e several times normal
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ARDS :a pulmonary
microvascular disease
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