2) concepts of lung protective ventilation
TRANSCRIPT
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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
HVZP40 ml/kg0 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
Tremblay L J Clin Invest 1997; 99:944-952
Biotrauma:
Protection
by PEEP
HVZP40 ml/kg0 cm H2O
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
Tremblay L J Clin Invest 1997; 99:944-952
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
Radford: in Respiratory Physiology (eds. Rahn and Fenn)
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
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
Rimensberger PC Crit Care Med 1999; 27:1946
8
30
P r e s s i o n
small tidal volume ventilation (5 ml/kg)
Optimal PEEP
Recruited vol
Rimensberger PC Crit Care Med 1999; 27:1946
8
30
P r e s s i o n
small tidal volume ventilation (5 ml/kg)
0
100
200
300
400
500
600
0 60 120 180 240
Time (min)
Postlavage
OxygenationGradient PaO2 /FiO2
Optimal PEEP
Recruited vol
Rimensberger PC Crit Care Med 1999; 27:1946
8
30
P r e s s i o n
small tidal volume ventilation (5 ml/kg)
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
Rimensberger PC Crit Care Med 1999; 27:1946
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
Radford: in Respiratory Physiology (eds. Rahn and Fenn)
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
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