protective ventilation for all patients...cressoni m et al. am j respir crit care med...
TRANSCRIPT
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Protective ventilationfor ALL patients
PAOLO PELOSI, MD, FERS
Department of Surgical Sciences and Integrated Diagnostics (DISC), San
Martino Policlinico Hospital– IRCCS for Oncology, University of Genoa, Italy
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Conflicts of Interest
I declareNO conflicts of interest
Pelosi P for the PROVE Network (www.provenet.eu)
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http://www.provenet.eu/
To performLarge multicenter clinical
studies, randomizedcontrolled trials, and
meta-analyses
PROtective VEntilation NETWORK
Pelosi P for the PROVE Network (www.provenet.eu)
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Pelosi P for the PROVE Network (www.provenet.eu)
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ρ x g x h
P = 5 cmH2O P = 10 cmH2O
LESS EDEMA-ATELECTASISLOWER PEEP-LOWER MORTALITY
HIGHER EDEMA-ATELECTASISHIGHER PEEP-HIGHER MORTALITY
The ARDS LungH
igherlesionalveolar-capillary
mem
braneLo
wer
lesi
onal
veol
ar-c
apill
ary
mem
bran
e
PaO2/FiO2 > 150 PaO2/FiO2 < 150
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Ventilator‐Induced Lung InjurySlutsky AS & Ranieri VM N Engl J Med 2013;369:2126-36
Pelosi P for the PROVE Network (www.provenet.eu)
• BAROTRAUMA• VOLUTRAUMA • BIOTRAUMA
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Putensen C. Ann Internal Med. 2009; 151:566
• 1,297 patients with ARDS from 6 RCTs
• outcome: hospital death
No Low VT atsimilar PEEP
High VT at similar PEEP Odds ratio
Brochard 116 – –
Brower 52 13/26 12/26 1.17 [0.39 – 3.47]
Brower 861 134/342 171/429 0.68 [0.51 – 0.90]
Stewart 120 30/60 28/60 1.14 [0.56 – 2.34]
0.75 [0.58 – 0.96]
No Low VT +high PEEP
High VT + low PEEP Odds ratio
Amato 53 13/29 17/24 0.33 [0.11 – 1.05]
Villar 95 17/50 24/45 0.41 [0.18 – 0.94]
0.38 [0.20 – 0.75]
[METANALYSIS]
Use of Lower Tidal VolumesBenefits Patients with ARDS
Pelosi P for the PROVE Network (www.provenet.eu)
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• international observational study
• 2,396 patients with mild, moderate or severe ARDS
Bellani G JAMA. 2016 Feb 23;315(8):788-800
LungSafe – Practice of Ventilation in ICUs Worldwide
Pelosi P for the PROVE Network (www.provenet.eu)
• VT > 8 ml/Kg in 40% of patients
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Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Pelosi P for the PROVE Network (www.provenet.eu)
Protective ventilation includes:
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• 2,184 ICU patients without ARDS from 7 studies
• outcome: duration of ventilation
Use of Lower Tidal VolumesBenefits Patients without ARDS
Serpa Neto A. Intensive Care Med. 2014; 40:950
[METANALYSIS]
Pelosi P for the PROVE Network (www.provenet.eu)
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• 2,184 ICU patients without ARDS from 7 studies
• outcome: hospital stay and ARDS development
Use of Lower Tidal VolumesBenefits Patients without ARDS
[METANALYSIS]
Serpa Neto A. Crit Care Med. 2015; 43:4155
Pelosi P for the PROVE Network (www.provenet.eu)
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Pelosi P for the PROVE Network (www.provenet.eu)
Peak pressure = 20-24 cmH2OPlateau pressure =16-19 cmH2O PEEP = 5-6 cmH2OPaO2/FiO2 = 260 mmHg
Volume controlled = 51%Pressure controlled = 49%
Serpa Neto A. Crit Care Med. 2015; 43:4155
Use of Lower Tidal VolumesBenefits Patients without ARDS
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RANDOMIZED CONTROLLED TRIALS PRotective VENTilation in Patients Not Fulfilling the Consensus
Definition for Moderate or Severe ARDS (PReVENT-NL)Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA). NCT02153294 NLM Identifier: NCT02153294Pts without moderate or severe ARDS:VT 4–6 vs. 8–10 ml/kg PBW
Preventive Strategies in Acute Respiratory Distress Syndrome (ARDS) (EPALI)
Corporacion Parc Tauli. NCT02070666 NLM Identifier: NCT02070666Pts without ARDS: VT ≤ 6 vs. 8 ml/kg PBW
Pelosi P for the PROVE Network (www.provenet.eu)
A new ARDS Network trial
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• international observational study
• 1,022 patients without ARDS
• 7.9 [6.8–9.1] mL/kg PBW
• VT > 8 ml/Kg in 40% of patients
PRoVENT – Practice of Ventilation in ICUs Worldwide
Serpa-Neto A et al. Lancet Respir Med. 2016 Nov;4(11):882-893.
Pelosi P for the PROVE Network (www.provenet.eu)
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Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Pelosi P for the PROVE Network (www.provenet.eu)
Protective ventilation includes:
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P = 14 cmH2OPEEP = 0 cmH2O
P = 45 cmH2OPEEP = 10 cmH2O
P = 45 cmH2OPEEP = 0 cmH2O
Experimental edema due to intermittent positive pressure ventilation with high inflation pressures
Protection by PEEPWebb HH, Tierney DF Am Rev Respir Dis. 1974 Nov;110(5):556-65
Pelosi P for the PROVE Network (www.provenet.eu)
Lower Tidal Volume&
Higher PEEP
Higher Tidal Volume&
Lower PEEP
Ventilator Induced Lung InjuryTidal Volume or PEEP?
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Use of Higher PEEP Benefits Patient with Moderate or Severe ARDS
• 2,299 ICU patients with ARDS from 3 investigations
• outcome: death
Briel M. et al. JAMA 2010; 303:865
[METANALYSIS]
Pelosi P for the PROVE Network (www.provenet.eu)
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Pelosi P for the PROVE Network (www.provenet.eu)
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Permissive atelectasis to minimize VILI
Healthy lungs
Stressσ =ΔF/ΔS(PL))
Strainε =ΔL/L0(VT/EELV)
ΔP =VT/Cst,rs =VT/EELV
Rocco PR et al. Curr Opin Anaesthesiol. 2012, 25(2):123-30
Energy =ΔP2 x(2xEst)
Power =Energy/Time
Intensity =Power/Area
Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print]
Higher DishomogeneitiesLess VILI with Less Stress, Strain, ∆P, Power, Intensity
Pelosi P for the PROVE Network (www.provenet.eu)
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Biological Impact of Transpulmonary Driving Pressurein Experimental Acute Respiratory Distress Syndrome
Samary CS et al. Anesthesiology. 2015 Aug;123(2):423-33.
Pelosi P for the PROVE Network (www.provenet.eu)
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Biological Impact of Transpulmonary Driving Pressurein Experimental Acute Respiratory Distress Syndrome
Samary CS et al. Anesthesiology. 2015 Aug;123(2):423-33.
Pelosi P for the PROVE Network (www.provenet.eu)
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Biological Impact of Transpulmonary Driving Pressurein Experimental Acute Respiratory Distress Syndrome
Samary CS et al. Anesthesiology. 2015 Aug;123(2):423-33.
Pelosi P for the PROVE Network (www.provenet.eu)
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% Increase
in Power
% Increase in Equation Motion Components
TVFlow∆ P
RR
PEEP
Ventilator-related causes of lung injury:The mechanical power
Gattinoni L et al. Intensive Care Med 2016;42:1567–75
Powerrs = 0.098 * RR * ∆V * (Ppeak – ½ * ∆P)
Pelosi P for the PROVE Network (www.provenet.eu)
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Power and Biological Markers in Experimental ARDSSamary CS et al. Anesthesiology. 2016 Nov;125(5):1070-1071
Pelosi P for the PROVE Network (www.provenet.eu)
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The Biological Effects of Higher and Lower PEEP in Pulmonary and Extrapulmonary ALI with IAH
Santos CL et al. Crit Care. 2014 Jun 13;18(3):R121
Pelosi P for the PROVE Network (www.provenet.eu)
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Volutrauma leads to higher lung inflammation thanatelectrauma in experimental ARDS
3 ml/kg
P
V
LIP
Cdyn
0 36
Cdyn
P
UIP P3 ml/kg=
2010
ml
cm H2 O
*
Comparable Tidal Volume and Driving PressureVOLUTRAUMA vs ATELECTRAUMA
ATELECTRAUMA VOLUTRAUMA
Guldner A et al. Crit Care Med. 2016 Sep;44(9):e854-65
Pelosi P for the PROVE Network (www.provenet.eu)
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Volutrauma leads to higher lung inflammation thanatelectrauma in experimental ARDS
Guldner A et al. Crit Care Med. 2016 Sep;44(9):e854-65
Static strain is more injuriousthan dynamic strain !
Pelosi P for the PROVE Network (www.provenet.eu)
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PEEP and Lymphatic drainagePelosi P, Rocco PRM, de Abreu MG (Crit Care 2018 – in press)
Pelosi P for the PROVE Network (www.provenet.eu)
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10
12
14
8
6
4
2
00 5 10 15 20
PEEP (cmH2O)
End ExpirationEnd Inspiration
Plateau Pressure (cmH2O)
**
31 ± 1.821 ± 1.8
**
26 ± 1.4
**
46 ± 3.238 ± 2.1
Rec
ruit
men
t (g
)Gattinoni, Pelosi et al. Am J Respir Crit Care Med 1995; 151:1807–1814
Aeration and Recruitment in ALI/ARDSat end- expiration and end-inspiration
Pelosi P for the PROVE Network (www.provenet.eu)
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PEEP of 15 cmH2O does not reduce lung inhomogeneities in ARDS
Cressoni M et al. Intensive Care Med. 2017 Mar 10. [Epub ahead of print]
The clinical question is:Atelectrauma is less harmful than
volutrauma due to a further increase of PEEP?Pelosi P for the PROVE Network (www.provenet.eu)
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Pv plasma
capillaries
PEEP PEEP
Lymph flow(thoracic duct)
2. Impeded drainage(compression thoracic duct)
1. Increased capillary pressure
edema
RVLV
PEEP
Courtesy Prof Hedenstierna
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Impact of acute hypercapnia and augmentedPEEP on right ventricle function in ARDS
Dessap AM et al Intensive Care Med (2009) 35:1850–1858Boufferace K et al. Current Opinion in Critical Care 2011,17:30–35
Pelosi P for the PROVE Network (www.provenet.eu)
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8.4 cmH2O
Bellani G et al. JAMA Feb 23 2016, 315 (8): 788-800
PEEP in ARDS – The Lung Safe Study
Severe ARDS
PEEP was relatively low (12 cmH2O or lower) independently from ARDS severity
Hypoxemia was treated by increasing FiO2
Pelosi P for the PROVE Network (www.provenet.eu)
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PEEP: High vs Low - RCTs
Low PEEP High PEEP
60-d
ay
mor
talit
y (%
)
05
1015202530354045
N = 545ALVEOLI LOVS EXPRESS
N = 983 N = 767
P = 0.29
P = 0.17 P = 0.22
Pelosi P for the PROVE Network (www.provenet.eu)
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Costa Leme A et al. JAMA. 2017 Apr 11;317(14):1422-1432
Effect of Lung Recruitment and Titrated PositiveEnd-Expiratory Pressure (PEEP) vs Low PEEP
on Mortality in Patients With ARDS
Pelosi P for the PROVE Network (www.provenet.eu)
PEEP 12 vs 16 cmH2O
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PEEP1967…….
Restin
Peace
The Funeral for Positive End-ExpiratoryPressure …better known as PEEP
“It was a dream for generations of anesthesiologists and intensivists”
Pelosi P for the PROVE Network (www.provenet.eu)
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Caironi P. et al. Crit Care Med 2015; 43:781–790
Lung Recruitability Is Better Estimated Accordingto the Berlin Definition of ARDS at Standard
5 cm H2O PEEP: A Retrospective Cohort Study
PEEP12-15 cmH2O
PEEP5-8 cmH2O
PEEP8-12 cmH2O
Pelosi P for the PROVE Network (www.provenet.eu)
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Chiumello D. et al. Crit Care Med 2014; 42:252–264
Bedside Selection of PEEP in Mild, Moderate, and Severe Acute Respiratory Distress Syndrome
No routine RMs !
SatO2 88-95PaO2 55-80 mmHg
Pelosi P for the PROVE Network (www.provenet.eu)
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Supine
Prone
Gattinoni, Pelosi et al. Anesthesiology 1991; 74(1):15-23Lung Height (%)
0 20 806040 1001
567
432
0
Lung inflation
Guerin C. et al. N Engl J Med. 2013 Jun 6;368(23):2159-68
P/F<150 mmHg while on FIO2>0.60;
PEEP = 10 cmH2O
Prone position homogenizes aeration and ventilation at low PEEP
![Page 41: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/41.jpg)
Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from4 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from4 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Pelosi P for the PROVE Network (www.provenet.eu)
Protective ventilation includes:
![Page 42: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/42.jpg)
In non ARDS patients lower VT + lower PEEP are associated with a shorter length of ICU stay
Guo L et al. Critical Care (2016) 20:226
MD <0 favors strategy A (Low VT/Low PEEP)
Serpa Neto A et al. Ann Intensive Care. 2016 Dec;6(1):109
Pelosi P for the PROVE Network (www.provenet.eu)
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Associations between PEEP and outcomeof patients without ARDS at onset of ventilation:a systematic review and
meta-analysis of randomized controlled trialsSerpa Neto et al. Ann. Intensive Care (2016) 6:109
High PEEP: No effect on duration of MV – Lower rate of ARDS (high I2)
Low PEEP = 2.0 ± 2.8 cmH2O High PEEP = 9.7 ± 4.0 cmH2O
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 44: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/44.jpg)
• international observational study
• 1,022 patients without ARDS
• PEEP > 5 cmH2Oin 60-40% of patients
PRoVENT – Practice of Ventilation in ICUs Worldwide
Serpa-Neto A et al. Lancet Respir Med. 2016 Nov;4(11):882-893.
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 45: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/45.jpg)
Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
Ventilation During General Anesthesia
for Surgery
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Level of PEEP (<10 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP (<10 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Protective ventilation includes:
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 46: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/46.jpg)
-750-500-250
0250500750
0 5 10 15 20 25
-1000
100200300400500600700
0 5 10 15 20 25
05
101520253035
0 5 10 15 20 25
PplatPEEPtot
V'aw ml/s
Volml
PawcmH2O
Time (s)
Driving Pressure (△P,rs)Bluth T et al. Curr Opin Anaesthesiol. 2016 Jun;29(3):421-9.
P,rs
∆P = Pplat,rs – PEEP = VT/Cst = VT/EELV
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Amato MBP, et al. N Engl J Med 2015;372:747-55c
Driving pressure and survivalin the ARDS
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 48: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/48.jpg)
• 2,396 pts with mild, moderate or severe ARDS
LungSafe – Practice of Ventilation in ICUs Worldwide
Bellani G JAMA. 2016 Feb 23;315(8):788-800
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 49: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/49.jpg)
• 653 patients from 12 studies
• RR for hospital death
• median settings in the first 3 days
ALLN = 653
ECMON = 545
ECCO2RN = 108
RR [95%–CI] (p–value) for hospital death
VT,ml/kg PBW
0.97[0.87–1.08](p = 0.602)
0.94[0.83–1.06](p = 0.294)
1.03[0.80–1.32](p = 0.817)
PEEP, cm H2O
0.97[0.92–1.02](p = 0.249)
0.97[0.91–1.03](p = 0.323)
0.92[0.83–1.02](p = 0.125)
Pplat, cm H2O
1.03[0.97–1.09](p = 0.298)
1.03[0.97–1.10](p = 0.308)
0.94[0.81–1.10](p = 0.454)
ΔP,cm H2O
1.07[1.02–1.12](p = 0.004)
1.06[1.01–1.12](p = 0.029)
1.19[1.04–1.35](p = 0.009)
adjusted for risk of death, age and severity of ARDS
[METANALYSIS]
IPD Metaanalysis of studies in ARDS–patients Receiving ELS
c
Serpa-Neto A et al Intensive Care Med. 2016 Nov;42(11):1672-1684
Pelosi P for the PROVE Network (www.provenet.eu)
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Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Level of PEEP (< 10 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP (< 10 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Pelosi P for the PROVE Network (www.provenet.eu)
Protective ventilation includes:
![Page 51: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/51.jpg)
• international observational study
• 1,022 patients without ARDS
• Driving pressure associated with mortality
PRoVENT – Practice of Ventilation in ICUs Worldwide
Serpa-Neto A et al. Lancet Respir Med. 2016 Nov;4(11):882-893.
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 52: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/52.jpg)
• international observational study
• 1,022 patients without ARDS
• P 10.0 [6.0-13] cm H2O
• P > 12 cmH2O in 30-40% of patients
PRoVENT – Practice of Ventilation in ICUs Worldwide
Serpa-Neto A et al. Lancet Respir Med. 2016 Nov;4(11):882-893.
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 53: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/53.jpg)
Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analyses and 2IPD meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analyses and 2IPD meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Level of PEEP (<10 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP (<10 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Low driving pressure(< 13cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Driving pressure(< 13cmH2O)
studies are lacking
Driving pressure(< 13cmH2O)
studies are lacking
Pelosi P for the PROVE Network (www.provenet.eu)
Protective ventilation includes:
![Page 54: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/54.jpg)
• international observational study
• 2,396 patients with mild, moderate or severe ARDS
LungSafe – Practice of Ventilation in ICUs Worldwide
Bellani G JAMA. 2016 Feb 23;315(8):788-800
Pelosi P for the PROVE Network (www.provenet.eu)
Pplat and Mortality in ARDS
![Page 55: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/55.jpg)
Villar J et al. Crit Care Med. 2017 Mar 1 [Epub ahead of print]
Plateau pressure or Driving Pressure and Survival in the ARDS
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 56: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/56.jpg)
• 2,396 pts with mild, moderate or severe ARDS
LungSafe – Practice of Ventilation in ICUs Worldwide
Bellani G JAMA. 2016 Feb 23;315(8):788-800
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 57: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/57.jpg)
• 2,396 pts with mild, moderate or severe ARDS
• Higher PEEP, lowerplateau and driving P, & lower respiratoryrate are associatedwith better survivalfrom ARDS
LungSafe – Potentially modifiable factorscontributing to outcome from ARDS
Laffey GC et al. Intensive Care Med 2016 (Epub Ahead of Print)
Pelosi P for the PROVE Network (www.provenet.eu)
![Page 58: Protective ventilation for ALL patients...Cressoni M et al. Am J Respir Crit Care Med 2014,189(2):149–158 Cressoni M et al. Anesthesiology. 2016 Feb 12. [Epub ahead of print] Higher](https://reader034.vdocuments.us/reader034/viewer/2022052005/6019152bcd2580078d475698/html5/thumbnails/58.jpg)
Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Level of PEEP (< 6 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP (< 6 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Driving pressure(< 13cmH2O)
studies are lacking
Driving pressure(< 13cmH2O)
studies are lacking
Driving pressure(< 13cmH2O)
Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Driving pressure(< 13cmH2O)
Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Driving pressure(< 13cmH2O)
Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Driving pressure(< 13cmH2O)
Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Pelosi P for the PROVE Network (www.provenet.eu)
Protective ventilation includes:
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Sutherasan Y et al. Crit Care. 2015 May 8;19:215
Factors associated with ARDS
1) Higher (> 17 cmH2O) plateau pressure (odds ratio 1.12, 95% CI interval 1.04 to 1.21)
Factors associated with ICU acquired pneumonia
1) Higher tidal volume (odds ratio 1.003, 95% CI 1.0003 to 1.01)
2) Higher (>5 cmH2O) applied PEEP levels(odds ratio 0.89, 95% CI 0.80 to 0.99)
Management and Outcome of Mechanically Ventilated in Patients after Cardiac Arrest
Pelosi P for the PROVE Network (www.provenet.eu)
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• international observational study
• 1,022 patients without ARDS
• Pplat 15.0 [13.0-20.0] cm H2O
• Pplat > 17 cmH2O in 30-40% of patients
PRoVENT – Practice of Ventilation in ICUs Worldwide
Serpa-Neto A et al. Lancet Respir Med. 2016 Nov;4(11):882-893.
Pelosi P for the PROVE Network (www.provenet.eu)
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Ventilation in Intensive Care Unit–patients with the Acute Respiratory
Distress Syndrome (ARDS)
Ventilation in Intensive Care Unit–patients with
Uninjured Lungs
Ventilation During General Anesthesia
for Surgery
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32] and
3 meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
mild ARDS moderate and severe ARDS
Protective ventilation includes:
Protective ventilation includes:
Protective ventilation includes:
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6 ml/kg predicted body weight
evidence comes from2 RCTs [31,32], 1
meta–analysis and 2IPD meta–analyses [17,18,33]*
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Tidal volume size6–8 ml/kg predicted body weight
evidence comes from2 RCTs [4] and
1 meta–analysis [5]
Level of PEEP (< 6 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP (< 6 cmH2O)??
Convincing RCTevidence is lacking1 meta‐analysis
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP5–10 cm H2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Level of PEEP≥ 10 cm H2O but < 15cmH2O
evidence comes from3 RCTs [7,8,9] and
1 IPD meta–analysis [10]
Driving pressure(< 13cmH2O)
Plateau pressure (< 17 cmH2O)??
studies are lacking
Driving pressure(< 13cmH2O)
Plateau pressure (< 17 cmH2O)??
studies are lacking
Driving pressure (< 15 cmH2O)Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Driving pressure (< 15 cmH2O)Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Driving pressure (< 15 cmH2O)Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Driving pressure (< 15 cmH2O)Pplat (< 25‐27 cmH2O)
suggestion comes fromseveral studies and
1 IPD meta–analysis [10]
Pelosi P for the PROVE Network (www.provenet.eu)
Protective ventilation includes:
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Practice of Ventilation in ARDS
Pelosi P for the PROVE Network (www.provenet.eu)
Bellani G JAMA. 2016 Feb 23;315(8):788-800
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Practice of Ventilation in ICUsSerpa-Neto A et al. Lancet Respir Med. 2016 Nov;4(11):882-893.
Pelosi P for the PROVE Network (www.provenet.eu)
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“Permissive Atelectasis” in ALL MV patientsPelosi P, Rocco PRM, de Abreu MG (Crit Care 2018 – in press)
InspirationExpiration
Pelosi P for the PROVE Network (www.provenet.eu)
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Permissive Atelectasis !
VT / P Pplat
PEEPEnergyPower
Energy = (∆P)2 / (2 x Est)
Power = Energy / Time (RR)
∆P = Pplat,rs – PEEP = VT/Cst = VT/EELV
“Less is More”
Regional Intensity = Power / Surface
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Permissive Atelectasis !
VT/ P Pplat
PEEPEnergyPower
Energy = (∆P)2 / (2 x Est)
Power = Energy / Time (RR)
∆P = Pplat,rs – PEEP = VT/Cst = VT/EELV
“Less is More”
Regional Intensity = Power / Surface
In ARDS patientsPEEP based on lower PaO2/FiO2 Table
PRONE POSITION !
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Protective Mechanical VentilationIn ALL patients
LOWER IS BETTER...ALSO PEEP in severe ARDS !
JUST DO IT !