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Spontaneous Breathing & VILI
Takeshi Yoshida, M.D., Ph.D.
EvidenceHarm of Spontaneous Effort
Case Reports
Strong EffortCoggeshall JW, Marini JJ. Arch Intern med 1985
Sp
O2
%
Case Reports
Strong Effort
Sp
O2
%After Paralysis
Coggeshall JW, Marini JJ. Arch Intern med 1985
Gainnier M, et al. Crit Care Med 2004
Paralysis
Better Oxygenation
Spontaneous effort
Pa
O2/F
iO2
Papazian L et al. New Engl J Med 2010
ACURASYS: Better Survival
Paralysis
Spontaneous Effort
P/F<120
30.8%
vs.
44.6%
(p=0.04)
• Secondary analysis of ARMA trial (NEJM 2000)
• Change in SP-D, VWF, IL-8 (day 0 vs. day 3) in patients with NMBA
P/F<120 P/F>120 P/F<120 P/F>120
Epithelial Injury
More severe(P/F<120)
Less severe(P/F<120)
P/F<120 P/F>120
Epithelial Injury Endothelial Injury
More severe(P/F<120)
Less severe(P/F<120)
More severe(P/F<120)
Less severe(P/F<120)
Epithelial Injury Endothelial InjurySystemic
inflammation
More severe(P/F<120)
Less severe(P/F<120)
More severe(P/F<120)
Less severe(P/F<120)
More severe(P/F<120)
Less severe(P/F<120)
MechanismHarm of Spontaneous Effort
Non-Dependent
Dependent
+5
-15
∆Ppl in non-dependent
0
+5
-15
∆Ppl in dependent
0
-5
-5
-5
-5
-5
-5
-5
-5
-5
-5NORMALLUNG
2018
Homogeneous Ventilation
Diaphragm
Non-Dependent
Dependent
+5
-15
∆Ppl in non-dependent
0
+5
-15
∆Ppl in dependent
0
Atelectasis
-10
-10
-5
-5
-5
-10
-10
-5
-5
-5
INJUREDLUNG
2018
Heterogeneous Ventilation
Diaphragm
Paralysis
(No Pendelluft)
Spontaneous Effort
(Pendelluft)
② Pendelluft
Paralysis
(No Pendelluft)
Spontaneous Effort
(Pendelluft)
② Pendelluft
Spontaneous Effort Paralysis
Airway Pressure
Esophageal Pressure
Nondependent(Air movement)
Dependent(Air movement)
Asymmetric Inflation: Pendelluft
Airway Pressure
Esophageal Pressure
Nondependent(Air movement)
Dependent(Air movement)
×>2 Stretch
Asymmetric Inflation: Pendelluft
Spontaneous Effort Paralysis
HU
Collapsed(Red)
Strong Effort
Spontaneous Effort
Muscle Paralysis Strong Effort
Spontaneous Effort
Muscle Paralysis Strong Effort
TreatmentHarm of Spontaneous Effort
Lower PEEP
Inflation Pattern
Lower PEEP Higher PEEP
Inflation Pattern
Lower PEEP
Dorsal ∆Ppl -20
Ventral ∆Ppl -10
High PEEP
Pendelluft, Overdistension
∆Ppl -13
∆Ppl -10
Curr Opin Crit Care 2019Am J Respir Crit Care Med 2018,
Lower PEEP Higher PEEP
Dorsal ∆Ppl -13
Ventral ∆Ppl -10
Even distension
Curr Opin Crit Care 2019
Dorsal ∆Ppl -20
Ventral ∆Ppl -10
Pendelluft, Overdistension
Am J Respir Crit Care Med 2018,
Am J Respir Crit Care Med 2018
PEEP: Spontaneous Effort↓
Am J Respir Crit Care Med 2018
PEEP: Spontaneous Effort↓
PEEP 5
∆ Pes -30
PEEP 5
∆ Pes -30
PEEP 16
∆ Pes -10
PEEP 16
∆ Pes -10
New Engl J Med 2019
• ROSE Trial• Reevaluate the impact of muscle paralysis• Moderate to severe ARDS• High ‘open-lung’ PEEP strategy
ROSE Trial
ACURASYS vs. ROSE
ACURASYS (ＮＥＪＭ 2010) ROSE 2019
SB：Survival↓ 自発呼吸：生存率差なし
ROSE(ＮＥＪＭ 2019)
SB：Survival↓ SB：No Difference
ACURASYS (ＮＥＪＭ 2010)
ACURASYS vs. ROSE
ConceptSpontaneous Breathing & VILI
Ventilator-Induced
Lung Injury (VILI)
Patient Self-Inflicted
Lung Injury (P-SILI)
Lung Injury
OVERDISTENSION
Ventilator Spontaneous Effort
Ventilator-Induced
Lung Injury (VILI)
Patient Self-Inflicted
Lung Injury (P-SILI)
Lung Injury
OVERDISTENSION
Ventilator Spontaneous Effort
‘Ventilation’-Induced Lung Injury