Potential Advantages Using Airway Pressure Release Ventilation Lewis J. Kaplan, MD, FACS, FCCM Associate Professor of Surg...
 
Objectives <ul><li>Introduction of APRV </li></ul><ul><li>Potential advantages </li></ul><ul><ul><li>Spontaneous breathing...
High CPAP Release  (T low ) Phase cycle APRV: Pressure and Flow PEEP i T high
Maximized Alveolar Recruitment <ul><li>Maintain functional alveolar gas exchange </li></ul><ul><ul><li>“Open lung model” <...
RUL COLLAPSE: Optimized PEEP, V T , Flow
APRV 1 HOUR
APRV 3 HOURS
WHAT APRV DOESN’T FIX RMSB
Which way do we go from here?
Spontaneous Breathing
Experimental ALI: Effect of Spontaneous Breathing <ul><li>Pulmonary shunt is decreased with spontaneous breathing </li></u...
Results: Experimental ALI torr cc % (Aeration Indexed to APRV +) * * * Adapted from: Wrigge H, et al.  Anesthesiology  200...
End Expiratory Lung Volume (N 2 ) Adapted from: Wrigge H, et al.  Anesthesiology  2003; 99(2):376-84
Conclusions <ul><li>APRV’s main effects upon oxygenation rely upon spontaneous breathing to: </li></ul><ul><ul><li>Increas...
Basilar Atelectasis
Spatial Ventilation and Perfusion Distribution <ul><li>Question: </li></ul><ul><ul><li>Mechanism of improved gas exchange ...
Summed Ventilation (ml/min) Sternum Spine
Summed Perfusion (ml/min) Sternum Spine
Conclusions <ul><li>APRV with spontaneous breathing: </li></ul><ul><ul><li>Decreased  shunt </li></ul></ul><ul><ul><li>Inc...
Hemodynamics
APRV vs PCV-IRV for ALI/ARDS <ul><li>PCV-IRV associated with hemodynamic compromise at extreme settings </li></ul><ul><ul>...
Etiology Of ALI/ARDS PNA  Abd sepsis  Trauma  BSI  TRALI   TRALI =  Transfusion Related Acute Lung Injury Percent Kaplan L...
Paw And Pharmacology Pawpk   Paw   %  NMB   % Sedatives pre  post  pre  post  pre  post  pre  post # or % * * * Kaplan LJ,...
C.I.   %  pre-DO 2 I  LVSWI   CVP pre  post  pre  post  pre  post  pre  post Hemodynamics Pre and Post * * * Kaplan LJ, et...
Conclusions <ul><li>APRV is an effective method of oxygenation patients with ALI/ARDS </li></ul><ul><li>Improves hemodynam...
APRV and Hemodynamics <ul><li>APRV with and without spontaneous breathing on hemodynamics  and  renal perfusion </li></ul>...
APRV and Renal Blood Flow % cc Indexed Hering R, et al.  Int Care Med  2002; 28(10):1426-33 * * * * * *
Conclusions <ul><li>Eliminating spontaneous breathing from APRV compromises cardiac performance </li></ul><ul><li>APRV wit...
Comfort
Reduced Sedative Needs <ul><li>Improved patient-ventilator synchrony </li></ul><ul><li>Patient remains engaged </li></ul><...
Reduced or Eliminated NMB <ul><li>Reduction rates of 70% and > </li></ul><ul><li>Elimination of prolonged neuromuscular bl...
APRV In The OR
Preserved Recruitment In The OR <ul><li>Common scenario </li></ul><ul><ul><li>Pt with ALI who needs operative intervention...
APRV In The OR <ul><li>Modified form of APRV proposed </li></ul><ul><ul><li>Intermittent CPAP (CPAP i ) </li></ul></ul><ul...
 
Summary: Potential Advantages <ul><li>Spontaneous breathing </li></ul><ul><ul><li>Hemodynamic support </li></ul></ul><ul><...
 
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1020 Kaplan Sun 3006

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1020 Kaplan Sun 3006

  1. 1. Potential Advantages Using Airway Pressure Release Ventilation Lewis J. Kaplan, MD, FACS, FCCM Associate Professor of Surgery Yale University School of Medicine Director, SICU & Surgical Critical Care Program
  2. 3. Objectives <ul><li>Introduction of APRV </li></ul><ul><li>Potential advantages </li></ul><ul><ul><li>Spontaneous breathing </li></ul></ul><ul><ul><li>Enhanced hemodynamics </li></ul></ul><ul><ul><li>Patient comfort </li></ul></ul><ul><ul><li>Family comfort </li></ul></ul><ul><ul><li>Prevention/maintenance function </li></ul></ul><ul><li>Eye to the future . . . </li></ul>
  3. 4. High CPAP Release (T low ) Phase cycle APRV: Pressure and Flow PEEP i T high
  4. 5. Maximized Alveolar Recruitment <ul><li>Maintain functional alveolar gas exchange </li></ul><ul><ul><li>“Open lung model” </li></ul></ul><ul><ul><li>Secretion clearance </li></ul></ul><ul><ul><li>Match regional time constants </li></ul></ul><ul><ul><li>Decrease hypoxic pulmonary vasoconstriction </li></ul></ul><ul><ul><ul><li>Decrease pulmonary artery pressures </li></ul></ul></ul><ul><ul><ul><li>Unload RV </li></ul></ul></ul><ul><ul><ul><li>Increase VR and CO </li></ul></ul></ul><ul><ul><li>Decrease shunt </li></ul></ul>
  5. 6. RUL COLLAPSE: Optimized PEEP, V T , Flow
  6. 7. APRV 1 HOUR
  7. 8. APRV 3 HOURS
  8. 9. WHAT APRV DOESN’T FIX RMSB
  9. 10. Which way do we go from here?
  10. 11. Spontaneous Breathing
  11. 12. Experimental ALI: Effect of Spontaneous Breathing <ul><li>Pulmonary shunt is decreased with spontaneous breathing </li></ul><ul><ul><li>Mechanism for aeration and hypoxia resolution? </li></ul></ul><ul><li>24 pigs, iv oleic acid injury, 2 groups </li></ul><ul><ul><li>APRV with or without spontaneous breathing </li></ul></ul><ul><ul><li>Hemodyamics, spirometry, EE lung volume </li></ul></ul><ul><ul><ul><li>Spiral CT, N 2 washout </li></ul></ul></ul><ul><li>Held at constant “PEEP” = 5 cm H 2 O </li></ul>Wrigge H, et al. Anesthesiology 2003; 99(2):376-84
  12. 13. Results: Experimental ALI torr cc % (Aeration Indexed to APRV +) * * * Adapted from: Wrigge H, et al. Anesthesiology 2003; 99(2):376-84
  13. 14. End Expiratory Lung Volume (N 2 ) Adapted from: Wrigge H, et al. Anesthesiology 2003; 99(2):376-84
  14. 15. Conclusions <ul><li>APRV’s main effects upon oxygenation rely upon spontaneous breathing to: </li></ul><ul><ul><li>Increase recruitment of nonaerated alveoli </li></ul></ul><ul><ul><li>Subsequently decreased shunt </li></ul></ul><ul><ul><li>Dependent regions well recruited </li></ul></ul><ul><li>Benefits are independent of enhanced CO 2 elimination </li></ul>
  15. 16. Basilar Atelectasis
  16. 17. Spatial Ventilation and Perfusion Distribution <ul><li>Question: </li></ul><ul><ul><li>Mechanism of improved gas exchange with APRV </li></ul></ul><ul><ul><ul><li>Known : APRV increases dorsal (juxta-diaphragmatic) alveolar recruitment </li></ul></ul></ul><ul><ul><ul><li>Unknown : Do those regions reperfuse? </li></ul></ul></ul><ul><li>Porcine model of ALI with oleic acid </li></ul><ul><ul><li>APRV with/without spontaneous breathing </li></ul></ul><ul><ul><ul><li>Mechanics, hemodynamics, gas exchange </li></ul></ul></ul><ul><ul><ul><li>Spatial distribution (V/Q) via single PET </li></ul></ul></ul>Neumann P, et al. Crit Care Med 2005; 33: 1090-1095
  17. 18. Summed Ventilation (ml/min) Sternum Spine
  18. 19. Summed Perfusion (ml/min) Sternum Spine
  19. 20. Conclusions <ul><li>APRV with spontaneous breathing: </li></ul><ul><ul><li>Decreased shunt </li></ul></ul><ul><ul><li>Increased ventilation and perfusion </li></ul></ul><ul><ul><ul><li>Dorsal, juxta-diaphragmatic regions </li></ul></ul></ul><ul><ul><ul><li>Areas previously derecruited </li></ul></ul></ul><ul><li>Increased ventilation of aerated and non-aerated lung with perfusion redistribution </li></ul><ul><ul><li>Increased efficiency per phase cycle </li></ul></ul>Neumann P, et al. Crit Care Med 2005; 33: 1090-1095
  20. 21. Hemodynamics
  21. 22. APRV vs PCV-IRV for ALI/ARDS <ul><li>PCV-IRV associated with hemodynamic compromise at extreme settings </li></ul><ul><ul><li>Volume load, pressors, acidosis </li></ul></ul><ul><li>H o : APRV unassociated with hemodynamic compromise, and reduces pressor and sedative needs (BIS score) </li></ul><ul><li>Patients with ALI/ARDS </li></ul><ul><li>PCV-IRV APRV </li></ul><ul><ul><li>NMB (-) </li></ul></ul>Kaplan LJ, et al. Crit Care 2001; 5(4):221-6
  22. 23. Etiology Of ALI/ARDS PNA Abd sepsis Trauma BSI TRALI TRALI = Transfusion Related Acute Lung Injury Percent Kaplan LJ, et al. Crit Care 2001; 5(4):221-6
  23. 24. Paw And Pharmacology Pawpk Paw % NMB % Sedatives pre post pre post pre post pre post # or % * * * Kaplan LJ, et al. Crit Care 2001; 5(4):221-6
  24. 25. C.I. % pre-DO 2 I LVSWI CVP pre post pre post pre post pre post Hemodynamics Pre and Post * * * Kaplan LJ, et al. Crit Care 2001; 5(4):221-6 # or %
  25. 26. Conclusions <ul><li>APRV is an effective method of oxygenation patients with ALI/ARDS </li></ul><ul><li>Improves hemodynamic performance vs PCV-IRV </li></ul><ul><li>Reduced NMB and sedative needs vs PCV-IRV </li></ul><ul><ul><li>Monitored by Bispectral Index </li></ul></ul><ul><li>Similar findings by another group </li></ul><ul><ul><li>Putensen C, et al. Am J Respir Crit Care Med 2001 164: 43-49 </li></ul></ul>Kaplan LJ, et al. Crit Care 2001; 5(4):221-6
  26. 27. APRV and Hemodynamics <ul><li>APRV with and without spontaneous breathing on hemodynamics and renal perfusion </li></ul><ul><li>H o : perfusion decreased by lack of spontaneous component </li></ul><ul><li>12 patients with ALI </li></ul><ul><ul><li>APRV with spont breathing versus </li></ul></ul><ul><ul><li>APRV w/o spont breaths, but . . . </li></ul></ul><ul><ul><ul><li>identical V E or Paw </li></ul></ul></ul><ul><ul><li>CI, Effective RBF, GFR </li></ul></ul>Hering R, et al. Int Care Med 2002; 28(10):1426-33
  27. 28. APRV and Renal Blood Flow % cc Indexed Hering R, et al. Int Care Med 2002; 28(10):1426-33 * * * * * *
  28. 29. Conclusions <ul><li>Eliminating spontaneous breathing from APRV compromises cardiac performance </li></ul><ul><li>APRV with spontaneous breathing preserves renal blood flow compared to APRV without a spontaneous component </li></ul><ul><li>APRV may provide a renal preserving strategy in patients with ALI </li></ul><ul><li>Their group achieved similar results in intestinal blood flow analysis </li></ul><ul><ul><li>Hering R, et al. Anesthesiol 2003; 99: 1137-44 </li></ul></ul>Ventilator strategy can directly impact regional DO 2 Poor regional DO 2 may accompany “acceptable” settings
  29. 30. Comfort
  30. 31. Reduced Sedative Needs <ul><li>Improved patient-ventilator synchrony </li></ul><ul><li>Patient remains engaged </li></ul><ul><ul><li>ADL’s </li></ul></ul><ul><ul><li>Response to therapy </li></ul></ul><ul><ul><ul><li>Analgesia </li></ul></ul></ul><ul><ul><ul><li>Ventilator weaning </li></ul></ul></ul><ul><ul><li>Early physical therapy </li></ul></ul><ul><ul><ul><li>Better preserved muscle mass </li></ul></ul></ul><ul><ul><li>Participate in therapeutic decision-making </li></ul></ul><ul><li>Family comfort improved </li></ul><ul><ul><li>Supports relationship with critical care team </li></ul></ul><ul><ul><li>Raises Press-Gainey satisfaction scores </li></ul></ul>
  31. 32. Reduced or Eliminated NMB <ul><li>Reduction rates of 70% and > </li></ul><ul><li>Elimination of prolonged neuromuscular blockade syndrome </li></ul><ul><li>Reduced pressure ulceration rate </li></ul><ul><li>Improved nurse work environment </li></ul><ul><ul><li>Less q 2 hour turning of a flaccid patient </li></ul></ul><ul><ul><ul><li>? Reduced on-the-job injury rates </li></ul></ul></ul><ul><ul><ul><ul><li>In the works . . . </li></ul></ul></ul></ul><ul><li>Preserved ability to use interactive sedation and analgesia scales </li></ul>Kaplan LJ, et al. Crit Care 2001; 5(4):221-6 Putensen C, et al Am J Respir Crit Care Med 2001; 43-49
  32. 33. APRV In The OR
  33. 34. Preserved Recruitment In The OR <ul><li>Common scenario </li></ul><ul><ul><li>Pt with ALI who needs operative intervention </li></ul></ul><ul><ul><ul><li>TRAUMA, Emergency General Surgery </li></ul></ul></ul><ul><ul><li>Well recruited on the ICU ventilator </li></ul></ul><ul><li>Appropriate SaO 2 in OR for a 2 hour case </li></ul><ul><li>Returns to the ICU with a marginal SaO 2 , bibasilar atelectasis </li></ul><ul><ul><li>Increased ventilator support for re-recruitment </li></ul></ul>
  34. 35. APRV In The OR <ul><li>Modified form of APRV proposed </li></ul><ul><ul><li>Intermittent CPAP (CPAP i ) </li></ul></ul><ul><ul><li>Required less V E and lower Pawpk </li></ul></ul><ul><ul><ul><li>Bratzke E, et al. Anesthesiol 1998; 89:334-340 </li></ul></ul></ul><ul><li>Currently: </li></ul><ul><ul><li>Transport on APRV and use TIVA for OR </li></ul></ul><ul><ul><ul><li>Fentanyl + Propofol </li></ul></ul></ul><ul><ul><li>O 2 tank support and Anesth. training </li></ul></ul><ul><ul><li>Eliminates/reduces OR derecruitment </li></ul></ul><ul><ul><li>Reduces intra-tidal recruitment/derecruitment </li></ul></ul>Habashi N, et al. Curr Opin Crit Care 2004; 10:549-557
  35. 37. Summary: Potential Advantages <ul><li>Spontaneous breathing </li></ul><ul><ul><li>Hemodynamic support </li></ul></ul><ul><ul><li>Regional DO 2 augmentation </li></ul></ul><ul><ul><li>Dependent alveolar recruitment </li></ul></ul><ul><ul><li>Dependent alveolar perfusion </li></ul></ul><ul><li>Combination mode with proning </li></ul><ul><li>Patient and family comfort </li></ul><ul><li>Prevention/maintenance function </li></ul><ul><ul><li>Sedatives and NMB agents </li></ul></ul><ul><li>Future: </li></ul><ul><ul><li>? Mortality reduction vs ARDSNet </li></ul></ul><ul><ul><ul><li>Awaiting trial data </li></ul></ul></ul>

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