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1020 Kaplan Sun 3006

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APRV

APRV

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  • 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
    • Introduction of APRV
    • Potential advantages
      • Spontaneous breathing
      • Enhanced hemodynamics
      • Patient comfort
      • Family comfort
      • Prevention/maintenance function
    • Eye to the future . . .
  • 4. High CPAP Release (T low ) Phase cycle APRV: Pressure and Flow PEEP i T high
  • 5. Maximized Alveolar Recruitment
    • Maintain functional alveolar gas exchange
      • “Open lung model”
      • Secretion clearance
      • Match regional time constants
      • Decrease hypoxic pulmonary vasoconstriction
        • Decrease pulmonary artery pressures
        • Unload RV
        • Increase VR and CO
      • Decrease shunt
  • 6. RUL COLLAPSE: Optimized PEEP, V T , Flow
  • 7. APRV 1 HOUR
  • 8. APRV 3 HOURS
  • 9. WHAT APRV DOESN’T FIX RMSB
  • 10. Which way do we go from here?
  • 11. Spontaneous Breathing
  • 12. Experimental ALI: Effect of Spontaneous Breathing
    • Pulmonary shunt is decreased with spontaneous breathing
      • Mechanism for aeration and hypoxia resolution?
    • 24 pigs, iv oleic acid injury, 2 groups
      • APRV with or without spontaneous breathing
      • Hemodyamics, spirometry, EE lung volume
        • Spiral CT, N 2 washout
    • Held at constant “PEEP” = 5 cm H 2 O
    Wrigge H, et al. Anesthesiology 2003; 99(2):376-84
  • 13. Results: Experimental ALI torr cc % (Aeration Indexed to APRV +) * * * Adapted from: Wrigge H, et al. Anesthesiology 2003; 99(2):376-84
  • 14. End Expiratory Lung Volume (N 2 ) Adapted from: Wrigge H, et al. Anesthesiology 2003; 99(2):376-84
  • 15. Conclusions
    • APRV’s main effects upon oxygenation rely upon spontaneous breathing to:
      • Increase recruitment of nonaerated alveoli
      • Subsequently decreased shunt
      • Dependent regions well recruited
    • Benefits are independent of enhanced CO 2 elimination
  • 16. Basilar Atelectasis
  • 17. Spatial Ventilation and Perfusion Distribution
    • Question:
      • Mechanism of improved gas exchange with APRV
        • Known : APRV increases dorsal (juxta-diaphragmatic) alveolar recruitment
        • Unknown : Do those regions reperfuse?
    • Porcine model of ALI with oleic acid
      • APRV with/without spontaneous breathing
        • Mechanics, hemodynamics, gas exchange
        • Spatial distribution (V/Q) via single PET
    Neumann P, et al. Crit Care Med 2005; 33: 1090-1095
  • 18. Summed Ventilation (ml/min) Sternum Spine
  • 19. Summed Perfusion (ml/min) Sternum Spine
  • 20. Conclusions
    • APRV with spontaneous breathing:
      • Decreased shunt
      • Increased ventilation and perfusion
        • Dorsal, juxta-diaphragmatic regions
        • Areas previously derecruited
    • Increased ventilation of aerated and non-aerated lung with perfusion redistribution
      • Increased efficiency per phase cycle
    Neumann P, et al. Crit Care Med 2005; 33: 1090-1095
  • 21. Hemodynamics
  • 22. APRV vs PCV-IRV for ALI/ARDS
    • PCV-IRV associated with hemodynamic compromise at extreme settings
      • Volume load, pressors, acidosis
    • H o : APRV unassociated with hemodynamic compromise, and reduces pressor and sedative needs (BIS score)
    • Patients with ALI/ARDS
    • PCV-IRV APRV
      • NMB (-)
    Kaplan LJ, et al. Crit Care 2001; 5(4):221-6
  • 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
  • 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
  • 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 %
  • 26. Conclusions
    • APRV is an effective method of oxygenation patients with ALI/ARDS
    • Improves hemodynamic performance vs PCV-IRV
    • Reduced NMB and sedative needs vs PCV-IRV
      • Monitored by Bispectral Index
    • Similar findings by another group
      • Putensen C, et al. Am J Respir Crit Care Med 2001 164: 43-49
    Kaplan LJ, et al. Crit Care 2001; 5(4):221-6
  • 27. APRV and Hemodynamics
    • APRV with and without spontaneous breathing on hemodynamics and renal perfusion
    • H o : perfusion decreased by lack of spontaneous component
    • 12 patients with ALI
      • APRV with spont breathing versus
      • APRV w/o spont breaths, but . . .
        • identical V E or Paw
      • CI, Effective RBF, GFR
    Hering R, et al. Int Care Med 2002; 28(10):1426-33
  • 28. APRV and Renal Blood Flow % cc Indexed Hering R, et al. Int Care Med 2002; 28(10):1426-33 * * * * * *
  • 29. Conclusions
    • Eliminating spontaneous breathing from APRV compromises cardiac performance
    • APRV with spontaneous breathing preserves renal blood flow compared to APRV without a spontaneous component
    • APRV may provide a renal preserving strategy in patients with ALI
    • Their group achieved similar results in intestinal blood flow analysis
      • Hering R, et al. Anesthesiol 2003; 99: 1137-44
    Ventilator strategy can directly impact regional DO 2 Poor regional DO 2 may accompany “acceptable” settings
  • 30. Comfort
  • 31. Reduced Sedative Needs
    • Improved patient-ventilator synchrony
    • Patient remains engaged
      • ADL’s
      • Response to therapy
        • Analgesia
        • Ventilator weaning
      • Early physical therapy
        • Better preserved muscle mass
      • Participate in therapeutic decision-making
    • Family comfort improved
      • Supports relationship with critical care team
      • Raises Press-Gainey satisfaction scores
  • 32. Reduced or Eliminated NMB
    • Reduction rates of 70% and >
    • Elimination of prolonged neuromuscular blockade syndrome
    • Reduced pressure ulceration rate
    • Improved nurse work environment
      • Less q 2 hour turning of a flaccid patient
        • ? Reduced on-the-job injury rates
          • In the works . . .
    • Preserved ability to use interactive sedation and analgesia scales
    Kaplan LJ, et al. Crit Care 2001; 5(4):221-6 Putensen C, et al Am J Respir Crit Care Med 2001; 43-49
  • 33. APRV In The OR
  • 34. Preserved Recruitment In The OR
    • Common scenario
      • Pt with ALI who needs operative intervention
        • TRAUMA, Emergency General Surgery
      • Well recruited on the ICU ventilator
    • Appropriate SaO 2 in OR for a 2 hour case
    • Returns to the ICU with a marginal SaO 2 , bibasilar atelectasis
      • Increased ventilator support for re-recruitment
  • 35. APRV In The OR
    • Modified form of APRV proposed
      • Intermittent CPAP (CPAP i )
      • Required less V E and lower Pawpk
        • Bratzke E, et al. Anesthesiol 1998; 89:334-340
    • Currently:
      • Transport on APRV and use TIVA for OR
        • Fentanyl + Propofol
      • O 2 tank support and Anesth. training
      • Eliminates/reduces OR derecruitment
      • Reduces intra-tidal recruitment/derecruitment
    Habashi N, et al. Curr Opin Crit Care 2004; 10:549-557
  • 36.  
  • 37. Summary: Potential Advantages
    • Spontaneous breathing
      • Hemodynamic support
      • Regional DO 2 augmentation
      • Dependent alveolar recruitment
      • Dependent alveolar perfusion
    • Combination mode with proning
    • Patient and family comfort
    • Prevention/maintenance function
      • Sedatives and NMB agents
    • Future:
      • ? Mortality reduction vs ARDSNet
        • Awaiting trial data
  • 38.