PV Curve and Lung Recruitment

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PV Curve and Lung Recruitment

  1. 1. PV curve and lung recruitment<br />Dr Jean-Michel Arnal<br />Intensive Care Unit. Hôpital Font Pré<br />Toulon France<br />jean-michel@arnal.org<br />
  2. 2. Mechanisms of Ventilator Induced Lung Injuries<br />Mechanical Injury<br />Barotrauma and/or volutraumaresulting from lung overdistension <br />Atelectraumaresulting from repeated alveolar recruitment/ derecruitment<br />Inflammatory Injury<br />Biotrauma: alveolar inflammation <br />
  3. 3. Prevention of VILI<br />Reduced tidal volume and airway pressure limitation strategy<br />Recruitment strategy: recruitment maneuver + PEEP to avoid derecruitment<br />
  4. 4. What do we know about ARDS?<br />Lower tidal volume and airway pressure limitation decreases mortality<br />No effect of PEEP on mortality<br />ARDS network. N Engl J Med 2000<br />ALVEOLI. Brower. N Engl J Med 2004<br />EXPRESS. Mercat JAMA 2008<br />LOVS. Meade. JAMA 2008<br />
  5. 5. Effect of PEEP on mortality in ARDS<br />Briel. JAMA 2010<br />
  6. 6. What do we know about PEEP?<br />PEEP does not recruit<br />Collapse / re-expansion occurs during tidal volume<br />Recruitment of previously collapsed lung with a recruitment maneuver<br />PEEP may avoid collapse and derecruitment in a lung previously expanded/recruited<br />
  7. 7. Recruitment<br />Collapsed compliant airways/ alveoli<br />Fluid occlusion of non collapsed airways<br />
  8. 8. Am J Respir Crit Care Med 2006<br />
  9. 9. 24 sur 26 patients<br />Am J Respir Crit Care Med 2006<br />
  10. 10. n = 68<br />
  11. 11. Recruitability depends on<br />Type of ARDS<br />Time from the beginning of the disease<br />Pressure<br />Chest wall compliance<br />
  12. 12. Type of ARDS<br />Mechanism: extra pulmonary > pulmonary<br />Localization: diffuse > lobar<br />Riva. Crit Care Med 2008<br />Puybasset. Intensive Care Med 2000<br />
  13. 13. Time from the beginning of the disease<br />Early phase<br />Protein rich edema fluids and polyneutrophils<br />Late phase<br />Fibrosing alveolitis<br />
  14. 14. Pressure<br />24 on 26 patients<br />Borges. Am J Resp Crit Care Med 2006<br />
  15. 15. Chest wall compliance<br />
  16. 16. Chest wall complianceAirway pressure is a rough estimate of transpulmonary pressure<br />Talmor. Crit Care Med 2006<br />
  17. 17. Assessment of recruitability<br />Early in the management of ARDS<br />When hemodynamic condition is controlled<br />Low flow inflation and deflation PV curve from 0 to 40 cmH2O<br />
  18. 18. Assessment of recruitability<br />
  19. 19. Assessment of recruitabilityShape of the curve<br />Grasso. <br />AJRCCM 2005<br />
  20. 20. Assessment of recruitabilityLinear compliance<br />Maggiore. <br />AJRCCM 2001<br />
  21. 21. Assessment of recruitabilityLinear compliance<br />CLIN = 37 mL/cmH2O<br />CLIN = 83 mL/cmH2O<br />
  22. 22. Assessment of recruitabilityHysteresis<br />Demory.<br />Intensive Care Med 2008<br />
  23. 23. Assessment of recruitabilityHysteresis<br />6 798 cmH2O.ml<br />25 115 cmH2O.ml<br />Demory. Intensive Care Med 2008<br />
  24. 24. Assessment of recruitabilityHysteresis and volume difference at 20 cmH2O<br />r2 = 0.97<br />Demory.<br />Intensive Care Med 2008<br />
  25. 25. Decision at the bedside<br />
  26. 26. Decision at the bedside<br />No recruitment maneuver<br />Low PEEP: <br />5 – 10 cmH2O<br />Recruitment maneuver<br />High PEEP: <br />> 10 cmH2O<br />
  27. 27. Definition of a recruitment maneuver<br />Use of a transient increase in transpulmonary pressure to reopen previously collapsed or non aerated lung units.<br />
  28. 28. Volume recruited depends on<br />Previous recruitment<br />Transpulmonary inflation pressure<br />Duration<br />PEEP setting after the RM<br />
  29. 29. Pressure and time<br />Albert.<br />J Appl Physiol 2009<br />
  30. 30. Time<br /> = 2,6 s<br />Rothen.<br />BJA 1999<br />12 anaesthetized patients with healthy lung<br />
  31. 31. Optimal duration of the recruitment maneuver<br /> = 2,3 ± 1,3 s<br />n = 50<br />Arnal. Intensive Care Med [submitted] <br />
  32. 32. Optimal duration of the recruitment maneuver<br />*<br />*<br />Recruitment maneuver<br />n = 50<br />Arnal. Intensive Care Med [submitted] <br />
  33. 33. Recruitment maneuver at the bedsideConditions<br />Passive patient: deep sedation ± paralysis<br />Stable hemodynamic condition: ΔPP < 13%<br />Cuff over inflated to avoid leaks<br />No contraindications<br />
  34. 34. Recruitment maneuver at the bedsideContraindications<br />High intracranial pressure<br />Emphysema<br />Bronchopleural fistula<br />Pregnancy<br />Right heart failure<br />
  35. 35. Recruitment maneuver at the bedsideSettings<br />
  36. 36. Volume increase during a recruitment maneuver<br />VRM= 100 mL<br />VRM= 240 mL<br />
  37. 37. How to set PEEP after recruitment maneuver?<br />Low inflection point on PV curve<br />Deflection point on PV curve<br />Maximum PEEP while limiting Pplat around 28 cmH2O<br />PEEP setting guided by esophageal measurement<br />PEEP setting guided by SpO2<br />Hickling. AJRCCM 1998<br />Hickling. AJRCCM 2001<br />EXPRESS. Mercat JAMA 2008<br />Talmor. N Engl J Med 2009<br />Lapinski. Intensive Care Med 1999<br />
  38. 38. PEEP setting guided by esophageal pressure<br />Randomized controlled trial<br />61 ARDS patients<br />Control: ARDSnet PEEP/FiO2 table<br />Intervention: PEEP end-expiration Ppulm 0 - 10 cmH2O<br />Talmor. N Engl J Med 2009<br />
  39. 39. PEEP setting guided by esophageal pressure<br />VT = 400<br />PEEP= 12<br />FiO2= 60%<br />Ppulmins= 3<br />Ppulmexp= -6<br />Talmor. N Engl J Med 2009<br />
  40. 40. PEEP setting guided by esophageal pressure<br />VT = 320<br />PEEP= 24<br />FiO2= 60%<br />Ppulmins= 12<br />Ppulmexp= 4<br />Talmor. N Engl J Med 2009<br />
  41. 41. PEEP setting guided by esophageal pressure<br />Talmor. <br />N Engl J Med 2009<br />
  42. 42. PEEP setting guided by esophageal pressure<br />Talmor.<br /> N Engl J Med 2009<br />
  43. 43. PEEP setting guided by esophageal pressure<br />Talmor.<br /> N Engl J Med 2009<br />
  44. 44. PEEP setting guided by esophageal pressure<br />65 years old woman, BMI = 32<br />Community acquired pneumonia<br />
  45. 45. PEEP setting guided by SpO2<br />n = 14<br />Lapinski. Intensive Care Med 1999<br />
  46. 46. PEEP setting guided by SpO2<br />Lapinski. Intensive Care Med 1999<br />
  47. 47. Conclusions<br /><ul><li> Recruitment strategy is part of protective ventilation in ARDS
  48. 48. PEEP does not recruit
  49. 49. Assessing recruitability is a pre-requisite for a rational setting of PEEP: low flow PV tool
  50. 50. High potential of recruitability patients: Recruitment strategy
  51. 51. Recruitment maneuver: 40 cmH2O (up to 60) for 10s
  52. 52. PEEP > 10 cmH20 (up to 25) guided by SpO2
  53. 53. Recruitment should be an early goal in the management of ARDS.</li></ul>Thank you… <br />

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