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PV Curve and Lung Recruitment

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Presented by Dr.J.M.Arnal

Presented by Dr.J.M.Arnal

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

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