see presentation

1,557 views

Published on

Published in: Health & Medicine, Education
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,557
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
107
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Yentis S. A view from the head end. Medical cartoons to ease the pain. TFM Publishing 2005
  • Van Kaam A, Haitsma J, DeJaegere A, et al: Open lung ventilation improves gas exchange and attenuates secondary lung injury in a piglet model of meconium aspiration. Crit Care Med 2004; 32:443–449
  • Christian Putensen and Hermann Wrigge. Clinical review: Biphasic positive airway pressure and airway pressure release ventilation Crit Care. 2004; 8(6): 492–497
  • Gajic O et al. Ventilator settings as a risk factor for acute respiratory distress syndrome in mechanically ventilated patients. Intensive Care Med. 2005 Jul;31(7):922-6
  • Schultz MJ, Haitsma JJ, Slutsky AS, Gajic O. What tidal volumes should be used in patients without acute lung injury? Anesthesiology. 2007 Jun;106(6):1226-31. Review.
  • Yentis S. A view from the head end. Medical cartoons to ease the pain. TFM Publishing 2005
  • Schultz MJ, Haitsma JJ, Slutsky AS, Gajic O. What tidal volumes should be used in patients without acute lung injury? Anesthesiology. 2007 Jun;106(6):1226-31. Review.
  • MacIntyre N. Discontinuing Mechanical Ventilatory Support. Chest. 2007; 132:1049-1056
  • MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest
  • MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest
  • MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest
  • MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest
  • MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest
  • Krishman, JA, Moore, D, Robeson, C, et al Prospective controlled trial of a protocol based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med 2004;169,673-678
  • Levine S et al. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans n Engl j med 358;13 march 27, 2008
  • Levine S et al. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans n Engl j med 358;13 march 27, 2008
  • Yentis S. A view from the head end. Medical cartoons to ease the pain. TFM Publishing 2005
  • Talmor, D et al. Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med Volume 34(5), May 2006, pp 1389-1394
  • Gatinoni L. Caironi P. Refining Ventilatory Treatment for Acute Lung Injury and Acute Respiratory Distress Syndrome. JAMA, February 13, 2008—Vol 299, No. 6
  • Verbrugge et al Clinical Physiology and Functional Imaging 2007 March
  • Seymour C et al. Airway Pressure Release and Biphasic Intermittent Positive Airway Pressure Ventilation: Are They Ready for Prime Time? The Journal of Trauma. Volume 62(5), May 2007, pp 1298-1309
  • Seymour C et al. Airway Pressure Release and Biphasic Intermittent Positive Airway Pressure Ventilation: Are They Ready for Prime Time? The Journal of Trauma. Volume 62(5), May 2007, pp 1298-1309
  • Fan E, Stephen TE. New Modalities of Mechanical Ventilation: High-frequency Oscillatory Ventilation and Airway Pressure Release Ventilation. Clinics in Chest Medicine - Volume 27, Issue 4 (December 2006)
  • Habashi: Crit Care Med, Volume 33(3) Supplement. March 2005.S228-S240
  • Christian Putensen, Hermann Wrigge Crit Care. 2004; 8(6): 492–497
  • High-frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV): a practical guide. Stawicki SP, Goyal M, Sarani B.J Intensive Care Med. 2009 Jul-Aug;24(4):215-29. Epub 2009 Jul 17
  • High-frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV): a practical guide. Stawicki SP, Goyal M, Sarani B. J Intensive Care Med. 2009 Jul-Aug;24(4):215-29.
  • A protocol for high-frequency oscillatory ventilation in adults: results from a roundtable discussion. Fessler HE, Derdak S, Ferguson ND, Hager DN, Kacmarek RM, Thompson BT, Brower RG. Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institutions
  • see presentation

    1. 1. Advanced Mechanical VentilationAdvanced Mechanical Ventilation StrategiesStrategies Raimis Matulionis, MDRaimis Matulionis, MD Assist. Professor of Anesthesiology/ CriticalAssist. Professor of Anesthesiology/ Critical Care MedicineCare Medicine UMass Memorial Medical CenterUMass Memorial Medical Center
    2. 2. ObjectivesObjectives  Review different modes ofReview different modes of mechanical ventilationmechanical ventilation  Discuss general therapeuticDiscuss general therapeutic principles and clinical applicationsprinciples and clinical applications  Review specific managementReview specific management principles for selectedprinciples for selected pathophysiological conditionspathophysiological conditions
    3. 3. Conventional VentilationConventional Ventilation  Limits recruitment to brief cyclic intervalsLimits recruitment to brief cyclic intervals at end-expiration or plateau pressureat end-expiration or plateau pressure  Alveolar volume is not maintainedAlveolar volume is not maintained  Delivers same distending pressure withDelivers same distending pressure with subsequent breathssubsequent breaths  Reproduces shear forces withoutReproduces shear forces without improving complianceimproving compliance  Does not guaranty sustained recruitmentDoes not guaranty sustained recruitment by being cyclical in natureby being cyclical in nature
    4. 4. TV vs PCTV vs PC  Greenfield LJ, Ebert PA, Benson DW. Atelectasis and surface tension properties of lung extracts following positive pressure ventilation and overinflation. SurgForum 1963 • Showed not only detrimental effects of baro trauma, but moreShowed not only detrimental effects of baro trauma, but more importantly – volu-traumaimportantly – volu-trauma • Volutrauma even more injurious as compared to barotraumaVolutrauma even more injurious as compared to barotrauma • Not appreciated at the time by critical care communityNot appreciated at the time by critical care community • Gas analyzers driven resp. function control with radiologicalGas analyzers driven resp. function control with radiological picture improvement confirmationpicture improvement confirmation • ? CT scan invention – turning point? CT scan invention – turning point
    5. 5. Christian Putensen, Hermann Wrigge Crit Care. 2004; 8(6): 492–497
    6. 6. TV vs Peak PressureTV vs Peak Pressure Large international mechanical ventilation study database Gajic et al Intensive Care Medicine 2005
    7. 7. Ventilator associated lung injuryVentilator associated lung injury  Ventilator induced lung injuryVentilator induced lung injury • VolutraumaVolutrauma  An overexpansion of alveolar units most often attributed toAn overexpansion of alveolar units most often attributed to high tidal volume ventilationhigh tidal volume ventilation • AtelectraumaAtelectrauma  Sheer stress-induced injury caused by unstable alveoliSheer stress-induced injury caused by unstable alveoli recruiting and derecruiting with each tidal breath mostrecruiting and derecruiting with each tidal breath most often attributed to low end-expiratory airway pressures in aoften attributed to low end-expiratory airway pressures in a heterogeneously injured lungheterogeneously injured lung • BiotraumaBiotrauma  A local and systemic inflammatory response of the lung toA local and systemic inflammatory response of the lung to the tissue damage produced bythe tissue damage produced by volutraumavolutrauma andand atelectraumaatelectrauma • BarotraumaBarotrauma  The development of extra-alveolar air most commonlyThe development of extra-alveolar air most commonly attributed to high airway pressure ventilationattributed to high airway pressure ventilation
    8. 8. Transpulmonary PressureTranspulmonary Pressure Verbrugge et al Clinical Physiology and Functional Imaging 2007 March Repeated disconnection of a sick lung results in a more severe stage of respiratory failure which requires higher opening pressures
    9. 9. Prospective Studies on Tidal Volumes inProspective Studies on Tidal Volumes in Patients without ALI/ARDSPatients without ALI/ARDS Schultz MJ et al. Anesthesiology. 2007 Jun
    10. 10. Ventilator weaningVentilator weaning  Two fundamental problemsTwo fundamental problems • (1) disease-imposed factors, such as(1) disease-imposed factors, such as mechanical and/or gas exchangemechanical and/or gas exchange • (2) clinician-imposed factors(2) clinician-imposed factors  delay in recognizing the ability of a patientdelay in recognizing the ability of a patient to have mechanical ventilation discontinuedto have mechanical ventilation discontinued  inappropriate ventilator settings thatinappropriate ventilator settings that overload (or underload) respiratory muscles,overload (or underload) respiratory muscles, preventing recoverypreventing recovery MacIntyre N. Discontinuing Mechanical Ventilatory Support. Chest. 2007; 132:1049-1056
    11. 11. Vent weaningVent weaning  Ventilator dependence :Ventilator dependence : • (1)(1) respiratory drive failurerespiratory drive failure involving the inability of theinvolving the inability of the patient to generate a reliable respiratory drive because of CNSpatient to generate a reliable respiratory drive because of CNS injury or drugs;injury or drugs; • (2)(2) oxygenation failureoxygenation failure involving rapid hemoglobininvolving rapid hemoglobin desaturation from a loss of expiratory pressure and/or a fall indesaturation from a loss of expiratory pressure and/or a fall in FIO2;FIO2; • (3)(3) oxygen delivery failureoxygen delivery failure resulting from anemia and/orresulting from anemia and/or cardiovascular failure involving dysrhythmias and/orcardiovascular failure involving dysrhythmias and/or hypotension from catecholamine release, edema formation, orhypotension from catecholamine release, edema formation, or coronary hypoxemia due to a loss of ventilatory support;coronary hypoxemia due to a loss of ventilatory support; • (4)(4) muscle failuremuscle failure involving muscle overload from abnormalinvolving muscle overload from abnormal respiratory system impedances in the setting of weakened,respiratory system impedances in the setting of weakened, fatigued, or metabolically disturbed muscles; andfatigued, or metabolically disturbed muscles; and • (5)(5) systemic inflammatory processessystemic inflammatory processes,, • (6)(6) nutritional impairmentsnutritional impairments, and, and • (7)(7) metabolic processesmetabolic processes associated with ongoing diseaseassociated with ongoing disease MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force
    12. 12. Vent weaningVent weaning  A multi-society-sponsored, evidence-basedA multi-society-sponsored, evidence-based task force recommendationstask force recommendations • (1) the lung injury is stable/resolving;(1) the lung injury is stable/resolving; • (2) the gas exchange is adequate with low(2) the gas exchange is adequate with low positive end-expiratory pressurepositive end-expiratory pressure (PEEP)/fraction of inspired oxygen (FIO2)(PEEP)/fraction of inspired oxygen (FIO2) requirements (requirements (egeg, PEEP, < 5 to 8 cm H2O;, PEEP, < 5 to 8 cm H2O; FIO2, < 0.4 to 0.5);FIO2, < 0.4 to 0.5); • (3) hemodynamic variables are stable ((3) hemodynamic variables are stable (egeg,, without significant needs for therapy withwithout significant needs for therapy with pressors); andpressors); and • (4) there is the capability to initiate(4) there is the capability to initiate spontaneous breathsspontaneous breaths MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force
    13. 13. Vent weaningVent weaning  Protocolized flow chart for ventilator discontinuationProtocolized flow chart for ventilator discontinuation MacIntyre et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force
    14. 14. Vent weaningVent weaning Criteria used in Weaning studies for considerationCriteria used in Weaning studies for consideration of weaningof weaning  Objective measurementsObjective measurements • Adequate oxygenationAdequate oxygenation eg:eg:  PO2 60 mm Hg on FIO2 0.4;PO2 60 mm Hg on FIO2 0.4;  PEEP 5–10 cm H2O;PEEP 5–10 cm H2O;  PO2/FIO2 150–300;PO2/FIO2 150–300; • Stable cardiovascular systemStable cardiovascular system eg:eg:  HR 140; stable BP;HR 140; stable BP;  no (or minimal) pressorsno (or minimal) pressors • Afebrile (temperature < 38°C)Afebrile (temperature < 38°C) • No significant respiratory acidosisNo significant respiratory acidosis • Adequate hemoglobin ( Hgb 8–10 g/dL)Adequate hemoglobin ( Hgb 8–10 g/dL) • Adequate mentationAdequate mentation eg:eg:  arousable,arousable,  GCS 13,GCS 13,  no continuous sedative infusionsno continuous sedative infusions • Stable metabolic status (Stable metabolic status (egeg, acceptable electrolytes), acceptable electrolytes) MacIntyre et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force
    15. 15. Vent weaningVent weaning  Subjective clinical assessmentsSubjective clinical assessments • Resolution of disease acute phase;Resolution of disease acute phase; • Clinical Care provider believesClinical Care provider believes discontinuation possible;discontinuation possible; • Adequate coughAdequate cough MacIntyre et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force
    16. 16. Vent weaningVent weaning  We conclude thatWe conclude that protocol-directedprotocol-directed weaning may beweaning may be unnecessary in aunnecessary in a closed ICU withclosed ICU with generous physiciangenerous physician staffing andstaffing and structured roundsstructured rounds Krishmanet al Prospective controlled trial of a protocol based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med 2004
    17. 17. Respiratory MusclesRespiratory Muscles  Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans • The combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers. • These findings are consistent with increased diaphragmatic proteolysis during inactivity. Levine S et al. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans n Engl j med 358;13 march 27, 2008
    18. 18. Ventilator Induced DiaphragmaticVentilator Induced Diaphragmatic DysfunctionDysfunction  All diaphragmatic muscles atrophied inAll diaphragmatic muscles atrophied in response to mechanical ventilationresponse to mechanical ventilation  Also, in critically ill, might be related to:Also, in critically ill, might be related to: • Neuromuscular blocker useNeuromuscular blocker use • Corticosteroid useCorticosteroid use • Mitochondrial dysfunctionMitochondrial dysfunction • General inflammatory response to intubationGeneral inflammatory response to intubation • General inflammatory response of respiratoryGeneral inflammatory response of respiratory musclesmusclesLevine S et al. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans n Engl j med 358;13 march 27, 2008
    19. 19. Respiratory MusclesRespiratory Muscles  Current concepts suggest that diaphragm atrophy associated with SIRS, sepsis, or barotrauma– volutrauma should be associated with an inflammatory-cell infiltrate or increase proinflammatory cytokines.  Neither of these findings, however, was evident in the diaphragm fibers from case subjects Levine S et al. Rapid Disuse Atrophy of Diaphragm Fibers in Mechanically Ventilated Humans n Engl j med 358;13 march 27, 2008
    20. 20. Volume ControlVolume Control  Tidal volume is preset to deliverTidal volume is preset to deliver desired amountdesired amount  Assist Control – will ‘assist’ everyAssist Control – will ‘assist’ every effort by the patienteffort by the patient  The effort needs to be =/> -0.5 to -2The effort needs to be =/> -0.5 to -2 cmH2OcmH2O  Every breath is delivered to set TVEvery breath is delivered to set TV  Risk of volu-, baro-trauma andRisk of volu-, baro-trauma and inadequate ventilationinadequate ventilation
    21. 21. Pressure ControlPressure Control  Pressure control ventilationPressure control ventilation • Preset pressurePreset pressure • TV not regulated and depends mostly onTV not regulated and depends mostly on lung compliancelung compliance • Enables to preset an Inspiratory time,Enables to preset an Inspiratory time, but flow and tidal volume variablebut flow and tidal volume variable • Eliminates risk of barotrauma since theEliminates risk of barotrauma since the pressure is presetpressure is preset • If needed – easier than AC to deliverIf needed – easier than AC to deliver inverted I:E ratioinverted I:E ratio
    22. 22. PCVPCV  Electro-impedance tomography estimate regional ventilation in patientsElectro-impedance tomography estimate regional ventilation in patients with ARDS.with ARDS.  Spontaneous breathing with CPAP is associated with better ventilation inSpontaneous breathing with CPAP is associated with better ventilation in the dependent well perfused lung regions.the dependent well perfused lung regions.  Spontaneous breathing with APRV is associated with better ventilation inSpontaneous breathing with APRV is associated with better ventilation in the dependent well perfused lung regions and the anterior lung areas.the dependent well perfused lung regions and the anterior lung areas.  When spontaneous breathing during APRV/BiPAP is abolished, mechanicalWhen spontaneous breathing during APRV/BiPAP is abolished, mechanical ventilation is directed entirely to the less well perfused, nondependentventilation is directed entirely to the less well perfused, nondependent anterior lung areas. PCV, pressure-controlled ventilationanterior lung areas. PCV, pressure-controlled ventilation
    23. 23. Modes of Partial Vent SupportModes of Partial Vent Support  IMVIMV – Patient is allowed to take breaths with preset TV– Patient is allowed to take breaths with preset TV  SIMVSIMV - No. of machine breaths supplied (- No. of machine breaths supplied (ieie, the fewer the, the fewer the No. of machine breaths, the more spontaneous breaths areNo. of machine breaths, the more spontaneous breaths are required)required)  PSVPSV - Level of inspiratory pressure assistance with- Level of inspiratory pressure assistance with spontaneous effortsspontaneous efforts  SIMV + PSVSIMV + PSV - Combining the adjustments of SIMV and- Combining the adjustments of SIMV and PSVPSV  Bi-LevelBi-Level –upper and lower pressure allowing patient to–upper and lower pressure allowing patient to breath spontaneously in betweenbreath spontaneously in between  APRVAPRV - Pressure difference between inflation and release- Pressure difference between inflation and release ((ieie, the less the pressure difference, the more spontaneous, the less the pressure difference, the more spontaneous breaths are required)breaths are required)
    24. 24. PSVPSV  Pressure support ventilationPressure support ventilation • Each breath is augmented to presetEach breath is augmented to preset positive pressurepositive pressure • Is only patient triggeredIs only patient triggered • May be used in conjunction SIMV, CPAP,May be used in conjunction SIMV, CPAP, PSV-PRO, Bi-Level ventilations wherePSV-PRO, Bi-Level ventilations where there is spontaneous respiratory drivethere is spontaneous respiratory drive
    25. 25. IMVIMV  Intermittent Mandatory VentilationIntermittent Mandatory Ventilation • Specific amount of ventilatory support isSpecific amount of ventilatory support is delivered as a preset positive pressuredelivered as a preset positive pressure breath to set TVbreath to set TV • Patient is aloud to take spontaneousPatient is aloud to take spontaneous breathsbreaths • Allows to preset rate and volume andAllows to preset rate and volume and eliminate any spontaneous effort by theeliminate any spontaneous effort by the patientpatient
    26. 26. SIMVSIMV  Synchronized IMVSynchronized IMV • Eliminates risk of barotrauma byEliminates risk of barotrauma by stacked breathsstacked breaths • Allows patient to breath at any rate andAllows patient to breath at any rate and volumevolume • Allows to manipulate vent settingsAllows to manipulate vent settings towards spontaneous ventilationtowards spontaneous ventilation eliminating any need of vent supporteliminating any need of vent support • That eventually becomes CPAPThat eventually becomes CPAP
    27. 27. CPAPCPAP  Patient maintains adequatePatient maintains adequate ventilation, while CPAP guarantiesventilation, while CPAP guaranties maintenance of continuous pressuremaintenance of continuous pressure to the airwayto the airway  Mechanism is directed by increasingMechanism is directed by increasing FRCFRC
    28. 28. PEEPPEEP  Positive end expiratory pressurePositive end expiratory pressure • FRC towards normal -> decreasesFRC towards normal -> decreases atelectasis and/or shuntingatelectasis and/or shunting • Recruits additional areas of the lung ->Recruits additional areas of the lung -> improved complianceimproved compliance • May increase intrathoracic pressureMay increase intrathoracic pressure Talmor, D et al. Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med Volume 34(5), May 2006
    29. 29. PEEP EffectPEEP Effect  Increases Mean airway pressureIncreases Mean airway pressure  Influences the status of lungInfluences the status of lung compliancecompliance  Impact on ventricular pre-loadImpact on ventricular pre-load  Pulmonary vascular resistancePulmonary vascular resistance  Decreases capillary perfusionDecreases capillary perfusion  Downregulates renal functionDownregulates renal function  Increases intracranial pressureIncreases intracranial pressure
    30. 30. PEEPPEEP  There is a sharp contrast between the results of experimental studies and clinical trials • Assessment of Low Tidal Volume and Elevated End- Expiratory Lung Volume to Obviate Lung Injury (ALVEOLI) study  randomized clinical trial comparing higher levels of PEEP with lower levels of PEEP in patients with ALI and ARDS  Stopped for futility • Expiratory Pressure (Express) trial  bedside assessment of lung mechanics instead of gas exchange • Lung Open Ventilation (LOV) trial  the level of PEEP administered either lower or higher, was selected according to an oxygenation scale conceptually similar to the one used in the previous ALVEOLI study Gatinoni L. Caironi P. Refining Ventilatory Treatment for Acute Lung Injury and Acute Respiratory Distress Syndrome. JAMA 2008
    31. 31. Protective mechanical ventilationProtective mechanical ventilation Gray bars represent the PEEP levels in the lung protective strategies and the white bars represent the PEEP levels in the control arms of the corresponding studies Verbrugge et al Clinical Physiology and Functional Imaging 2007 March
    32. 32. Bi-LevelBi-Level  Essentially is a form of PCVEssentially is a form of PCV • Allows patient breath spontaneouslyAllows patient breath spontaneously between preset upper and lowerbetween preset upper and lower pressure levelspressure levels • Allows preset time ratio – the timeAllows preset time ratio – the time allowed at each pressure levelallowed at each pressure level
    33. 33. Seymour C et al. The Journal of Trauma. Volume 62(5), May 2007, pp 1298-1309
    34. 34. APRV/ Bi-LevelAPRV/ Bi-Level  The P high is equivalent to a CPAP level;The P high is equivalent to a CPAP level;  T high is the duration of P high.T high is the duration of P high.  The CPAP phase (P high) is intermittently released to a Plow for a briefThe CPAP phase (P high) is intermittently released to a Plow for a brief duration (T low) reestablishing the CPAP level on the subsequent breath.duration (T low) reestablishing the CPAP level on the subsequent breath.  Spontaneous breathing may be superimposed at both pressure levels andSpontaneous breathing may be superimposed at both pressure levels and is independent of time-cycling.is independent of time-cycling. From:From: Habashi: Crit Care Med, Volume 33(3) 2005.Habashi: Crit Care Med, Volume 33(3) 2005.
    35. 35. APRVAPRV  Phigh = 30 cm H20;Phigh = 30 cm H20;  Plow = 0 cm H20;Plow = 0 cm H20;  Thigh = 5.4 sec;Thigh = 5.4 sec;  Tlow = 0.6 sec;Tlow = 0.6 sec;  RR = 10 breaths/min;RR = 10 breaths/min;  expiratory flowexpiratory flow sensitivity = 25%;sensitivity = 25%;  PS on Plow = 10 cmPS on Plow = 10 cm H20H20 Seymour C et al. The Journal of Trauma. Volume 62(5), May 2007, pp 1298-1309
    36. 36. APRVAPRV Fan E, Clinics in Chest Medicine Volume 27, Issue 4 (December 2006)
    37. 37. APRVAPRV  During APRV:During APRV: • patients can control the frequency and duration of spontaneous inspiration and expirationpatients can control the frequency and duration of spontaneous inspiration and expiration • not confined to a preset I:E ratio,not confined to a preset I:E ratio, • spontaneous tidal volumes maintain a sinusoidal flow pattern similar to normal spontaneousspontaneous tidal volumes maintain a sinusoidal flow pattern similar to normal spontaneous breathsbreaths • allows critically ill patients effectively augment spontaneous ventilation in response toallows critically ill patients effectively augment spontaneous ventilation in response to changing metabolic needschanging metabolic needs • By doing that may promote synchrony during mechanical ventilation and improve V/QBy doing that may promote synchrony during mechanical ventilation and improve V/Q matchingmatching Habashi: Crit Care Med, Volume 33(3) 2005
    38. 38. APRV/Bi-LevelAPRV/Bi-Level  With airwayWith airway pressure limitspressure limits kept equal, thekept equal, the differences withdifferences with and withoutand without spontaneousspontaneous breathingbreathing Christian Putensen, Hermann Wrigge Crit Care. 2004; 8(6): 492–497
    39. 39. HFOVHFOV  Attempts to deal with potential risks of mechanicalAttempts to deal with potential risks of mechanical ventilation:ventilation: • barotrauma,barotrauma, • volutrauma,volutrauma, • atelectrauma,atelectrauma, • and oxygen toxicityand oxygen toxicity  Can be considered when conventional ventilation fails toCan be considered when conventional ventilation fails to safely and adequately provide respiratory support andsafely and adequately provide respiratory support and generally considered beneficial for patients with severegenerally considered beneficial for patients with severe pulmonary failure becausepulmonary failure because • (a) it uses much smaller tidal volumes than conventional(a) it uses much smaller tidal volumes than conventional ventilation,ventilation, • (b) it maintains the lungs/alveoli open- preventing(b) it maintains the lungs/alveoli open- preventing atelectrauma and barotrauma,atelectrauma and barotrauma, • (c) it improves ventilation/perfusion (V/Q) matching by(c) it improves ventilation/perfusion (V/Q) matching by ensuring uniform aeration of the lungensuring uniform aeration of the lung
    40. 40. HFOVHFOV ARDSNET.ORG OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 88-95%  Use a minimum PEEP of 5 cm H2 O. Consider use of incremental FiO2 /PEEP combinations such as shown below (not required) to achieve goal.  Lower PEEP/higher FiO2  FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.8 0.9 0.9 0.9 1.0 1.0 1.0 1.0  PEEP 5 5 8 8 10 10 10 12 14 14 16 18 18 20 22 24  A protocol for high-frequency oscillatory ventilation in adults:A protocol for high-frequency oscillatory ventilation in adults: results from a roundtable discussion.results from a roundtable discussion. Fessler HEFessler HE,, Derdak SDerdak S,, Ferguson NDFerguson ND,, Hager DNHager DN,, Kacmarek RMKacmarek RM,, Thompson BTThompson BT,, Brower RGBrower RG.. Division of Pulmonary and Critical Care Medicine, Johns Hopkins MedicalDivision of Pulmonary and Critical Care Medicine, Johns Hopkins Medical InstitutionsInstitutions
    41. 41. HFOVHFOV
    42. 42. Avalon: 13-31 Fr sizesAvalon: 13-31 Fr sizes
    43. 43. UK Adult ECMO StudyUK Adult ECMO Study CESAR. Peek and Firmin 2000-2006CESAR. Peek and Firmin 2000-2006 180 ARDS Pts , 30 centers Consent Randomize 90 Conventional 90 Optimal+ECMO 47% Survival 63% Survival
    44. 44. ECMO for H1N1 ARDSECMO for H1N1 ARDS Australia/ New Zealand 2009Australia/ New Zealand 2009  201 intubated ARDS cases in 15 ECMO centers201 intubated ARDS cases in 15 ECMO centers  68 failing on optimal Rx, on ECMO68 failing on optimal Rx, on ECMO  Average patient, 2 days on vent,Average patient, 2 days on vent, FiO2 1.0. P 36/18FiO2 1.0. P 36/18 PaO2 56, PaCO2 69PaO2 56, PaCO2 69 OI = PPlat x FiO2 / PaO2 = 64OI = PPlat x FiO2 / PaO2 = 64 77% survived to D/C77% survived to D/C ( JAMA,Oct, 2009)( JAMA,Oct, 2009)
    45. 45. ReferencesReferences  MacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanicalMacIntyre, NR, Cook, DJ, Ely, EW, et al (2001) Evidence based guidelines for weaning and discontinuing mechanical ventilation: a collective task force facilitated by the American College of Chest Physicians; the American Association forventilation: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 120(suppl),375S-395SRespiratory Care; and the American College of Critical Care Medicine. Chest 120(suppl),375S-395S  Esteban, A, Frutos, F, Tobin, MJ, et al A comparison of four methods of weaning from mechanical ventilation. N Engl JEsteban, A, Frutos, F, Tobin, MJ, et al A comparison of four methods of weaning from mechanical ventilation. N Engl J Med 1995;332,345-350[Abstract/Free Full Text]Med 1995;332,345-350[Abstract/Free Full Text]  Brochard, L, Ramos, A, Benito, S, et al Comparison of these methods of gradual withdrawal from ventilatory supportBrochard, L, Ramos, A, Benito, S, et al Comparison of these methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994;50,896-903during weaning from mechanical ventilation. Am J Respir Crit Care Med 1994;50,896-903  Ely, EW, Baker, AM, Dunagan, DP, et al Effect on the duration of mechanical ventilation of identifying patients capableEly, EW, Baker, AM, Dunagan, DP, et al Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996;335,1864-1869of breathing spontaneously. N Engl J Med 1996;335,1864-1869  Kollef, MH, Shapiro, SD, Silver, P, et al A randomized controlled trial of protocol directed vs. physician directed weaningKollef, MH, Shapiro, SD, Silver, P, et al A randomized controlled trial of protocol directed vs. physician directed weaning from mechanical ventilation. Crit Care Med 1997;25,567-574from mechanical ventilation. Crit Care Med 1997;25,567-574  Esteban, A, Alía, I, Ibañez, J, et al Modes of mechanical ventilation and weaning: a national survey of SpanishEsteban, A, Alía, I, Ibañez, J, et al Modes of mechanical ventilation and weaning: a national survey of Spanish hospitals; the Spanish Lung Failure Collaborative Group. Chest 1994;106,1188-1193hospitals; the Spanish Lung Failure Collaborative Group. Chest 1994;106,1188-1193  Esteban, A, Anzueto, A, Alía, I, et al How is mechanical ventilation employed in the intensive care unit? An internationalEsteban, A, Anzueto, A, Alía, I, et al How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000;161,1450-1458utilization review. Am J Respir Crit Care Med 2000;161,1450-1458  Argov, Z, Mastaglia, FL Disorders of neuromuscular transmission caused by drugs.Argov, Z, Mastaglia, FL Disorders of neuromuscular transmission caused by drugs. N Engl J MedN Engl J Med 19791979  Lemaire, F, Teboul, JL, Cinotti, L, et al Acute left ventricular dysfunction during unsuccessful weaning from mechanicalLemaire, F, Teboul, JL, Cinotti, L, et al Acute left ventricular dysfunction during unsuccessful weaning from mechanical ventilation.ventilation. AnesthesiologyAnesthesiology 19881988  Molloy, DW, Dhingra, S, Solven, F, et al Hypomagnesemia and respiratory muscle power.Molloy, DW, Dhingra, S, Solven, F, et al Hypomagnesemia and respiratory muscle power. Am Rev Respir DisAm Rev Respir Dis 1984;1291984;129,497-498,497-498  Bark, H, Heimer, D, Chaimowitz, C, et al Effect of chronic renal failure on respiratory muscle strength.Bark, H, Heimer, D, Chaimowitz, C, et al Effect of chronic renal failure on respiratory muscle strength. RespirationRespiration 1988;541988;54,151-163,151-163  Pingleton, SK, Harmon, GS Nutritional management in acute respiratory failure.Pingleton, SK, Harmon, GS Nutritional management in acute respiratory failure. JAMAJAMA 1987;2571987;257,2094-2099,2094-2099  Casaburi, R, Gosselink, R American Thoracic Society/European Respiratory Society joint statement: skeletal muscleCasaburi, R, Gosselink, R American Thoracic Society/European Respiratory Society joint statement: skeletal muscle dysfunction in chronic obstructive pulmonary disease.dysfunction in chronic obstructive pulmonary disease. Am J Respir Crit Care MedAm J Respir Crit Care Med 1999;159(suppl)1999;159(suppl),1-40,1-40  Huang, CJ, Lin, HC Association between adrenal insufficiency and ventilator weaning.Huang, CJ, Lin, HC Association between adrenal insufficiency and ventilator weaning. Am J Respir Crit Care MedAm J Respir Crit Care Med 2006;1732006;173,276-280,276-280
    46. 46. ReferencesReferences  Esteban, A, Alia, I, Gordo, F, et al (1997) Extubation outcome after spontaneous breathing trials with T-tube orEsteban, A, Alia, I, Gordo, F, et al (1997) Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation: the Spanish Lung Failure Collaborative Group [published erratum appears in Am J Respirpressure support ventilation: the Spanish Lung Failure Collaborative Group [published erratum appears in Am J Respir Crit Care Med 1997; 156:2028]Crit Care Med 1997; 156:2028] Am J Respir Crit Care MedAm J Respir Crit Care Med 156156,459-465,459-465  Esteban, A, Alia, I, Tobin, MJ, et al (1999) Effect of spontaneous breathing trial duration on outcome of attempts toEsteban, A, Alia, I, Tobin, MJ, et al (1999) Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation: the Spanish Lung Failure Collaborative Group.discontinue mechanical ventilation: the Spanish Lung Failure Collaborative Group. Am J Respir Crit Care MedAm J Respir Crit Care Med 159159,512-,512- 518518  Vallverdu, I, Calaf, N, Subirana, M, et al (1998) Clinical characteristics, respiratory functional parameters, and outcomeVallverdu, I, Calaf, N, Subirana, M, et al (1998) Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation.of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care MedAm J Respir Crit Care Med 158158,1855-1862,1855-1862  Esteban, A, Frutos, F, Tobin, MJ, et al (1995) A comparison of four methods of weaning patients from mechanicalEsteban, A, Frutos, F, Tobin, MJ, et al (1995) A comparison of four methods of weaning patients from mechanical ventilation: the Spanish Lung Failure Collaborative Group.ventilation: the Spanish Lung Failure Collaborative Group. N Engl J MedN Engl J Med 332332,345-350,345-350  Ely, EW, Baker, AM, Dunagan, DP, et al (1996) Effect on the duration of mechanical ventilation of identifying patientsEly, EW, Baker, AM, Dunagan, DP, et al (1996) Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously.capable of breathing spontaneously. N Engl J MedN Engl J Med 335335,1864-1869,1864-1869  Brochard, L, Rauss, A, Benito, S, et al (1994) Comparison of three methods of gradual withdrawal from ventilatoryBrochard, L, Rauss, A, Benito, S, et al (1994) Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation.support during weaning from mechanical ventilation. Am J Respir Crit Care MedAm J Respir Crit Care Med 150150,896-903,896-903  Kollef, MH, Shapiro, SD, Silver, P, et al (1997) A randomized, controlled trial of protocol-directed versus physician-Kollef, MH, Shapiro, SD, Silver, P, et al (1997) A randomized, controlled trial of protocol-directed versus physician- directed weaning from mechanical ventilation.directed weaning from mechanical ventilation. Crit Care MedCrit Care Med 2525,567-574,567-574  Chopin, C, Chambrin, MC, Mangalaboyi, J, et al (1989) Carbon dioxide mandatory ventilation (CO2MV): a new methodChopin, C, Chambrin, MC, Mangalaboyi, J, et al (1989) Carbon dioxide mandatory ventilation (CO2MV): a new method for weaning from mechanical ventilation; description and comparative clinical study with I.M.V. and T. tube method infor weaning from mechanical ventilation; description and comparative clinical study with I.M.V. and T. tube method in COPD patientCOPD patient Int J Clin Monit ComputInt J Clin Monit Comput 66,11-19,11-19  Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive endexpiratorypressures in patients with theBrower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive endexpiratorypressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327-336.acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327-336.  MeadeMO,Cook DJ, Guyatt GH, et al; Lung Open Ventilation Study Investigators. Ventilation strategy using low tidalMeadeMO,Cook DJ, Guyatt GH, et al; Lung Open Ventilation Study Investigators. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratoryvolumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):637-645.distress syndrome: a randomized controlled trial. JAMA. 2008;299(6):637-645.  Mercat A, Richard J-CM, Vielle B, et al; Expiratory Pressure (Express) Study Group. Positive end-expiratory pressureMercat A, Richard J-CM, Vielle B, et al; Expiratory Pressure (Express) Study Group. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA.setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008; 299(6):646-655.2008; 299(6):646-655.  The ANZIC Influenza Investigators. Critical care services and 2009 H1N1 influenza in Australia and New Zealand. N EnglThe ANZIC Influenza Investigators. Critical care services and 2009 H1N1 influenza in Australia and New Zealand. N Engl J Med (2009) 361:1925–34J Med (2009) 361:1925–34  Davies A, Jones D, Bailey M, et al. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratoryDavies A, Jones D, Bailey M, et al. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome. J Am Med Assoc (2009) 302:1888–95distress syndrome. J Am Med Assoc (2009) 302:1888–95  Nonventilatory strategies for patients with life-threatening 2009 H1N1 influenza and severe respiratory failure.Nonventilatory strategies for patients with life-threatening 2009 H1N1 influenza and severe respiratory failure. Napolitano LM, Park PK, Raghavendran K, Bartlett RH.Crit Care Med. 2010 Apr;38(4 Suppl):e74-90.Napolitano LM, Park PK, Raghavendran K, Bartlett RH.Crit Care Med. 2010 Apr;38(4 Suppl):e74-90.
    47. 47. ReferencesReferences  Combination of high frequency oscillatory ventilation and interventional lung assist inCombination of high frequency oscillatory ventilation and interventional lung assist in severe acute respiratory distress syndrome. Lubnow M, Luchner A, Philipp A,severe acute respiratory distress syndrome. Lubnow M, Luchner A, Philipp A, Buchner S, Jeron A, Karagiannidis C, Bein T, Pawlik M, Jungbauer C, Schmid C,Buchner S, Jeron A, Karagiannidis C, Bein T, Pawlik M, Jungbauer C, Schmid C, Riegger GA, Pfeifer M, Müller T.J Crit Care. 2010 Jan 13Riegger GA, Pfeifer M, Müller T.J Crit Care. 2010 Jan 13  High-frequency oscillatory ventilation (HFOV) and airway pressure release ventilationHigh-frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV): a practical guide. Stawicki SP, Goyal M, Sarani B. J Intensive Care Med.(APRV): a practical guide. Stawicki SP, Goyal M, Sarani B. J Intensive Care Med. 2009 Jul-Aug;24(4):215-29.2009 Jul-Aug;24(4):215-29.  Extracorporeal membrane oxygenation for the support of infants, children, andExtracorporeal membrane oxygenation for the support of infants, children, and young adults with acute myocarditis: a review of the Extracorporeal Life Supportyoung adults with acute myocarditis: a review of the Extracorporeal Life Support Organization registry. Rajagopal SK, Almond CS, Laussen PC, Rycus PT, Wypij D,Organization registry. Rajagopal SK, Almond CS, Laussen PC, Rycus PT, Wypij D, Thiagarajan RR. Crit Care Med. 2010 Feb;38(2):382-7.Thiagarajan RR. Crit Care Med. 2010 Feb;38(2):382-7.

    ×