The new PEEP step method for transpulmonary pressure - too good to be true? Paolo Pelosi - SSAI2017
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A talk by Paolo Pelosi at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All of the conference content can be found here: https://scanfoam.org/ssai2017/ Developed in collaboration between scanFOAM, SSAI and SFAI.
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The new PEEP step method for transpulmonary pressure - too good to be true? Paolo Pelosi - SSAI2017
- 1. ppelosi@hotmail.com Transpulmonary pressure in critically ill patients: too good to be true? Paolo Pelosi, MD, FERS SSAI Meeting – Malmoe September 7th - 2017 Department of Surgical Sciences and Integrated Diagnostics (DISC), SAN MARTINO POLICLINICO HOSPITAL – IRCCS for Oncology, University of Genoa, Genoa, Italy
- 2. Conflicts of Interest I declare NO conflicts of interest
- 3. Conventional Ventilator Graphics Paw Flow Volume Pes Flow/Volume loops Brochard L et al Crit Care. 2012 Dec 12;16(2):219
- 4. Lung SAFE Esophageal and transpulmonary pressure was measured of mechanically ventilated patients Bellani G et al. JAMA 315:788–800 (2016) Esophageal Pressure in LUNG SAFE in less than 1%
- 5. • Partitioning of respiratory mechanics • Assess lung recruitability • Guide recruitment maneuver • Optimization of ventilator settings: – PEEP – Tidal volume / Inspiratory pressure • Detection of reverse triggering • Transpulmonary pressure • Work of breathing/ pressure time product • Patient-ventilator synchrony Passive Spont Applications of esophageal pressure Theerawit P et al Expert Review of Respiratory Medicine (2017)
- 6. Atelectrauma Stress Strain PTPEND-INSP < 15- 20 cmH2O ΔPL < 10-15 cmH2O Recruitment strategy: - PTP RM < 25 cmH2O - PTPEND-EXP = 0 - 5 cmH2O Applications in ARDS
- 8. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 9. Pleural pressure ? Esophageal pressure Heart Esophagus Ballon Catheter Transducer Multiple holes Air
- 10. Optimum inflation volume Mojoli F et al. Minerva Anestesiol 81(8): 855-864, 2015 • Patient in semi recumbent position • Retrieve feeding tube (?) • Insert dedicated catheter
- 12. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 13. Insertion of the esophageal catheter: technique Akoumianaki E et al Am J Respir Crit Care Med 189:520–531, 2014
- 14. DPes = 1,92 + 0,92 DPao R2 = 0,99 P < 0,0001 A. Patients with Inspiratory efforts (occluded airways) DPes = -3.62 + 0,94 DPao R2 = 0,95 P < 0,0001 B. Patient without inspiratory efforts (compression of the chest during occlusion) Paw (cmH2O) Pes (cmH2O) Flow (L/min) End-expiratory occlusion Positioning of esophageal catheter: without and with spontaneous breathing Akoumianaki E et al Am J Respir Crit Care Med 189:520–531, 2014
- 15. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 16. Transpulmonary pressure: wafers and ravioli
- 17. Vertical Gradient of Regional Lung Inflation in Adult Respiratory Distress Syndrome Pelosi P et al Am J Respir Crit Care Med 1994; 149:8-13 Ppl ≈ Pes – 5 cmH2O Ppl ≈ Pes Ppl ≈ Pes + 5 cmH2O ARDS LUNG
- 18. -5 0 5 10 15 20 -5 5 10 15 20 Esophageal pressure (cmH2O) Pleuralpressure(cmH2O) Inspiratory Expiratory Ppl dependent lung Ppl middle lung Ppl non dependent lung Pleural vs Esophageal Pressures Pelosi P et al. Am J Respir Crit Care Med. 2001 Jul 1;164(1):122-30.
- 19. Expiratory transpulmonary pressure from esophageal pressure in ARDS Yoshida T et al. (2017) Am J Respir Crit Care Med195:A7528.
- 20. What about Absolute Values of Transpulmonary Pressure ? Rocco Pr et al. Curr Opin Anaesthesiol 2012 Apr;25(2):123-30
- 21. Esophageal pressure ≠ pleural pressure Δ esophageal pressure = Δ pleural pressure What is esophageal pressure? Rocco Pr et al. Curr Opin Anaesthesiol 2012 Apr;25(2):123-30
- 22. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 23. tangentialsurfacetension Alveolar pressure = 0 cmH2O Interstitial pressure = -10 cmH2O Interstitial pressure = -56 cmH2O Alveolar pressure = 30 cmH2O veincapillary Fluid air EXPIRATION INSPIRATION alveolar space alveolar space alveolar space stress Interstitial pressure is different from Ppl Pleural pressure = - 3 cmH2O Pleural pressure = 6 cmH2O TPP, exp = 3 cmH2O TPP, exp = 24 cmH2O TiP, exp = 10 cmH2O TiP, exp = 86 cmH2O
- 24. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 26. Elastance derived measurement 22 6 3 20 17 16 Mietto C et al. Anaesthesiol Intensive Ther. 2015;47 Spec No:27-37 Lung Elastance: EL = (PTP EI – PTP EE )/VT Elastance ratio: EL/ETOT Est,L/Est,rs = 26/32=0.8 22 cmH2Ox0.8 = 17.6 cmH2O Absolute difference P,L INSP = +2 cmH2O EXP = -11 cmH2O
- 27. 30 12 6 0 Released derived measurementReleased derived measurement P transpulmonary =P transpulmonary = ΔΔPaw –Paw – ΔΔPesPes PL, insp = (30 – 0) – (12 – 6) = 24 cmH2O Mietto C et al. Anaesthesiol Intensive Ther. 2015;47 Spec No:27-37 PL, exp = (10 – 0) – (9 – 6) = 7 cmH2O 10 9 Absolute difference P,L INSP = +18 cmH2O EXP = +1 cmH2O
- 28. Pleural Pressure and Optimal PEEP Based on Esophageal Pressure Versus Chest Wall Elastance: Incompatible Results Gulati G et al. Crit Care Med 2013;41:1951–1957 Recommended PEEP determined by the esophageal pressure and the chest wall elastance based methods
- 29. Chiumello D. et al. Crit Care Med 2014; 42:252–264 Bedside Selection of PEEP in Mild, Moderate, and Severe Acute Respiratory Distress Syndrome
- 30. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 31. Courtesy of MBP Amato. Local Ppl changes transmission during spontaneous breathing in the injured lung Ppl in Nondependent Lung Ppl in Dependent Lung Negative Change in Pes Saddy et al., Semin Respir Crit Care Med, 2014
- 32. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 33. Prolonged Cycling Double Triggering ReverseTriggering Short Cycling Ineffective Effort Do we really need esophageal pressure to detect patient-ventilator assyncronies ?
- 34. Pitfalls of esophageal and transpulmonary pressure measurements • Type of catheter and inflation • Positioning and validation tests • What esophageal pressure measures? • Interstitial vs esophageal pressure • Methods to estimate transpulmonary pressures • During spontaneous-assisted breathing • Detection of patient-ventilator assyncronies • Clinical conditions impairing interpretation
- 35. • Chest tube • Additional nasogastric tube • Pleural effusion ? • One lung injury ? • Prone position ? What we don’t know about esophageal pressure ?
- 36. Esophageal and transpulmonary pressures: the dark sides 1 • Technical Difficulties - Type of the catheter - Correct position and inflation of the balloon - Valid occlusion test - Cardiac artefacts • Sources of errors - Elastance of the balloon - Elastance of the esophagus - Weight of the heart (supine - prone) • Interstitial pressure is different from pleural and esophageal pressure
- 37. • Validity of absolute values ? - Pleural gradient vs single esophageal pressure value - TP: Absolute difference between airway and esophageal pressure - TP: Elastance method - TP: Release method - All methods give different absolute transpulmonary pressure results ! - ΔPes = ΔPpl, mean ? - Do not target PEEP on absolute end-exp transpulmonary pressure • Esophageal pressure is not really needed to detect patient ventilator asynchrones • Clinical conditions impair interpretation of data Esophageal and transpulmonary pressures: the dark sides 2
- 38. Conclusions
Editor's Notes
- Carbone 004 (ARDS vers)
- Campus 005 (studio\2011)
- Le critère 2 vise à éviter l’inclusion de patients présentant des atélectasies des 2 bases. Le rapport PaO2 / FiO2 est mesuré avec ou sans PEP, à n’importe quel niveau de FiO2. Il s’agit de patients atteint d’ALI (Acute Lung Injury), comme dans l’étude de l’ARDSnetwork. Les critères 1, 2 et 3 doivent être réunis depuis moins de 48 heures. Les patients ayant bénéficié de VNI avant l’intubation peuvent être inclus dans les 48 heures suivant l’intubation. Les patients intubés de puis plus de 48 heures mais réunissant les critères 2 et 3 depuis moins de 48 heures peuvent être inclus. La « personne de confiance » a été définie par l’article xxx de la loi du xxx, modifiant la loi du xxx sur la protection des personnes se prêtant à la recherche biomédicale (« loi Huriet »).
- Le critère 2 vise à éviter l’inclusion de patients présentant des atélectasies des 2 bases. Le rapport PaO2 / FiO2 est mesuré avec ou sans PEP, à n’importe quel niveau de FiO2. Il s’agit de patients atteint d’ALI (Acute Lung Injury), comme dans l’étude de l’ARDSnetwork. Les critères 1, 2 et 3 doivent être réunis depuis moins de 48 heures. Les patients ayant bénéficié de VNI avant l’intubation peuvent être inclus dans les 48 heures suivant l’intubation. Les patients intubés de puis plus de 48 heures mais réunissant les critères 2 et 3 depuis moins de 48 heures peuvent être inclus. La « personne de confiance » a été définie par l’article xxx de la loi du xxx, modifiant la loi du xxx sur la protection des personnes se prêtant à la recherche biomédicale (« loi Huriet »).