Lecture presented by Dr Lluis Blanch at Egyptian Critical Summit 2015, the leading medical event and exhibition for Critical Care Medicine

1. Dr. Lluís Blanch
Senior Critical Care
Director of Research and Innovation
Corporació Sanitària Parc Taulí
Cairo, 12th of January 2015
New directions
in Mechanical
Ventilation
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2. L.Blanch is inventor of one Corporació Sanitaria Parc
Taulí owned US patent: “Method and system for
managed related patient parameters provided by a
monitoring device,” US Patent No. 12/538,940.
L.Blanch owns 10% of BetterCare S.L. which is a
research and development company, spin off of
Corporació Sanitària Parc Taulí.
Financial Disclosures
Lluis Blanch MD, PhDD
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3. Objectives MV
• Safety
• Efficacy
– Oxygenation
– Ventilation
– Work of Breathing
• Comfort / Synchrony
– Surveillance of Flow & Pressure
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4. Daily Use of Modes of Mechanical Ventilation
2010
Esteban A et al. AJRCCM 2013;188:220-30
VCV
PSV
PCV
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5. Paw & TV & PEEP
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6. • Volume Control
- Set VT
- Set Flow waveform
- Set Flow rate
- Set Inspiratory Time
- Variable pressure
- Linear Rate/VE
• Pressure Control
- Set Pressure
- Set Inspiratory Time
- Variable VT
- Variable Flow waveform
- Variable Flow rate
- Non-linear Rate/VE
Pressure vs Volume ControlPressure vs Volume Control
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7. Effect of VT & PEEP on Compliance
Suter PM et al. Chest 1978; 73:158
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8. Amato MBP et al.
N Eng J Med 1998; 338:347-54
Targets during MV in Patients with ARDS
VT 12
PEEP
VT 6
PEEP VT 6
VT 12
ARDS Network
N Eng J Med 2000; 342:1301-8
ARDS Network
N Eng J Med 2004; 351:327-36
VT 6
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9. Protective ventilation strategy during general
anesthesia for abdominal surgery improves post-
operative pulmonary function: a randomized trial
N Engl J Med 2013;369:428-37.
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10. A Trial of Intraoperative Lung Protective
Ventilation in Abdominal Surgery
• VT 6 to 8 ml/kg PBW
• PEEP 6 to 8 cmH2O
• Recruitment Maneuver
• VT 10 to 12 ml/kg PBW
• No PEEP
• No Recruitment Maneuver
Recruitment maneuver = CPAP 30 cmH2O during 30 sec
after intubation and every 30 min thereafter
VS.
Lung-Protective Ventilation Traditional Ventilation
In both groups:
- Plateau pressure < 30 cmH2O
- Volume-controlled ventilation mode
- FiO2 adjusted to maintain SpO2 ≥ 95%
- RR adjusted to maintain ETCO2 between 35 and 40 mmHg
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11. 0.000.100.200.300.50
Days since surgery
Probabilityofevent
1 3 7 15 30
0.40
Protective ventilation
Traditional ventilation
No. at Risk
Traditional ventilation 182 163 145 142 142
Lung-protective ventilation 192 184 179 176 175
P<0.001
Major Pulmonary and Extra-pulmonary Complications
within 30 days after surgery
A Trial of Intraoperative Lung Protective
Ventilation in Abdominal Surgery
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12. Need for intubation or NIV for ARF
within 30 days after surgery
No. at Risk
Traditional ventilation 190 175 166 164 163
Lung-protective ventilation 191 190 190 187 187
1 3 7 15 30
0.000.100.200.300.500.40
Probabilityofevent
Days since surgery
Protective ventilation
Traditional ventilation
P<0.001
A Trial of Intraoperative Lung Protective
Ventilation in Abdominal Surgery
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13. AJRCCM December-2014 as 10.1164/rccm.201409-1598OC
Timing of Low Tidal Volume Ventilation and ICU Mortality in
ARDS:Study of 482 ARDS patients with 11,558 twice-daily VT assessments
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14. In-Hospital Time to Death
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15. Relationship between the initial response to
changes in PEEP following randomization and
mortality.
(1,732) patients
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16. Am J Respir Crit Care Med 2002; 165: 165-170
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17. 40 studies (1,185 patients) met inclusion criteria.
Ventilatory parameters were not
significantly altered by an RM, except
for higher PEEP post-RM (11 vs 16
cmH2O)
Hypotension (12%) and desaturation
(9%) were the most common adverse
events.
Given the uncertain benefit of transient oxygenation
improvements in patients with ALI and the lack of information
on their influence on clinical outcomes, the routine use of
RMs cannot be recommended or discouraged at this time.
Am J Respir Crit Care Med Vol 178. pp 1156–1163, 2008
P/F Ratio
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18. N Engl J Med 2013;368:806-13.
N Engl J Med 2013;368:795-805.
Why?: deleterious effects of heavy sedation and NBA,
hemodynamic compromise due to adverse effects of
high mean airway pressure on the right ventricle, or
increased VALI among HFOV non-responders.
Durbin CG, Blanch L, Fan E, Hess D. Respir Care 2014
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19. 20
+5
20
-5
Influence of Chest Wall Compliance & IAP & Obesity in
Transpulmonary Pressure and Lung Volume
Ptp = 25 Ptp = 15
Ptp = Paw - Peso
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20. EsophagealEsophageal--Pressure Guided Group:Pressure Guided Group:
Better oxygenation & CrsBetter oxygenation & Crs
Less mortality (17% vs 39%, p=0.05)Less mortality (17% vs 39%, p=0.05)
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21. Airway Pressure
Esophageal Pressure
Transpulmonary Pressure
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22. PEEP titrated in order to obtain values of end-expiratory
transpulmonary pressure ranging between 0 and 10 cmH2O
Airway Pressure
Esophageal Pressure
Transpulmonary Pressure
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23. Neuromuscular Blockers
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24. Settings: PCV at 20 cmH2O; VT 7-9 ml/kg
PEEP 8 cmH2O; FiO2 1 for 4 hours
SB weak (propofol)
Ptp 29.6 cmH2O
SB strong (doxapram)
Ptp 34.5 cmH2O
Crit Care Med 2012; 40
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25. Transpulmonary Pressure Variations
Volume Assist-Control Pressure Assist-Control
PLPL
Akoumianaki E et al. AJRCCM 2014;189:520-31
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26. Crit Care Med 2013; 41:536–545
4 groups of 7 rabbits
VT 5-7 ml/kg. Pplat<30 cmH2O. PEEP 9-11 cmH2O
Mild ALI
+ NMBA
Mild ALI
+ SB
Severe ALI
+ NMBA
Severe ALI
+ SB
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27. n engl j med 363;12 nejm.org september 16, 2010
Once the assigned Ramsay
sedation score was 6 and the
ventilator settings were adjusted,
a 3-ml rapid intravenous infusion
of 15 mg of cisatracurium
besylate or placebo was
administered, followed by a
continuous infusion of 37.5 mg
per hour for 48 hours.
177 162
cisatracurium placebo
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28. n engl j med 363;12 nejm.org september 16, 2010
At 28 days in cisatracurium
group more:
- ventilator-free days
- days without organ failure
- less pneumothorax
At 28 days in cisatracurium
group similar number of
patients with ICU-acquired
paresis
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29. The mechanisms underlying the beneficial effect of
neuromuscular blocking agents remain speculative. A brief
period of paralysis early in the course of ARDS may facilitate lung-
protective mechanical ventilation by improving patient–ventilator
synchrony and allowing for the accurate adjustment of tidal volume
and pressure levels, thereby limiting the risk of both asynchrony related
alveolar collapse and regional alveolar pressure increases with
overdistention. Another possible mechanism of the benefit involves a
decrease in lung or systemic inflammation.
n engl j med 363;12 nejm.org september 16, 2010
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30. Patient Ventilator
Interaction & Comfort
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31. VCV & Increased Work of Breathing
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32. PSV: Ineffective Efforts
Paw
(cmH2O)
Pes
(cmH2O)
Flow
(L/s)
Time (s)
Brochard L. Principles & Practice of Mechanical Ventilation. Tobin M, ed. 2007
Can occur when:
- too much PSV
-presence of autoPEEP
-inadequate triggering
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33. CHEST 2004; 126:851–859
36 pts
Different PSV &
PEEP levels
Ineffective Efforts
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34. PSV: Expiratory Trigger Setting
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35. PSV from
20 to 13 cmH2O
Cycling off 45%
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36. Murias G, Villagrá A, Blanch L. Minerva Anestesiol 2013;79:434-44
Ppl
Ppl
Paw
Paw
Increase
respiratory
effort
ASV PAV NAVA
SmartCare IntelVentVCV
PSV
PCV
Normal
respiratory
effort
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37. Crit Care Med 2007;35:1048
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38. Critical Care 2014, 18:550
12 COPD patients underwent three 30-minute trials
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39. Critical Care 2014, 18:550
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40. Respiratory Physiology & Neurobiology 203 (2014) 82–89
The weak EAdi–PTPdi linear relationship during NAVA and poor
triggering function during PAV+ may limit the effectiveness o fthese
modes to proportionally assist the inspiratory effort
Short term study in
22 difficult to wean
critically ill
patients:
PAV+, NAVA, PSV
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41. CHEST 2004; 126:851–859
36 pts
Different PSV &
PEEP levels
Comfort Borg Scale
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42. Crit Care Med 2011;39 (on line)
45 patients (47%) reported dyspnea (respiratory effort in
seven cases, air hunger in 15, both in 16, and neither of
these in seven).
Dyspneic and nondyspneic patients did not differ in terms
of age, SAPS II or indication for MV.
Dyspnea was significantly associated with anxiety (OR,
8.84; 95%CI, 3.26 –24.0), assistcontrol ventilation (OR,
4.77; 95% CI, 1.60–4.3), and heart rate (OR, 1.33 per 10
beats/min; 95% CI, 1.02–1.75).
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43. J Crit Care. 2009 March ; 24(1): 74–80
Patient ventilator asynchrony was assessed by determining the number of
breaths demonstrating ineffective triggering, double triggering, short cycling,
and prolonged cycling.
In 20 ICU patients airway pressure and airflow were recorded for 15 minutes.
For one unit decrease in RASS,
ITI increased by 2.7%, p = 0.04
ITI=
ineffectively triggered breaths
total number breaths
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44. Crit Care Med 2014; 42:74–82
14 pts. PSV & NAVA.
Propofol, BIS & RSS
PSV
NAVA
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45. Vaschetto R et al. Crit Care Med 2014; 42:74–82
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46. Alexopoulou C et al.
ICM 2013;39:1040-47
Sleep Architecture
in 14 patients.
PAV+
PSV
% Total
Sleep Time
PAV+ improved
synchrony but failed
to improve sleep
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47. New Directions in MV
Low VT and Paw: always
PEEP yes: attention to the effects
NMB drugs: short period in early
ARDS
HFOV: gone after RCTs
P-V interaction: pay attention
Proportional modes: slow entry
Comfort & Sleep: still work to do
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