Pathophysiology of mechanical ventilation cairo program dec 2011

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Presentation of Dr.Papadakos in second Pulmonary Medicine Virtual conference

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Pathophysiology of mechanical ventilation cairo program dec 2011

  1. 1. Pathophysiology of Mechanical Ventilation PJ Papadakos MD FCCM FCCP Director CCMProfessor Anesthesiology, Surgery and Neurosurgery University of Rochester School of Medicine Rochester NY Professor Respiratory Care State University Of New York Genesee Community College Batavia NY
  2. 2. 20 year collaboration Rotterdam and now Berlin
  3. 3. Funding over the Years:SiemensErasmus UniversityEuropean UnionBerlin UniversityAstra ZenecaBOCLilly
  4. 4. The Facts on Mortality
  5. 5. Dept. of Anesthesiologymortality rate (%) Mechanical ventilation overall ventilated ARDS Esteban et al. JAMA 2002; 287
  6. 6. Dept. of AnesthesiologyNinety-day mortality10080 41.3% 44.2%604020 0 non-ARDS ARDS Luhr et al. Intensive Care Med 2000: 26:508-17
  7. 7. Basic PhysiologyThe Base of Good Care In all trauma patients
  8. 8. What do these have in common
  9. 9. ARDS NetShowed that we are mammals!
  10. 10. Lung Skeleton
  11. 11. Lung Skeleton  Force-bearing structure  Elastin and collagen that are embedded in a the extracellular matrix  Two fiber systems connected at alveolar levels one originating from the hilum and the other from the visceral pleura in the peripheryPapadakos, Karcz and Lachman Mechanical Ventilation in Trauma, Curr Opin inAnesthesiol 23 2010
  12. 12. Microstructure
  13. 13. The Breathing Muscle It Goes up andDown
  14. 14. Chest Expansion Generating Flow
  15. 15. Change in muscle fibers Type I Type IIa Type Iid/x Type IIb Slow Fast Fast Fast Shanely et al. AJRCCM 2002;166:1369-74
  16. 16. Controlled mechanical ventilation Powers et al. JAP 2002;92:1851-8
  17. 17. St. Michael’s Hospital A teaching hospital affiliated with the University of TorontoLevine et al. NEJM 2008; 358:1327-35
  18. 18. 47 Days 3 Days Knisely et al. J Pediatric 1988;113:1074-7
  19. 19. Physiology of Atelectasis
  20. 20. Fact !Each lung hasa tendency to collapse
  21. 21. Decreased Oxgenenation
  22. 22. Eskaros and Papadakos Respiratory Monitoring in Millers Anesthesia 7th
  23. 23. Lung Mechanics change with Lung Collapse
  24. 24. Shear Forces
  25. 25. VOLUTRAUMA trauma fromhigh lung volumes ATELECTRAUMA (RACE) trauma from low lung volumes
  26. 26. Pulmonary Surfactant
  27. 27. Surfactant 90% lipids 10% ProteinsHydrophilic: SP-A and SP-DHydrophobic: SP-B and SP-C
  28. 28. Curr Opin Crit Care 10, 2004: 18-22
  29. 29. Pulmonary Surfactant wasinitiallyidentified as a lipoproteincomplex that reducessurface tension at the air-liquid interface of the lung
  30. 30. Lipids Levels of total phospholipids decrease over time with cyclic opening and closing especially phosphatidylcholine and phosphatidylglycerol, which are essential for lowering surface tension at the alveolar capillary membrane.Tsangaris l. et al Eur Respir J 2003, 21:495-501
  31. 31. The cycle opening andclosing of AlveolarUnits Deplete Surfactant and lead tofurther collapse through clumping.
  32. 32. Key to Immunology And host defence
  33. 33. Lung host defence mechanisms the lung is constantly challenged by inhaled pathogenPollutants an particles
  34. 34. of a family of proteins known as collectins.
  35. 35. Surfactant Proteins A and SP-D potentially bind several receptors, including Toll receptors
  36. 36. SURFACTANT INACTIVATION DECREASED SURFACTANT ACTIVITY HIGH INCREASEDPERMEABILITY SURFACE TENSION EDEMA AT ALVEOLAR WALL INCREASED SUCTION FORCES ACROSS ALVEOLAR WALL
  37. 37. Cascade of cytoactive molecules
  38. 38. From our Lab in Rotterdam:
  39. 39. Dept. of Anesthesiology Ventilator-associated lung injuryPurine conc BALF (M) 4 3 2 1 0 Surfactant Control 7/0 45/10 45/0 Verbrugge et al. Crit Care Med
  40. 40. Effect of ventilation on renal 100 failure% of renal failure entry 75 72-96 h 50 535.9 507.2 280.1 25 14 86 18 18 0 Conventional Protective ventilation ventilation (n=22) (n=22)
  41. 41. Effect of ventilation on hepatic failure% of hepatic failure 40 entry 30 72-96 h 20 535.9 507.2 280.1 10 0 23 9 5 0 Conventional Protective ventilation ventilation (n=22) (n=22)
  42. 42. A Systemic Inflammatory Process
  43. 43. Nosocomial Pneumonia
  44. 44. Medicare and Insurance Guidelines
  45. 45. Nosocomial Pneumonia Head of Bed Up Suctioning Mouth and Subglotic Mouth Care Oral intubation and Special ET tubes Hand washing and gowns Low gastric volumes Humidification
  46. 46. Presence of atelectasis Leads to impairment of host defense promotes nosocomial pneumonia
  47. 47. Nosocomial Pneumonia True Protection
  48. 48. Many Things Do Not Work
  49. 49. Critical Care Medicine 36, #3: 782-788 2008
  50. 50. Lets Jump into some up coming ideas on ventilation
  51. 51. Dept. of Anesthesiology Surfactant Depletion followed by 4 hrs of Mechanical ventilation P/F-ratio: P/F -Ratio: 310 650© B. Lachmann Open Lung Strategy ARDS Network Protocol
  52. 52. ARDSnet PermissivePEEP table = atelectasis M.Amato
  53. 53. PermissiveAtelectasis
  54. 54. PermissiveARDSnetatelectasis
  55. 55. PermissiveAtelectasis
  56. 56. PermissiveARDSnetatelectasis
  57. 57. PROTETORA Open Lung
  58. 58. Regional Spectrum of Opening Pressures Opening Superimposed Pressure Pressure Inflated 0 Small Airway 10-20 cmH2O Collapse Alveolar Collapse 40-60 cmH2O (Reabsorption) Consolidation (modified from Gattinoni)
  59. 59. PEEP Is natural It keeps recruited units open Must be titrated
  60. 60. Dept. of Anesthesiology Healthy Tween Tween & PEEP© B. Lachmann Steinberg et al. Am J Respir Crit Care Med; 2004; 169: 57-63
  61. 61. Dept. of AnesthesiologyPEEP levels used in patients on mechanical ventilation: international data 50 40 Patients (%) 30 20 10 0 0 1 to 5 6 to 10 11 to 15 >15 PEEP (cm H2O) Esteban et al. Am J Respir Crit Care Med 2000:161:1450-8
  62. 62. Barbas et al. Am J Respir Crit Care Med; 2002,
  63. 63. Hamdan A. A , Papadakos PJ Saunders Manual of Critical Care 2002
  64. 64. Small Positive End-Expiratory Pressure Decrease Results in Dramatic Pa02 ChangesIn a Experimental Model of ARDSSchwaiberger, Lachmann,Papadakos and LeonhardtATS 2011
  65. 65. 1998,VOLUME 338 February, 5 NUMBER 6 NUMBER 6
  66. 66. Survival function - Amato et al. 1.0Cumulative Survival .8 Protective .6 P < 0.001 .4 Control .2 N = 53 0.0 0 10 20 30 Time after Entry ( days )
  67. 67. Many ThanksTo my many Friends

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