8th Pulmonary Medicine Update Course 2008 presentation by Dr.Lluis Blanch, Spain. Scribe Knowledge Resources(www.scribeofegypt.com)

1. 8th Pulmonary Medicine Update Course
The Egyptian Society of ICM & Trauma
Pressure – Volume Curves in
ARDS: Are they Useful ?
Lluis Blanch M.D.
Consultant, Critical Care Center, Hospital of Sabadell
Scientific Director, Corporacio Parc Tauli
University Institut Fundació Parc Taulí
Universitat Autónoma de Barcelona
Sabadell, Spain
lblanch@tauli.cat
Cairo, February 6 - 7, 2008

2. Human ARDS
Albaiceta GM, Blanch L, Lucangelo U. Current Opinion in Crtical Care 2008;14:80-86

3. Assessment of Pulmonary Morphology in ALI
Significance of Lower Inflection Point in the P-V Curve
Overdistension
ZEEP LIP + 2 cmH2O LIP + 7 cmH2O
Vieira et al. Am J Resp Crit Care Med 1999; 159:1612-1623.

4. Assessment of Pulmonary Morphology in ALI
Absence of Lower Inflection Point in the P-V Curve
Overdistension
ZEEP PEEP 10 cmH2O PEEP 15 cmH2O
Vieira et al. Am J Resp Crit Care Med 1999; 159:1612-1623.

5. Alveolar Recruitment with PEEP Alveolar Overdistension with PEEP
Current Opinion in Critical Care 2007;13:332-337

6. Pt # 4 Pt # 1
2100 2100
1800 1800
1500 1500
Volume (mL)
Volume (mL)
1200 1200
900 900
600 600
300 300
0 0
0 10 20 30 40 50 0 10 20 30 40 50
Pel (cm H2 O) Pel (cm H2 O)
Pt # 17 Pt # 14
2100 2100
1800 1800
1500 1500
Volume (mL)
Volume (mL)
1200 1200
900 900
600 600
300 300
0 0
0 10 20 30 40 50 0 10 20 30 40 50
Pel (cm H2 O) Pel (cm H2 O)
Maggiore S et al. AJRCCM 2001; 164: 795-801

7. Assessment of alveolar derecruitment by computed tomography
(left panel) and pressure-volume curves (right panel).

8. Comparison of alveolar derecruitment assessed by the computed
tomography and pressure–volume curve methods.

9. Crit Care Med 2003;31:2514-19

10. Crit Care Med 2003;31:2514-19

11. P-V Maneuver Using the Constant Low-Flow Method
Current Opinion in Critical Care 2008;14:80-86

12. COPD + Pneumonia
after intubation
VT
autoPEEP PEEP

13. Obese patient
Stroke + Moderate ALI
VT
PEEP

14. Frequency distribution of 197 discrete measurements
of lower inflection point (LIP) from 16 clinical studies
Respir Care • April 2007 Vol 52 No 4

15. Am J Resp Crit Care Med 1997;156:846-854

16. The Effects of Changing VT in Patients with ARDS
Roupie E et al. Am J Respir Crit Care Med 1995;152:121.

17. 30 ARDS pts. Ventilated according
the “ARDSnet Strategy”
Pulmonary cytokines were lower in the “more protected”
than in the “less protected” (P < 0.05). Ventilator free days
were 7 ± 8 and 1 ± 2 in the “more protected” and “less
protected”, respectively (P = 0.01). Plateau pressure in
“more protected” ranged between 25 and 26 cmH2O and in
“less protected” between 28 and 30 cmH2O (P = 0.006).

18. 30 min.period

19. Effect of Mechanical Ventilation on
Inflammatory Mediators in Patients with
ARDS. A Randomized Controlled Trial.
Control Group: VT 11 ml/kg, PEEP 6.5 cmH2O
Lung Protective Group: VT 7.5, PEEP 14.8 cmH2O
Ranieri VM et al. JAMA 1999; 282: 54-61

20. Crit Care Med 2006;34:1311-8
Design:
RCT severe ARDS PaO2/FiO2 < 200 mmHg
High PEEP & Low VT versus Low PEEP & Moderate VT
Control Group: VT 9-11 ml/kg PBW & PEEP > 5 cmH2O
Treat. Group: VT 5-8 ml/kg PBW & PEEP Pflex + 2 cmH2O
Outcome:
Control n=45. Mortality 53.3%
p = 0.04
Treatment n=50. Mortality 32%

21. Useful Clinical Information from P/V Curves
1. Easy & safe at the bedside
2. LIP may be beginning of substantial
recruitment
3. Absence of LIP: focus on UIP
4. When LIP and UIP appears in the P-V curve
regional mechanical differences are less
important
5. Impaired chest wall mechanics is problematic
6. Outcome can be optimized using P-V curves