A presentation by Steen Christensen at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. Department of Anesthesia and Intensive Care Medicine
l
Adjuvant therapy and advanced
mechanical ventilation
34th SSAI conference
Malmø
Steffen Christensen, MD, PhD
Department of Intensive Care
Aarhus University Hospital, Denmark

2. Department of Anesthesia and Intensive Care Medicine
l
Conflicts of Interest
No financial conflicts of interest

3. Department of Anesthesia and Intensive Care Medicine
l
Guidelines, reviews and meta-analysis

4. Department of Anesthesia and Intensive Care Medicine
l
Rescue therapies for severe ARDS
Hypoxemic respiratory failure refractory to
lung-protective ventilation
1. Ventilate ( LPV using adjuncts)
2. Oscillate ( HFOV)
3. Cannulate ( VV-ECMO // ECCO2R )

5. Department of Anesthesia and Intensive Care Medicine
l
Lung-protective ventilation using
adjuncts
Lung-protective ventilation
Low-tidal volume 4-8 ml/kg PBW
Plateau pressure < 30 cm H20
Driving pressure < 15 cm H20 (?)
High PEEP
…. Still hypoxemic then what ? Adjuncts ?
Prone position?
Neuromuscular blocker ?
Steroids ?
Inhaled nitric oxide/prostacyclin ?

6. Department of Anesthesia and Intensive Care Medicine
l
…… two (important?) issues ….
• Low-tidal volume 4-8 ml/kg PBW ?
Tidal volume
PBW ”Index” of healthy lung size
• Driving pressure < 15 cm H20 ?
Tidal volume
Respiratory system compliance
”Crude marker” of lung volume

7. Department of Anesthesia and Intensive Care Medicine
l

8. Department of Anesthesia and Intensive Care Medicine
l

9. Department of Anesthesia and Intensive Care Medicine
l
… two (important?) issues …
Assisted ventilation vs controlled ventilation ??

10. Department of Anesthesia and Intensive Care Medicine
l

11. Department of Anesthesia and Intensive Care Medicine
l
…. And then back to the adjuncts….
Prone positioning?
Neuromuscular blockade ?
Steroids ?
Inhaled nitric oxide/prostacyclin

12. Department of Anesthesia and Intensive Care Medicine
l
• PROSEVA: ”expert centers”
• Severe ARDS
• More than 12 hours
• PEEP level?
Fan et al, AJRCCM,2017

13. Department of Anesthesia and Intensive Care Medicine
l
Prone positioning – not just rescue?
Albert AJRCCM, feb 2014

14. Department of Anesthesia and Intensive Care Medicine
l
Prone positioning

15. Department of Anesthesia and Intensive Care Medicine
l
Neuromuscular blokade

16. Department of Anesthesia and Intensive Care Medicine
l
• Inclusion P/F <150 but effect
limited to P/F ratio<120
• PEEP low ( 9 cm H20)
• Cisatracurium
• >50% placebo group
received NMBA as needed

17. Department of Anesthesia and Intensive Care Medicine
l
Neuromuscular blokade
Mechanism is largely unknown
 No breath-stalking asynchrony
(Beitler, ICM 2016)
 Reduce biotrauma
(Forel, CCM 2006)
 Reduce oxygen consumption (?)
 Improved ventilation/perfusion relationships (?)
 Prevention of pendelluft effect (?)

18. Department of Anesthesia and Intensive Care Medicine
l

19. Department of Anesthesia and Intensive Care Medicine
l

20. Department of Anesthesia and Intensive Care Medicine
l
Potential beneficial effects in ARDS:
 Lower shunt fraction
 Lower PVR
 Improve oxygenation

21. Department of Anesthesia and Intensive Care Medicine
l
High Frequency Oscillatory Ventilation (HFOV)
Ideal for lung protective ventilation:
• Very low tidal volume
reduces stress/strain
• Relatively high mPaw
prevent atelectrauma
recruit collapsed regions

22. Department of Anesthesia and Intensive Care Medicine
l

23. Department of Anesthesia and Intensive Care Medicine
l
AJRCCM 2017

24. Department of Anesthesia and Intensive Care Medicine
l
 Prone positioning
 Neuromuscular blockade
?? Controlled ventilation
?? Steroids
?? Inhaled nitric oxide/prostacyclin
?? HFOV
In severe ARDS:

25. Department of Anesthesia and Intensive Care Medicine
l
Thank you
Email: steffen.christensen@auh.rm.dk