ICS State of the Art Meeting 2015

1. SOA 2015 Debates
Rob Mac Sweeney
@critcarereviews | www.bit.do/SOA15
London, December 8th
2015

2. No Conflicts of InterestNo Conflicts of Interest

3. www.bit.do/SOA15

5. Stretching
the
Lung
Isn't
Harmful

6. VILI
Doesn't
Exist

7. So
What
Exactly
is
This ?

9. The Charge of the Light Brigade

11. Overwhelming Odds

14. Experimental
MA
RCT
Observational

15. Pressure
Volume

16. 0 mins 5 mins 20 mins
Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from
experimental studies. Am J Respir Crit Care Med 1998;157:1–30
45 cm H2
0

17. Pressure
Volume

18. Dreyfuss D, Soler P, Basset G, Saumon G. High Inflation Pressure Pulmonary Edema.
Am Rev Respir Dis 1988;137:1159–1164

19. Pressure
Volume
PEEP

20. Webb HH, Tierney DF. Experimental pulmonary edema due to intermittent
positive pressure ventilation with high inflation pressures: protection by positive
end-expiratory pressure. Am Rev Respir Dis 1974;110:556–565
14/0 45/10 45/0cm H2
0

22. Surgical Patients without ARDS

23. Surgical Patients without ARDS
Critically ill without ARDS

24. Surgical Patients without ARDS
Critically ill without ARDS
Critically ill with ARDS

25. Surgical Patients without ARDS
Critically ill without ARDS
Critically ill with ARDS
Organ Donors without ARDS

26. vs
6 - 8 ml/kg
&
6–8 cmH2
0 PEEP
&
Recruitment
12 ml/kg
&
≥ 30 cmH2
0
10 - 12 ml/kg
&
0 cmH2
0 PEEP
&
No Recruitment

27. Post-Operative Complications
vs
6 - 8 ml/kg
&
6–8 cmH2
0 PEEP
&
Recruitment
12 ml/kg
&
≥ 30 cmH2
0
10 - 12 ml/kg
&
0 cmH2
0 PEEP
&
No Recruitment
p=0.001RR 0.40 (0.24 - 0.68)

28. vs6 ml/kg 10 ml/kg

29. Development of ARDS
vs6 ml/kg 10 ml/kg
2.6% 13.5%vs p = 0.01

30. 6 ml/kg
&
≤ 30 cmH2
0
12 ml/kg
&
≥ 30 cmH2
0
vs

31. vs
6 ml/kg
&
≤ 30 cmH2
0
12 ml/kg
&
≥ 30 cmH2
0
Mortality
31% 40%vs p = 0.01

32. vs
10-12 ml/kg
&
PEEP
3-5 cmH2
0
6-8 ml/kg
&
PEEP
8-10 cmH2
0

33. vs
10-12 ml/kg
&
PEEP
3-5 cmH2
0
6-8 ml/kg
&
PEEP
8-10 cmH2
0
Lungs Harvested
54% 27%vs P=0.004

34. vs Higher VtLower Vt

35. vs Higher VtLower Vt
RR 0.33 (0.23 to 0.47)
Development of ARDS

36. vs
RR 0.64 (0.46–0.89)
Higher VtLower Vt
Mortality
RR 0.33 (0.23 to 0.47)
Development of ARDS

37. Perspective

38. Lord Raglan

40. Lord Cardigan

42. Experimental & Physiological Studies

43. Experimental & Physiological Studies
Interventional Studies

45. 6 ml/kg 12 ml/kg

46. 6 ml/kg
158
12 ml/kg
Day 1
Pa02 / FiO2
176

47. 6 ml/kg
158
12 ml/kg
Day 1
Pa02 / FiO2
176
Day 3
Pa02 / FiO2
160 177

48. 6 ml/kg
158
12 ml/kg
Day 1
Pa02 / FiO2
176
Day 3
Pa02 / FiO2
160 177
Mortality 31% 40%

49. Miscommunication

59. “Into the Valley of Death”

64. Officer Louis Nolan
The man blamed for the
misunderstanding
leading to the
Charge of the Light Brigade

65. Officer Louis Nolan
He was Killed at the Start of
the Charge....

66. Carnage

67. 118
Wounded
Captured
Killed
127
60

68. 13th
Light Dragoons – Survivors of the Charge of the Light Brigade
195Survived

69. Cornet assistant Surgeon Henry Wilkin, 11th Hussars.
Charge of the Light Brigade Survivor (photo Roger Fenton)

70. UK
11,000 ARDS
Cases
Cornet assistant Surgeon Henry Wilkin, 11th Hussars.
Charge of the Light Brigade Survivor (photo Roger Fenton)

71. UK
11,000 ARDS
Cases
Europe
40,000 ARDS
Deaths
Cornet assistant Surgeon Henry Wilkin, 11th Hussars.
Charge of the Light Brigade Survivor (photo Roger Fenton)

72. Memorials

73. Memorial in the Balaklava valley to the British who fell in the Crimean War.

75. History

77. “the lungs of one man may
bear, without injury, as great a
force as another man can
exert; which by the bellows
cannot always be determin’d”.
Fothergill J: Observations on a case published in the last volume of the medical essays,
&c. of recovering a man dead in appearance, by distending the lungs with air. Phil Trans
R Soc Med 1744–1745;43:275–281

78. 6.3 ml/kg

79. REST
Study

81. “Into the VALI of Death”

82. SOA 2015 Debates
Rob Mac Sweeney
@critcarereviews | www.bit.do/SOA15
London, December 8th
2015