Presented by Dr Lluis Blanch at the Egyptian African Critical care Summit held at Cairo, Egypt. The Egyptian African Critical care Summit is the leading Critical care and Emergency medicine medical conference in Egypt.

1. Dr. Lluís Blanch Torra
Senior Critical Care
Former President of SEMICYUC
WFSICCM Council member
Director of Institut d’Investigació i
Innovació Parc Taulí I3PT
Cairo, 10 January 2017
Novel Mechanical Ventilation
Strategies

2. ARDS + VILI causes MOF
SlustkyAS, Ranieri VM N Engl J Med ; November 28, 2013

3. Intensive Care Med 2016;42:1567–75
Tidal volume, pressures and flow are all components
of the energy load, which, expressed per unit of time,
is the mechanical power
Mechanical Power = multiplying each component of the
equation of motion by the variation of volume and RR

4. Intensive Care Med 2016;42:1567–75
%
Increase
in Power
% Increase in Eq Motion Components
TV
Flow
Δ P
RR
PEEP

5. Lung Stress & Strain
Stress = F =Ptp
Strain = VT/FRC

6. Alveolar Interdependence
Mead J et al. J Appl Physiol 1970; 28:596-608
Stress
(tensión)
Strain
(deformación)
Strech
(estiramiento)
Shear
(cizallamiento)

7. PEEP
PEEP
HIGH
PEEP
HIGH
PEEP
Intensive Care Med
DOI 10.1007/s00134-016-
4324-5

8. In-Hospital Time to Death

9. (1,732) patients
ΔPEEP>0
ΔPEEP≤0
Relationship between the initial response to changes in
PEEP following randomization and mortality.
Changes in oxygenation
following increased PEEP
are strongly associated
with adjusted mortality
(cyan line) whereas
changes in oxygenation
with decreased or
unchanged PEEP are not
associated with adjusted
mortality

10. Clinical classification of the ARDS for predicting
outcome and guiding medical therapy
300 consecutive, mechanically ventilated patients meeting criteria for
moderate and severe ARDS (PaO2/FiO2≤200 mmHg on PEEP≥5 cmH2O),
ARDS Onset
Villar J,.. Blanch L... Kacmarek R. Crit Care Med 2015;43.346-53

11. Clinical classification of the ARDS for predicting
outcome and guiding medical therapy
Villar J,.. Blanch L... Kacmarek R. Crit Care Med 2015;43.346-53
300 consecutive, mechanically ventilated patients meeting criteria for
moderate and severe ARDS (PaO2/FiO2≤200 mmHg on PEEP≥5 cmH2O)
ARDS at 24 hours

12. The driving pressure (ΔP = VT/Crs), can be routinely
calculated for patients who are not making inspiratory
efforts as the plateau pressure minus PEEP.
ΔP = Pplat - PEEP
3562 patients with ARDS enrolled in 9 previouslyreported RCT
N Engl J Med February 19, 2015

13. Amato M
NEJM 2015
Risk of
Death
Airway
Pressure
cmH2O
Matched PEEP Matched ΔP Matched Pplat

14. JAMA. 2016;315(8):788-800

15. Courtesy of MBP Amato.
Local Ppl changes transmission
during spontaneous breathing
in the injured lung
Ppl in Nondependent Lung
Ppl in Dependent Lung
Negative Change in Pes

16. SPONTANEOUS BREATHING DURING MECHANICAL VENTILATION - RISKS,
MECHANISMS & MANAGEMENT
YOSHIDA, FUJINO, AMATO & KAVANAGH
AJRCCM Articles in Press. 27-October-2016

17. Transpulmonary Pressure Variations
Akoumianaki E et al. AJRCCM 2014;189:520-31
Volume Assist-Control Pressure Assist-Control
PLPL
Low assistance
favors negative
alveolar pressures

18. SPONTANEOUS BREATHING DURING MECHANICAL VENTILATION - RISKS,
MECHANISMS & MANAGEMENT
YOSHIDA, FUJINO, AMATO & KAVANAGH
AJRCCM Articles in Press. 27-October-2016
Ptp (Paw-Ppl) (30 – 10) = 20
Ptv (Pcap-Ppl) (12 – 10) = 2
Ptp (Paw-Ppl) (30 – (-20) = 50
Ptv (Pcap-Ppl) (8 – (-20) = 28

19. 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

20. Crit Care Med 2013; 41:536–545
4 groups of 7 rabbits. Assisted PCV
VT 5-7 ml/kg. Pplat<30 cmH2O. PEEP 9-11 cmH2O
MildALI
+ NMBA
MildALI
+ SB
Severe ALI
+ NMBA
Severe ALI
+ SB

21. Crit Care Med 2016 DOI: 10.1097/CCM.0000000000001649
12.7 10.8
22.8 17.0
ΔPtp
cmH2O
ΔPtp
cmH2O
Tidal Recruitment + Pendelluft

22. Am J Respir Crit Care Med 2017;195:67–7
2,813 p. with ARDS, 436 managed with NIV on Days 1 & 2
Entire Sample PaO2/FiO2 < 150 PaO2/FiO2 > 150
Kaplan-Meier survival curves in the propensity score matched samples
of patients managed with noninvasive and invasive ventilation

23. Novel Ventilator Strategies …
It’s not the ventilator mode or set up that
makes a difference …
… It’s the knowledge and skills of the
clinician that makes the difference.
Adapted from Dean Hess. Cairo, February 2010