1 / 50

Non-ECMO rescue therapies for ARDS

Non-ECMO rescue therapies for ARDS. Division of Pulmonary, Allergy and Critical care medicine Department of Internal medicine Pusan National University Yangsan Hospital Hye Ju Yeo. ARDS related problems. Hypoxemia. PAH RVF. Complications. End stage ARDS. Principles of therapy.

keitht
Download Presentation

Non-ECMO rescue therapies for ARDS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Non-ECMO rescue therapies for ARDS Division of Pulmonary, Allergy and Critical care medicine Department of Internal medicine Pusan National University Yangsan Hospital HyeJu Yeo

  2. ARDS related problems • Hypoxemia • PAH • RVF • Complications

  3. End stage ARDS

  4. Principles of therapy Avoid complications Buy time

  5. Rescue therapies

  6. Ventilator induced lung injury Over-distension Shearing force - Cyclic opening and closure Dreyfuss et Am. Rev. Respir. Dis. 132:880 N Engl J Med 2007;357:1113

  7. Low tidal volume 6ml/PBW vs 12ml/PBW N Engl J Med 1998;338:347-54

  8. Lowtidal volume • Multicenter trial, 861 • Plateau pr<50 cmH2O vs plateau pr <30 cmH2O * Absolute risk reduction 9% (31% vs 40%) Relative risk reduction 22% * *p<.001 NEJM 2000;342:1301-1308

  9. Lung Protective Strategy Overdistension Pplat <30 Optimal PEEP > LIP + 3cmH2O Atelectasis Shearing force EurRespir J 2003

  10. Higher vs Lower PEEP No benefit Mean PEEP 8.3 vs 13.2 Hospital mortality 24.9 % vs 27.5%, p=0.48 VFD 14.5 vs 13.8, p=0.50 NEJM 2004;351:327-36

  11. Higher vs Lower PEEP • Higher PEEP: better PO2 transiently (same at day 7) • Higher PEEP: Pplat PFratio ≤200 JAMA. 2010;303(9):865-73

  12. NEJM 1998;338:347-54 Less energy More homogenous lung NEJM 2004;351:327-36 LucianoGattinoni JAMA. 2010;303(9):865-73

  13. Baby lung & Heterogeneity Optimal TV Optimal PEEP

  14. Protect baby lung • Low tidal volume • ultraprotective ventilation + ECCO2R • NMBA • ECMO

  15. How much low tidal volume for baby lung ? The lower, the better ? How much smaller ?

  16. Low tidal volume may not be protective ? Am J RespirCrit Care Med. 2007;175(2):160–6

  17. Baby lung = Functional lung size = Optimal TV ? • Driving pressure (ΔP = VT/CRS =Pplat-PEEP) N Engl J Med 2015;372:747-55

  18. Effect of driving pressure on mortality in ARDS patients during lung protective ventilation in two RCTs (Acurasys, Proseva) Critical Care 2016; 20:384 mechanical power as ΔPrs × VT × respiratory rate

  19. Ultraprotective ventilation TV 3ml/Kg + ECCO2R vs TV 6ml/Kg Intensive Care Med. 2013; 39(5): 847

  20. Ultraprotective ventilation TV 3ml/Kg + ECCO2R vs TV 6ml/Kg Intensive Care Med. 2013; 39(5): 847

  21. Pplat − PEEP Intensive Care Med. 2013; 39(5): 847

  22. SUPERNOVA pilot trial moderate ARDS (PaO2/FiO2 100–200 mmHg, with PEEP ≥ 5 cmH2O) TV 6 5, 54.5, 4.54ml/PBW, PEEP was titrated to a target PPLAT of 23–25 cmH2O 28d survival 73% Hospital discharge 62% VFD 11 24h 8h 24h 8h Intensive Care Med. 2019 Feb 21.

  23. Timing of low tidal volume is important! Higher tidal volumes shortly after ARDS onset were associated with a greater risk of ICU mortality compared with subsequent tidal volumes.  Am J RespirCrit Care Med. 2015 Jan 15;191(2):177-85

  24. Spontaneuous breathing in ARDSHarm or good ?

  25. Spontaneuous breathing in ARDS Insptranspulmonary pr. decreases negative swing in esophageal pr. is decreasing.

  26. Spontaneuous breathing in ARDS Crit Care Med. 2012;40:1578–85

  27. NMB in early ARDS Severe ARDS PF ratio <150, PEEP ≥5 340 randomized Ramsey level6 15mg bolus  continuous infusion for 48 hours ICU acquired weakness – no difference Adjusted Cox regression model: HR 0.68 95% CI 0.48-0.98, p=0.04 NEJM 2010;363:1107-1116

  28. ARDS lung = Heterogenous lung Pinhu et al Lancet 2003;361:332

  29. From heterogeneity to homogeniety • Prone position • Recruitment • HFOV • APRV

  30. Proningeffect Ventral-> Dorsal Am J RespirCrit Care Med 2013: 188 (11) ;1286–1293

  31. Prone position effect PF < 150 < 36h after MV start at least 16 consecutive hours N Engl J Med 2013;368:2159-68

  32. Atelectasis during Induction of General Anesthesia in Obese Patients PEEP ! Prone ? Coussa M et al., Anesth Analg 2004;98:1491

  33. LPV + Recruitment responder PF ratio 20% Am J RespirCrit Care Med. 2002;165(2):165-70.

  34. Currently RM, no routine use Mean PF ratio 119 vs 117 28d mortality 55.3% vs 49.3%, p=0.041 6 M mortality 65.3% vs 59.9%, p=0.04 VFD 5.3 vs 6.4, p=0.03 Pneumothorax 3.2% vs1.2% , p=0.001 JAMA. 2017; 318(14): 1335–45

  35. Non-recruiter Recruiter Higher PEEP strategy frequently fails to induce alveolar recruitment and may increase the risk of alveolar overinflation. Am J RespirCrit Care Med. 2005 May 1;171(9):1002

  36. Recruitability Lower Percentage of Potentially Recruitable Lung Higher Percentage of Potentially Recruitable Lung 5 cm of water 5 cm of water 45 cm of water 45 cm of water In ARDS, the percentage of potentially recruitable lung is extremely variable and is strongly associated with the response to PEEP. N Engl J Med 2006;354:1775-86

  37. how to set it at the individual level • Transpulmonary pressure and esophageal balloon manometry no outcomes evidence • Set PEEP to keep TPP around 0-10 cmH2O at end-expiration. • Set VT or driving pressure to keep TPP no greater than  25 cmH2O at end-inspiration

  38. Electrical impedance tomography no outcomes evidence

  39. Individualized approach for RM PF ratio <200 with PEEP 5 PEEP response? PF ratio↑ ≥20% PaCO2 stable (10% margin) Crs stable (10% margin) PEEP responder PEEP non-responder No recruitment LPV+other rescue Recruitment – higher PEEP △P <12 PNUYH protocol

  40. HFOV (High frequency oscillatory ventilation) Sustaining high mPaw Overdistensioninjury Atelectasis injury

  41. Perfect scenario, but.. Nobenefit N Engl J Med 2013; 368:795-805 N Engl J Med 2013; 368:806-813

  42. APRV (Airway pressure release ventilation) 80-95% overdistension • Long I time strategies atelectasis Ann Thorac Med. 2007; 2(4): 176–179

  43. autopeep & TV creep Incomplete emptying (autoPEEP) Crit Care Med 2005 Vol. 33, No. 3

  44. great idea, little evidence Intensive Care Med. 2017; 43(11): 1648–59

  45. Selectivepulmonary vasodilators Funtioning alveoli Inhaled NO - No outcome benefit, Renal failure Inhaled prostacyclin -No benefit (mortality, PF ratio) Cochrane Database Syst Rev.2017;7:CD007733 Cochrane Database Syst Rev.2016;(6):CD002787.

  46. Take Home Message • Early detection • Low tidal volume shortly after ARDS onset • Paralyze the patient in early period(<48h) • Protect baby lung - how much lower tidal volume? • driving pressure • ECCO2R ? • Make the lung homogenous • Prone • Recruitment according to PEEP response

  47. Simply Pressure and volume limited MV Optimal sedation/analgesia Still hypoxemic? PF < 150 Higher PEEP Neuromuscular blockade Profound hypoxemia PF <60 Contraindication to proning Still hypoxemic? PF<100 No contraindication to proning? Prone positioning Still hypoxemic? PF<100 No improvement/complication during proning? ECMO PNUYH protocol

  48. It’s not easy but it’s worth it

  49. Thank you for your attention

More Related