Noninvasive Mechanical Noninvasive Mechanical Ventilation,Prone Ventilation,Prone

position, surfactant and position, surfactant and NONO

Gül GürselGül GürselGazi University School of Gazi University School of

Medicine, ICU of Department of Medicine, ICU of Department of Pulmonary DiseasesPulmonary Diseases

The use of a low-tidal volume(6ml/kg The use of a low-tidal volume(6ml/kg predicted body weight), plateau pressure-predicted body weight), plateau pressure-limited strategy has been demonstrated to limited strategy has been demonstrated to reduce mortality from 40 to 31%.reduce mortality from 40 to 31%.

Is there a role for NIMV in ARDS?Is there a role for NIMV in ARDS?Impact of fluid and catheter strategy on Impact of fluid and catheter strategy on

outcome.outcome.What is the role of prone position?What is the role of prone position?Pharmacologic therapies??Pharmacologic therapies??

CorticosteroidsCorticosteroidsSurfactantSurfactantNONO

Is there a role for NIMV in ARDS? A meta-Is there a role for NIMV in ARDS? A meta-analysisanalysis

StudyStudy VentilatorVentilator ModModee

InterfacInterfacee

Pressure Pressure rangerange

Antonelli et alAntonelli et al

1 center, 15 solid 1 center, 15 solid organ transplant organ transplant ptnsptnsJAMA 2000; 283:235JAMA 2000; 283:235

ICUICU BiPABiPAPP

FFMFFM IPAP: 14-IPAP: 14-2020

EPAP: 5-10EPAP: 5-10

Delclaux et alDelclaux et al

6 center, 81 ptns, 6 center, 81 ptns, heterogeneousheterogeneousJAMA 2000;284-JAMA 2000;284-23522352

Non-Non-conventionconventionalal

CPAPCPAP FFMFFM 7.5-107.5-10

Ferrer et alFerrer et al

1 center, 15 1 center, 15 heterogeneous heterogeneous ptnsptnsAJRCCM AJRCCM 2003;168:1438-442003;168:1438-44

Non-Non-conventionconventionalal

BiPABiPAPP

FFMFFM

Nasal Nasal maskmask

IPAP: 10-IPAP: 10-2424

EPAP: 4-12EPAP: 4-12

Agarval et al Resp Med 2006

The addition of NIMV to standard care The addition of NIMV to standard care in the setting of ARDS did not reduce in the setting of ARDS did not reduce the rate of endotracheal intubation and the rate of endotracheal intubation and had no effect on ICU survivalhad no effect on ICU survival

Exclusion criteriaExclusion criteria

►Coma, seizures or nerological Coma, seizures or nerological disturbancesdisturbances

►Hemodynamic or ECG instabilityHemodynamic or ECG instability►Active bleedingActive bleeding►Need for endotracheal intubation Need for endotracheal intubation

(secretions, to protect airways)(secretions, to protect airways)►Recent facial trauma, Recent facial trauma,

gastroesophageal surgerygastroesophageal surgery►More than 2 organ failuresMore than 2 organ failures

► During the 25 monthsDuring the 25 months

► 5888 patients were admitted to the ICUs of 5888 patients were admitted to the ICUs of the 3 centersthe 3 centers

► 459(8%) met ARDS criteria459(8%) met ARDS criteria

► 332(69%) were admitted as intubated or 332(69%) were admitted as intubated or required immediate intubationrequired immediate intubation

► 147(31%) were eligible for study participation 147(31%) were eligible for study participation and received NIMVand received NIMV 69 primary ARDS69 primary ARDS 78 secondary ARDS78 secondary ARDS

► <31% of patients with ARDS are treated with NPPV.<31% of patients with ARDS are treated with NPPV.

► NIMV was succesful in avoiding intubation in 79 NIMV was succesful in avoiding intubation in 79 (%54)(%54) patients. patients.

► Avoidance of intubation was associated with a lower Avoidance of intubation was associated with a lower insidence of septic complications and increased ICU insidence of septic complications and increased ICU survival.survival.

► SAPSII>34 and a PaO2/FiO2<175 after 1 hr of NIMVSAPSII>34 and a PaO2/FiO2<175 after 1 hr of NIMV were independently associated with the need for were independently associated with the need for endotracheal intubation.endotracheal intubation.

Changes in P/F over time in patients avoided Changes in P/F over time in patients avoided or required intubationor required intubation

35% 48%

Timing to endotracheal intubation. 70% of NIMV failures were intubated within 48 hrs of initiating NIMV

Risk Factors for NIMV FailureRisk Factors for NIMV Failureobservational cohort studyobservational cohort study

► 54 patients with ARDS54 patients with ARDS► 38(70.3%) failed, among them all 19 38(70.3%) failed, among them all 19

patients with shockpatients with shock► In logistic regression restricted to patients In logistic regression restricted to patients

without shockwithout shock►Metabolic acidosis (OR:1.27, 95%CI:1.03-0.07 Metabolic acidosis (OR:1.27, 95%CI:1.03-0.07

per U of BD)per U of BD)►Severe hypoxemia(OR:1.03, 95%CI:1.01-0.05, Severe hypoxemia(OR:1.03, 95%CI:1.01-0.05,

per U decrease in p/f)per U decrease in p/f)

Rana S et al, CC 2006;10(3)R79

AIMAIM

►To evaluate the effects of various To evaluate the effects of various NIMV settings on NIMV settings on

►DyspneaDyspnea►respiratory mechanicsrespiratory mechanics

►Work of breathingWork of breathing►Respiratory driveRespiratory drive

►arterial blood gases in patients with arterial blood gases in patients with ALIALI

Dyspne score assessmentDyspne score assessment

► Both PSV settings reduced neuromuscular Both PSV settings reduced neuromuscular drive, unloaded the inspiratory muscles, drive, unloaded the inspiratory muscles, and improved dyspneaand improved dyspnea

► CPAP used alone was unable to reduce CPAP used alone was unable to reduce inspiratory effortinspiratory effort

► A PEEP level of 10 cmHA PEEP level of 10 cmH22O improved O improved oxygenation compared with initial/final oxygenation compared with initial/final baseline and with PEEP 5 cmHbaseline and with PEEP 5 cmH22OO

► The geatest improvement in dyspnea was The geatest improvement in dyspnea was obtained with the highest level of PSVobtained with the highest level of PSV

Prone PositionProne Position

► Proning improves oxygenation in 70% Proning improves oxygenation in 70% of ARDS patients.of ARDS patients.

PRONE POSITIONPRONE POSITION

► Effect of prone position in ARDSEffect of prone position in ARDS

Reduction in shuntReduction in shunt Perfusion is preferentially directed to dorsal lung Perfusion is preferentially directed to dorsal lung

regions regions The gravitational pleural pressure gradient is The gravitational pleural pressure gradient is

more uniformmore uniform Pleural pressure is reduced in dependent regionsPleural pressure is reduced in dependent regions The regional ventilation/perfusion ratio is more The regional ventilation/perfusion ratio is more

uniform and better matcheduniform and better matched Improved airway drainageImproved airway drainage Improved lymphatic drainageImproved lymphatic drainage

http://ajrccm.atsjournals.org/content/vol164/issue9/images/large/RCCM2103121.f6.jpeg

Randomized controlled trials evaluating prone Randomized controlled trials evaluating prone positioning in ARDSpositioning in ARDS

StudyStudy Patients Patients nono

InterventioInterventionn

Mortality Mortality rates (%)rates (%)

pp

Gattinoni et Gattinoni et al al 11

304304 6h/d for 6h/d for 10d10d

63 & 5963 & 59 0.650.65

Guerin et al Guerin et al 22 791791 8 h/d8 h/d 32 & 3232 & 32 0.770.77

Mancebo et al Mancebo et al 33

136136 20h/d20h/d 50 & 6250 & 62 0.220.22

1- N Eng J Med 2001;345:568-5732- JAMA 2004;292:2379-23873- Am J Respir Crit Care Med 2006;173:1233-1239

Effectes of the prone position Effectes of the prone position on ventilator induced lung on ventilator induced lung

injuryinjury► Authors measured lung stress as the Authors measured lung stress as the

transpulmonary plateau pressure and lung transpulmonary plateau pressure and lung strain as tidal volume/EELV ratio and found strain as tidal volume/EELV ratio and found both of them were reduced with the prone both of them were reduced with the prone position.position.

► The probabbility of VALI can be reduced by The probabbility of VALI can be reduced by the prone positionthe prone position

► Mentzelopoulos SD, et al Eur Respir J 2005; 25:534-544Mentzelopoulos SD, et al Eur Respir J 2005; 25:534-544

Am J Respir Crit Care Med 2006;173:1233-1239

► Despite leading to short-term improvements in Despite leading to short-term improvements in oxygenetation, prone positioning during MV has oxygenetation, prone positioning during MV has failed to improve mortality rates in multiple failed to improve mortality rates in multiple randomized controlled trials and can not be randomized controlled trials and can not be recommended for the broad population of recommended for the broad population of patients requiring MV due to ARDS. However for patients requiring MV due to ARDS. However for those patients who has severe persistent those patients who has severe persistent hypoxemia PP may be considered as a rescue hypoxemia PP may be considered as a rescue therapy. therapy.

FLUID MANAGEMENTFLUID MANAGEMENT

► Pulmonary edema, even when noncardiogenic in Pulmonary edema, even when noncardiogenic in origin, increases with a rise in hydrostatic pressures.origin, increases with a rise in hydrostatic pressures.

► A modest decrease in pulmonary vascular pressure A modest decrease in pulmonary vascular pressure could reduce the quantitiy of pulmonary edema in could reduce the quantitiy of pulmonary edema in experimental studies.experimental studies.

► Increased EVLW has been associated with poor Increased EVLW has been associated with poor outcome in ARDS patients.outcome in ARDS patients.

► Balancing the risks of increased edema vs those of Balancing the risks of increased edema vs those of decrease vital organ perfusion with a lower decrease vital organ perfusion with a lower intravascular pressure has remained difficult.intravascular pressure has remained difficult.

Calfee CS et al Chest 2007; 131:913-920

►NHLBI FACTT Fluid And Catheter NHLBI FACTT Fluid And Catheter Treatment Trial. Treatment Trial. N Eng J Med 2006; N Eng J Med 2006; 354:2564-75354:2564-75

Utility of catheterization with a CVC vs Utility of catheterization with a CVC vs PACPAC

Liberal fluid management vs conservative Liberal fluid management vs conservative fluid managementfluid management

► Mortality RateMortality Rate► PAC group 27.4%; CVC group, 26.3; p=0.69; PAC group 27.4%; CVC group, 26.3; p=0.69;

95% CI for difference -4.4 to 6.6%)95% CI for difference -4.4 to 6.6%)► Conservative fluid management armsConservative fluid management arms

Had significantly more ventilator free daysHad significantly more ventilator free days More significant improvements in pulmonary More significant improvements in pulmonary

physiologyphysiology►PEEP, Pplat, PaO2/FiO2, oxygenation index, lung injury PEEP, Pplat, PaO2/FiO2, oxygenation index, lung injury

scorescore More ICU free daysMore ICU free days 2.9% reduction in the 60-day mortality 2.9% reduction in the 60-day mortality

rate(p:0.30)rate(p:0.30) No difference in incidence or prevalance of shock No difference in incidence or prevalance of shock

or RRTor RRT

SURFACTANT THERAPYSURFACTANT THERAPY

Spragg RG, et al. N Eng J Med 2004; 351:890

INHALED NOINHALED NO

►Selective pulmonary vasodilation and Selective pulmonary vasodilation and improvement ventilation-perfusion improvement ventilation-perfusion mismatchmismatch

Pharmacotherapies investigated as Pharmacotherapies investigated as possible treatment for ALI/ARDSpossible treatment for ALI/ARDS

TherapyTherapy OutcomesOutcomes ReferencesReferences

SurfactantSurfactant No significant No significant mortality mortality benefit(Adult)benefit(Adult)

AJRCCM 2003;167:1562-6AJRCCM 2003;167:1562-6

N Engl J Med 2004;351:884-N Engl J Med 2004;351:884-892892

NONO Improves oxygenation Improves oxygenation but no mortality but no mortality benefitbenefit

JAMA 2004;291:1603-9JAMA 2004;291:1603-9

CS(TherapeutiCS(Therapeutic)c)

No mortality benefit; No mortality benefit; may increase risk in may increase risk in patients with ARDS of patients with ARDS of >14 day duration>14 day duration

N Engl J Med N Engl J Med 2006;354:1671-842006;354:1671-84

CONCLUSIONCONCLUSION► 30% of ARDS patients may benefited from 30% of ARDS patients may benefited from

NIMVNIMV

► Conservative fluid management strategy Conservative fluid management strategy may increase ventilator-free days, CVC or may increase ventilator-free days, CVC or PAC does not influence outcomePAC does not influence outcome

► Prone position may be useful in as rescue Prone position may be useful in as rescue therapy in a patient with severe hypoxemia therapy in a patient with severe hypoxemia but does not improve survivalbut does not improve survival

► Corticosteroids, surfactant and NO are Corticosteroids, surfactant and NO are ineffective in improving outcomes.ineffective in improving outcomes.