2012 Pelosi

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[email protected]

Department of Surgical Sciences and

Integrated Diagnostics (DISC)

University of Genoa, Italy

Lung Recruitment in

ALI/ARDS

JRUR, Marseille, France, 2012

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AGENDA

• ARDS: principles of treatment

• Recruitment in ARDS:

- The rationale

- Experimental data

- “New” recruitment maneuvres

• Clinical data

• Recruitment and prone position

• How to set PEEP after Recruitment

• Conclusions

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Superimposed Pressure

Opening Pressure

Normal 0

Alveolar Collapse (Reabsorption) 20-30 cmH2O

Small Airway Collapse

10-20 cmH2O

Consolidation

The ARDS Lung

Rouby Intensive Care Med 2000

Gattinoni JAMA 1993, Pelosi AJRCCM 1994, Gattinoni AJRCCM 2002, Gattinoni ICM 2005

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x g x h

P = 5 cmH2O P = 10 cmH2O

LESS EDEMA-ATELECTASIS

LOWER PEEP – LOWER MORTALITY

HIGHER EDEMA-ATELECTASIS

HIGHER PEEP – HIGHER MORTALITY

EDEMA – ATELECTASIS IN ALI/ARDS

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Mild Moderate Severe

TimingAcute onset within 1 week of a known clinical insult or new/worsening

respiratory symptoms

Hypoxemia PaO2/FiO2 201-300with PEEP/CPAP 5

PaO2/FiO2 200 withPEEP 5

PaO2/FiO2 100 withPEEP 10

Origin of EdemaRespiratory failure not fully explained by cardiac failure or fluid

overload**

RadiologicalAbnormalities

Bilateral opacities* Bilateral opacities*Opacities involving at

least 3 quadrants*

AdditionalPhysiologicalDerangement

N/A N/AVE Corr > 10 L/min

orCRS<40 ml/cmH2O

*Not fully explained by effusions, nodules, masses, or lobar/lung collapse; use training set of CXRs

**Need objective assessment if no risk factor present (See table)VE Corr = VE x PaCO2/40

ARDS

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300 250 200 150 100 50

Low Tidal Volume Ventilation

Higher PEEP

HFO

Prone Positioning

ECMO

Low – Moderate PEEP

NeuromuscularBlockade

PaO2 /FiO2

Increasing Severity of Lung Injury

Mild ARDS Moderate ARDS Severe ARDS

I n c r e a s i n g

I n

t e n s i t y

o f I n t e r v e n t i o n

NIV

ECCO2-R

iNO

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Mechanical Ventilation of Sepsis-Induced AcuteRespiratory Distress Syndrome (ARDS)

We suggest recruitment maneuvers inpatients with severe refractory

hypoxemia (Grade 2C).

SURVIVING SEPSIS CAMPAIGN GUIDELINES

2012

R. Phillip Dellinger and Rui MorenoOn behalf of the SSC Committee (SCCM-ESICM)

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AGENDA



- The rationale

- Experimental data


• Clinical data



• Conclusions

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The concept of PEEP and Recruitment

optimal-PEEP

recruited vol.

Pelosi P, De Abreu G, Rocco PR Crit Care. 2010 Mar 9;14(2):210.

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Recruitment in ALI/ARDS ?

WHY NOT ?

• Improves oxygenation• Improves respiratory mechanics

• Increases lung volume/reduces atelectasis• Not associated with major adverse effects

• Before PEEP setting

•After dysconnection from MV or suctioning

• Rescue maneuvre

WHEN ?

Pelosi P, De Abreu G, Rocco PR Crit Care. 2010 Mar 9;14(2):210.

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ICM 2003,29:218

CCM 2001, 1255: 1260

45%

23%

20%

Fan E et al. Am J Respir Crit Care Med Vol 178. pp 1156–1163, 2008

Recruitment Maneuvers for Acute Lung Injury:

A Systematic Review

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AGENDA



- The rationale

- Experimental data


• Clinical data



• Conclusions

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Santiago VR et al Crit Care Med. 2010 Nov;38(11):2207-14.

Recruitment maneuver in experimental acute lung

injury: the role of alveolar collapse and edema

ALI-M with the same alveolar collapse

but less edema compared to ALI-S

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Silva PL et al. Critical Care 2010, 14:R114

Hypervolemia induces and potentiates lung damage

after RM in a model of sepsis-induced ALI

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Effects of pressure profile and duration of RM on lung morpho-

functional and biological impact in experimental lung injury

Silva Pl et al Crit Care Med. 2011 May;39(5):1074-81.

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AGENDA



- The rationale

- Experimental data


• Clinical data



• Conclusions

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“New” recruitment Maneuvres:

Assisted VentilationSigh

Variable Ventilation

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Ventilator Induced Lung Injury Spieth P et al. Crit Care Med. 2011 Apr;39(4):746-55

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Effects of frequency and inspiratory plateau

pressure during recruitment manoeuvres

on lung and distal organs in acute lung injurySteimback PW et al Intensive Care Med 35:1120-1128, 2009

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16 ml/kgVolutrauma

1,6 ml/kgAtelectrauma

S

h e a r s t r e s s

B i o t r a u m a

Variable VTs improve different lung protective ventilation

strategies in experimental ALISpieth PM et al Am J Respir Crit Care Med 2009 15;179(8):684-93

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Variable VTs improve different lung protective ventilation

strategies in experimental ALISpieth PM et al Am J Respir Crit Care Med 2009 15;179(8):684-93

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AGENDA



- The rationale

- Experimental data


• Clinical data



• Conclusions

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Recruitment Maneuvers for Acute Lung Injury:

A Systematic ReviewFan E et al. Am J Respir Crit Care Med Vol 178. pp 1156–1163, 2008

Hypotension

Desaturation

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Respiratory and hemodynamic changes during

decremental open lung PEEP titration in ARDSGernoth W et al Critical Care 2009, 13:R59; Epub 2009 Apr 17

Right ventricular Tei index [%]

39±1142±10

36±11

BeforeDuring RM

After

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Non recruiter

0

2

4

6

8

10

12

14

Weight (grams)

Peep 5 cmH2O

Paw 45cmH2O

Peep 5 cmH2O

Paw 45cmH2O Gattinoni et al NEJM 2006, 354(17):1775-86

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Paw 45cmH2O

Recruiter

Peep 5 cmH2O

Weight (grams)

0

10

20

30

40

50

60

Peep 5 cmH2O

Paw 45cmH2O

Gattinoni et al NEJM 2006, 354(17):1775-86

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potential for lung recruitment [% total lung weight]

F r e q u e n c y

[ n o . o

f p a t i e n t s ]

0

2

4

6

8

10

1214

16

18

20

22

24

ALI patients

ARDS patients

higher

21 ± 10%

(374 ± 236 grams)

lower

5 ± 4%

(59 ± 51 grams)

Potential for lung recruitment


R it t i f ti f l i ht

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Recruitment is a function of lung weight

Potential for recruitment [% total lung weight] -10 0 10 20 30 40 50 60 70

[ % t o

t a l l u n g w e i g h t ]

-5 0 5

10 15 20 25 30 35


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Mortality at ICU-discharge

mortality

[%]

quartiles of potential for lung recruitment 1st 0

10 20 30 40 50 60

lower-

potential

2nd 3rd 4th 17

n =

17

17

17

higher-

potential

P=0.006


H l i th l it bilit i l ARDS

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How large is the lung recruitability in early ARDS: a

prospective case series of patients monitored by CT

De Matos GFJ et al Critical Care 2012, 16:R4

- Less than 72 hours onset

- PaO2/FIO2 < 200, with PEEP 10 cmH2O, FIO2 of 1.0 and pressure-controlled

ventilation with driving pressure set at 15 cmH2O

Ho large is the l ng recr itabilit in earl ARDS a

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Optimal duration of a sustained inflation recruitment

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Arnal JM et al Intensive Care Med (2011) 37:1588–1594


maneuver in ARDS patients


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Arnal JM et al Intensive Care Med (2011) 37:1588–1594


maneuver in ARDS patients

A 10-s sustained inflation RM maybe recommended to achieve a plateau in the volume

recruited and to prevent hemodynamic compromise

Prolonged moderate pressure recruitment manoeuvre

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results in lower optimal PEEP and plateau pressure

Lowhagen K et al Acta Anaesthesiol Scand 2011; 55: 175–184


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results in lower optimal PEEP and plateau pressure

Lowhagen K et al Acta Anaesthesiol Scand 2011; 55: 175–184

Randomised controlled trial of an open lung strategy with

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p g gy

staircase recruitment, titrated PEEP and targeted low airway

pressures in patients with ARDSHodgson et al. Critical Care 2011, 15:R133


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p g gy




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p g gy



Clinical efficacy and safety of recruitment maneuver in patients

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with acute respiratory distress syndrome using low tidal volume

ventilation: a multicenter randomized controlled clinical trial

Xiu-Mimg XI et al Chin Med J 2010;123(21):3100-3105

Clinical efficacy and safety of recruitment maneuver in patients

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with acute respiratory distress syndrome using low tidal volume

ventilation: a multicenter randomized controlled clinical trial

Xiu-Mimg XI et al Chin Med J 2010;123(21):3100-3105

AND Less organ failure at day 28th

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AGENDA

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AGENDA



- The rationale

- Experimental data


• Clinical data



• Conclusions

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Focal loss of areation Diffuse loss of areation

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SUPINE AFTER 12H PRONE

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Lung

recruitment:

No more non

aerated zones

Lung

recruitment:

More normally

aerated zones

Non

AeratedNon

Aerated

Aerated

Hyperinflation Hyperinflation

Nougaret et al, in progress

Sigh in supine and prone during ARDS

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g p p gPelosi P et al Am J Respir Crit Care Med 2003; 167: 521-527

Prone position and recruitment manoeuvre: the

bi d ff t i ti

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combined effect improves oxygenationRival G et al. Critical Care 2011, 15:R125


bi d ff t i ti

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combined effect improves oxygenation

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Prone position: CO2 and Survival

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Gattinoni et al Crit Care Med 2003;31:2727

AGENDA

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- The rationale

- Experimental data


• Clinical data



• Conclusions

Oxygenation and collapsed tissue

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Borges et al Am J Respir Crit Care Med 174; 268-278, 2006

PaO2 / FiO2 < 150

at PEEP 5 cmH2O

Assessment of Pulmonary Morphology in ALI

Absence of Lower Inflection Point in the P-V Curve

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Vieira et al. Am J Resp Crit Care Med 1999; 159:1612-1623.

Overdistension

Assessment of Pulmonary Morphology in ALI

Significance of Lower Inflection Point in the P-V Curve

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gVieira et al. Am J Resp Crit Care Med 1999; 159:1612-1623.

Overdistension

Elastance to titrate PEEP in ALI/ARDS C lh AR P l i P l I i C M d 2008 D 34(12) 2291 9

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Carvalho AR, Pelosi P et al. Intensive Care Med. 2008 Dec;34(12):2291-9

The stress index: is it useful to set TV ?Fanelli V et al Crit Care Med 2009 Mar;37(3):1046-53

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Fanelli V et al Crit Care Med. 2009 Mar;37(3):1046-53.

Grasso S et al Crit Care Med. 2004 Apr;32(4):1018-27Ranieri VM et al. Am J Respir Crit Care Med. 1994 Jan;149(1):19-27

PEEP-induced changes in lung volume in ARDS.

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Two methods to estimate alveolar recruitmentDellamonica J et al Intensive Care Med (2011) 37:1595–1604

Probes

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Réanimation Polyvalente, Hôpital Pitié-Salpêtrière, Université Paris 6

Probe 5-10 MHz Lung

periphery

Probe 4-5 MHz

Deep Lung

Curvilinear

probe

15 11 2008

Phased array probe 3 MHz

Hemodynamic monitoring

Convex probe 3.5 MHz

Lung and hemodynamicapplications

Linear probe 7.5 MHz

vascular application

Image quality

1 to 17 cm

Lung imaging for titration of mechanical ventilation

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The role of lung ultrasoundLuecke T, Corradi F, Pelosi P Curr Opinion in Anaesthesiology, 2011 ( Ahead of Print)

Lung imaging for titration of mechanical ventilation

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The role of lung ultrasoundLuecke T, Corradi F, Pelosi P Curr Opinion in Anaesthesiology, 2011 ( Ahead of Print)

Peep 5 cmH2O Peep 5 cmH2O

Bedside Ultrasound Assessment of

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PEEP–induced Lung RecruitmentBouhemad B et al. Am J Respir Crit Care Med 183: 341–347, 2011

LUNG ULTRASOUND PROTOCOL

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Pelosi P, Corradi F Anesthesiology 2012 ( Ahead of Print)

How to perform a PEEP trial

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Time

5

10

15

20

25

30

35

40

P r e s s u r e ( c m H 2 O )

5 min 1-2 min 5-10 min per step

in most severe ARDS patients ?

PEEP to achieve

the “ best” Cst,rsVT 6 ml/Kg IBW

Pelosi P, Abreu GM, Rocco PR Crit Care 2010; 14(2):210.

How to perform a PEEP trial

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in most severe ARDS patients ?

Maximal PEEP to achieveVT 6 ml/Kg IBW,

with Pplat,rs = 30-27 cmH2O

Time

5

10

15

20

25

30

35

40

P r e s s u r e ( c m H 2 O )

5 min 1-2 min 5-10 min per step

Pelosi P, Abreu GM, Rocco PR Crit Care 2010; 14(2):210.

AGENDA

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- The rationale

- Experimental data


• Clinical data

• Recruitment and prone position• How to set PEEP after Recruitment

•

Conclusions

Use of computed tomography scanning to guide lung

recruitment and adjust PEEP in ALI/ARDS

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Pelosi P. et al. Curr Opin Crit Care. 2011 Jun;17(3):268-74

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Thanks

Royal Library, British Museum, London, UK

2012 Pelosi

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