Optimizing Driving Pressure (ΔP) · Tidal Volume Respiratory Rate PEEP Static (PEEP component)...
Transcript of Optimizing Driving Pressure (ΔP) · Tidal Volume Respiratory Rate PEEP Static (PEEP component)...
Optimizing Driving Pressure (ΔP) :
( Is Power relevant...? )
Marcelo B. P. Amato
University of São Paulo, Brazil
Toronto, November, 2018
I disclose the following financial relationships (all happening in the
last 5 years) with commercial entities that produce healthcare-
related products or services, relevant to the content I am
presenting:
Company Relationship Content Area
Medtronics Consultant Mechanical Ventilation
Orange Med Consultant Mechanical Ventilation
Philips / Dixtal Research grants E.I.T.
Timpel S.A. Research grants, minority shares E.I.T.
Conflict of Interest Disclosure
Marcelo B.P. Amato
0
0
Time
PA
ΔP
Volume control
Zero Flow
Pre
ssure
( cm
H2O
)F
low
(
L /
se
c)
VSET
Relative Risk of Death in the Hospital versus ΔP in the Combined Cohort after Multivariate Adjustment.
Amato MBP et al. N Engl J Med 2015;372:747-755
Figure 2b : Combined population of ARDS ( N = 3080 )
*: adjusted for age, APACHE/SAPS risk, arterial-pH, P/F ratio , and study-trial
low
-PP
PLA
T &
low
-DP
hig
h-P
PP
LA
T &
low
-DP
low
-PP
PLA
T &
hig
h-D
P
hig
h-P
PP
LA
T &
hig
h-D
P
Y D
ata
0.5
0.7
1.0
1.4
2.0
∆P ≤ 14 ∆P >14
PPLAT ≥ 30 PPLAT ≥ 30PPLAT < 30PPLAT < 30
P < 0.01
P < 0.001
P = 0.92
Mo
rtal
ity
ris
k (
adju
sted
*)
*: adjusted for study-trial, age, APACHE/SAPS risk, arterial-pH, P/F ratio
(N = 529)
(N = 882)
(N = 260)
(N = 1406)
Figure-2b
?@
? ?30
Worse!
Better!
P11P P12P P13PP11A P12A P13AGROUPS
Methods
P16A P15P
SHAM VILI(3-4 hours)
P16A
ARDSNET – after 48 hs OLA – after 48 hs
P11P P12P
P15P
P11A
P14A
vs.
2nd PET
Sagital
Coronal
Axial
Slice ViewHigh PEEP Group
2nd PET
Low PEEP Group
0.022
Ki (m
in-1
)
0.000
18F-FDG
uptake scale
PLATOOLA VS ARDSNET
TEMPO
BASAL POS VILI 0h 6h 12h 24h 36h FINAL
cm
H2
O
0
10
20
30
40
50 ARDSNET
OLA
Plateau Pressure
VILI
Extreme CyclicStress
Same Maximal
Stress !
DELTA DE PRESSÃOOLA VS ARDSNET
TEMPO
BASAL POS VILI 0h 6h 12h 24h 36h FINAL
cm
H2O
0
10
20
30
40
50ARDSNET
OLA
Driving Pressure
VILI
High
Cyclic Stress
Low Stress
Extreme CyclicStress
Anterior.
Posterior
RN
A co
llag
en
typ
e I
control VILI VILI +40hs prot.
P < 0.001
VILI +40hs OLALow Cyclic
StressHigh Cyclic
Stress
Before
1 monthafter ARDS
6 monthsafter ARDS
Toufen et al - submitted to ICM 2018
Risk factors for low FVC at 6 months
Driving pressure (cmH2O)
Vita
l c
ap
acity
-6 m
onth
s
Toufen et al - submitted to ICM 2018
∆P < 13 cmH2O(n = 9)
∆P ≥ 13 cmH2O(n = 9)
Toufen et al - submitted to ICM 2018
Anesthesia
Left-Lung
Ventilation
VT = 6 mL/kg
PPLAT = 29 cmH2O
PEEP = 0 cmH2O
P = 29 cmH2O !!!!!
Gattinoni et al. 2016
Anesthesiology 2016
DynamicStatic
vs.
dissipated
Amato et al.
1998
(N = 53)
Brochard et al.
Brower et al.
Stewart et al.
1998-1999
(N = 288)
ARDSnet2000
(N = 861)
Alveoli2004
(N = 545)
ExpressLOVSTalmor et al.
2008
(N = 1811)
TOTAL2013
(N = 3562)
time1998 2012
Plateau Pressure
Relative Risk
0.75 1.00 1.25 1.50 1.75
1.08 [1.00-1.17]
1.33 [1.24-1.43]Driving Pressure
Tidal Volume
Respiratory Rate
PEEP
1.16 [1.09-1.24]POWER
UNIVARIATE
Plateau Pressure
Relative Risk
0.75 1.00 1.25 1.50 1.75
1.08 [1.00-1.17]
1.33 [1.24-1.43]
Plateau Pressure
Driving Pressure
Tidal Volume
Respiratory Rate
PEEP
MULTIVARIATE
POWER
Plateau Pressure
Relative Risk
0.75 1.00 1.25 1.50 1.75
1.08 [1.00-1.17]
1.33 [1.24-1.43]
Plateau Pressure
Driving Pressure
Tidal Volume
Respiratory Rate
PEEP
Static (PEEP component)
Dynamic (dynamic component)
P < 0.001 P = 0.178
5XN = 3562 Pts.
Is it worth to decrease VT or P by 20%,
at the expense of increasing RR by 20%?
Animal experiment: pigs with ARDS
randomization
6 mL/kg
RR = 28
4.5 mL/kg
RR = 80
Power = 15 J/min Power = 30 J/min
∆P ≥ 13
Power = 15 J/min
Low frequency - higher VT
∆P < 13
Power = 30 J/min
Higher frequency - lower VT
Is it worth to decrease VT or P by 20%,
at the expense of increasing RR by 20%?
YES !and forget about power !
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
Ris
k of V
ILI
N = 3562 Pts.
5XN = 3562 Pts.
1. Power calculations do not add relevant
information
2. Better use Driving Pressure only
3. Increasing Respiratory rate may be dangerous
4. But Less dangerous than increasing P
4. Each patient has an optimum RR in which
P is minimized with minimum risks
5. This ideal RR is usually above 30
breaths/min
Thank you!!!!
keeping constant Alveolar Ventilation...
Respiratory Rate
Tid
al V
olu
me
∞
Dead Space
VA = RR x ( VT – VD )
keeping constant Alveolar Ventilation...
Respiratory Rate
Drivin
g
Pre
ssu
re
∞
Minimum P
VA = RR x ( VT – VD )
keeping constant Alveolar Ventilation...
Respiratory Rate
RR
re
late
d d
am
ag
e
∞
keeping constant Alveolar Ventilation...
Respiratory Rate
Tid
al V
olu
me
∞
Dead Space
VA = RR x ( VT – VD )
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
Ris
k of V
ILI
Reducing P∆P = constant,
but RR increases !
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
VT / VD
?
Ris
k of V
ILI
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
VT / VD
Ris
k of V
ILI
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
VT / VD
Ris
k of V
ILI
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
VT / VD
60 ?
Ris
k of V
ILI
Methods
• Target: PaCO2 of 57 – 63 mmHg
– PEEP: ARDSnet PEEP table
– MODE: VCV square wave flow
81
* = P < 0.05 vs VT = 6 mL/kg
7.5
Tid
al V
olu
me
( m
L / k
g )
6.1
5.24.6
4.3
3.8
2.8
I____I
14
22
15 1312
13
Drivin
g
pre
ssure
(c
mH
2O
)
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
VT / VD
60 ?
Ris
k of V
ILI
Thank you!!!!
A B C
Lun
g V
olu
me
Airway Pressure
PPLATPEEP PPeak
EELV
VT
A = Static / PEEP componentB = Dynamic / Elastic componentC = Resistive component
Model E
Model D
P = 0.089 P = 0.369 P < 0.001
P < 0.001 P = 0.178
P or PL ?
( PAW - Pesoph )
Transpulmonary Driving Pressure (∆PL)
Airw
ay
Drivin
g P
ressure
(∆
P)
Thank you!!!!
Mental Experiment….( Einstein’s elevator )
Effects of Gravity on the space around:
PPLAT = 14
PEEP = 0
PPLAT = 45
PEEP = 10
PPLAT = 45
PEEP = 0
Webb & Tierney 1974; Am Rev Respir Dis;110:556
N = 3080
?
N = 3080
?
How much you are concerned?
Situation 1:
VT = 8.2 mL/kg
PPLAT = 22 cmH2O
PEEP = 10 cmH2O
Situation 2:
VT = 6.0 mL/kg
PPLAT = 28 cmH2O
PEEP = 5 cmH2O
X
A Quasi-Experimental, Before-After Trial Examining the Impact of an Emergency
Department Mechanical Ventilator Protocol on Clinical Outcomes and Lung-Protective
Ventilation in Acute Respiratory Distress Syndrome.
Critical care medicine, Feb 2017
Brian M Fuller; Ian T Ferguson; and 11 more
DOI: 10.1097/CCM.0000000000002268
P = 12 cmH2O P = 23 cmH2O !!!!
Relative Risk of Death in the Hospital versus ΔP in the Combined Cohort after Multivariate Adjustment.
Amato MBP et al. N Engl J Med 2015;372:747-755
Transpulmonary Driving Pressure (∆PL)
Airw
ay
Drivin
g P
ressure
(∆
P)
Patients submitted to risky anesthesia ( N =1783)
*: adjusted for age, APACHE/SAPS risk, arterial-pH, P/F ratio , and study-trial
JAMA. 2016;315(8):788-800
Epidemiology, Patterns of Care, and
Mortality for Patients With Acute
Respiratory Distress Syndrome in
Intensive Care Units in 50 Countries
N = 12.906
Relative Risk of Death in the Hospital versus ΔP in the Combined Cohort after Multivariate Adjustment.
Amato MBP et al. N Engl J Med 2015;372:747-755
Spontaneous effort ‘magnify’ overall PL
….And the same happens with ∆P
PL = Pplat – Ppl
PL : transpulmonary pressure
PAO : alveolar pressure
Ppl : pleural pressure
PL = 30 – (+8)
PL : transpulmonary pressure
= 22
PL = Pplat– Ppl
PL = 30 – (-4) = 34
Controlled Spontaneous
VT = 360 mL VT = 550 mL
CRS = 18 mL/cmH2O
∆P = 20 cmH2O
PEEP = 10 PEEP = 10
∆P = ??
CRS = 18 mL/cmH2O
550/18 = 30.5= ??
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
Ris
k of V
ILI
N = 3562 Pts.
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
Ris
k of V
ILI
Reducing
P
∆P = constant,
but RR increases !
PEEP
PLAT
Role of Strain Rate in the Pathogenesis of Ventilator-Induced Lung Edema*.Protti, Alessandro; Maraffi, Tommaso; Milesi, Marta; Votta, Emiliano; Santini, Alessandro; Pugni, Paola; Andreis, Davide; Nicosia, Francesco; Zannin, Emanuela; Gatti, Stefano; Vaira, Valentina; MD, PhD; Ferrero, Stefano; Gattinoni, Luciano; MD, FRCP
Critical Care Medicine. 44(9):e838-e845, September 2016.DOI: 10.1097/CCM.0000000000001718
Flow Rate
4
Role of Strain Rate in the Pathogenesis of Ventilator-Induced Lung Edema*.Protti, Alessandro; Maraffi, Tommaso; Milesi, Marta; Votta, Emiliano; Santini, Alessandro; Pugni, Paola; Andreis, Davide; Nicosia, Francesco; Zannin, Emanuela; Gatti, Stefano; Vaira, Valentina; MD, PhD; Ferrero, Stefano; Gattinoni, Luciano; MD, FRCP
Critical Care Medicine. 44(9):e838-e845, September 2016.DOI: 10.1097/CCM.0000000000001718
PsycologicalBarrier?
Gattinoni et al. 2016
Gattinoni et al. 2016
A B C
Lun
g V
olu
me
Airway Pressure
PPLATPEEP PPeak
EELV
VT
A = Static / PEEP componentB = Dynamic / Elastic componentC = Resistive component
Gattinoni et al. 2016
RR x V x PEEP
“Potential Energy”(???????)
RR x V x P
Gattinoni et al. 2016
Energy Dissipated in Large Airways
(???????)
Plateau Pressure
Calculated Terms
Relative Risk
0.75 1.00 1.25 1.50 1.75
Driving Pressure (x5) & RR (x1)…………………….
1.33 [1.24-1.43]
1.36 [1.27-1.45]
∆P ≥ 13
∆P < 13
∆P ≥ 13
∆P < 13
keeping constant Alveolar Ventilation...
Respiratory Rate
Tid
al V
olu
me
∞
Dead Space
VA = RR x ( VT – VD )
RESPIRATORY RATE
30 60 90 120 150 300
TID
AL
V
OL
UM
E
( m
L /
iB
W )
0
2
4
6
8
RR vs VT/ibw
RR vs REAL DATA
HFOV
keeping constant Alveolar Ventilation...
Respiratory Rate ∞
VT / VD
60 ?
Ris
k of V
ILI
P or PL ?
( PAW - Pesoph )
Transpulmonary Driving Pressure (∆PL)
Airw
ay
Drivin
g P
ressure
(∆
P)
Transpulmonary Driving Pressure (∆PL)
Airw
ay
Drivin
g P
ressure
(∆
P)
Airway Driving Pressure (∆P) cmH2O
Tra
nspulm
onary
Drivin
g P
ressure
(∆
PL)
Time
Pre
ssure
20
22
24
26
28
30
32
34
36
Col 2
Col 1
Peak Airway pressure
Peak Alveolar pressure
Plateau Pressure
after long pause
0 0
0 1 2 3 4 5 6 7 8 9 10
Time (seconds)
Pre
ssure
(cm
H2O
)
Airway pressures
Alveolar pressures (estimated by MLR)
SR
SR : Stress relaxation
P1
Tpause ≤ 0.5 sec.
Panel B Panel C
Panel A
Ki (m
l/m
in/m
l) Borges & Hedenstierna 2017
One week later…
LIM 09 - HCFMUSP
Grafico driving pressure
LIM 09 - HCFMUSP
Grafico driving pressure
Cyclic Strain)
Cyc
lic
Str
ess
Eduardo Costa, Marcelo Amato, Arthur Slutsky (unpublished data)
UnadjustedAdjusted for Confounders
P<0.001
P<0.001
P=0.01
P=0.28
Ris
ko
fD
eat
h(l
og
od
ds)
Ris
ko
fD
eat
h(l
og
od
ds)
Driving Pressure Driving Pressure
Plateau Pressure Plateau Pressure
JAMA. 2016;315(8):788-800
Epidemiology, Patterns of Care, and
Mortality for Patients With Acute
Respiratory Distress Syndrome in
Intensive Care Units in 50 Countries
N = 12.906
P = 0.004
Results: …”among 545 patients……
…Driving Pressure was the only ventilatory
parameter during ECMO that showed an
independent association with in-hospital
mortality”… (ajusted HR = 1.06 [1.03-1.10])
Association between ventilatory settings and development of acute
respiratory distress syndrome in mechanically ventilated patients due to
brain injury
Eva Tejerina, MD, PhD; Paolo Pelosi, MD, PhD; Alfonso Muriel, MSc, PhD; Oscar Peñuelas, MD; Yuda Sutherasan, MD;
Fernando Frutos-Vivar, MD; Nicolás Nin, MD; Andrew R. Davies, MD; Fernando Rios, MD; Damian A. Violi, MD; Konstantinos
Raymondos, MD; Javier Hurtado, MD; Marco González, MD; Bin Du, MD; Pravin Amin, MD; Salvatore M. Maggiore, MD;
PhD; Arnaud W. Thille, MD; Marco Antonio Soares, MD; Manuel Jibaja, MD; Asisclo J. Villagomez, MD; Michael A. Kuiper,
MD; Younsuck Koh, MD; Rui P.Moreno, MD, PhD; Amine Ali Zeggwagh, MD; Dimitrios Matamis, MD Antonio Anzueto, MD;
Niall D. Ferguson, MD, MSc; Andrés Esteban, MD, PhD. for VENTILA group
ARDS No-ARDS
Driving Pressure
DELTA DE PRESSÃOOLA VS ARDSNET
TEMPO
BASAL POS VILI 0h 6h 12h 24h 36h FINAL
cm
H2O
0
10
20
30
40
50ARDSNET
OLA
Driving Pressure
VILI
High
Cyclic Stress
Low Stress
Extreme CyclicStress
PLATOOLA VS ARDSNET
TEMPO
BASAL POS VILI 0h 6h 12h 24h 36h FINAL
cm
H2
O
0
10
20
30
40
50 ARDSNET
OLA
Plateau Pressure
VILI
Extreme CyclicStress
Same Maximal
Stress !
Anterior.
Posterior
RN
A co
llag
en
typ
e I
control VILI VILI +40hs prot.
P < 0.001
VILI +40hs OLALow Cyclic
StressHigh Cyclic
Stress