Ventilation des patients à poumons sains : Réduire le ...jrur.org/site/wp-content/uploads/2014/02/Samir-Jaber.pdf · Peñuelas 1, Victor Abraira 2, Konstantinos Raymondos 4, Fernando

Samir JABER

Department of Critical Care Medicine and Anesthesiology (DAR B)Saint Eloi University Hospital and Montpellier School of Medicine

80 Avenue Augustin Fliche; 34295 Montpellier. FRANCEMail : [email protected] ; Tel : +33 4 67 33 72 71

Ventilation des patients à poumons sains :

Réduire le volume courant ?

Marseille – 17 Avril 2014

Déclaration de liens

Déclare les liens suivants (consultants) :

• Drager France • Maquet France• Fisher Paykel• Hamilton

Background

De-recruitment Overdistension

Low TV No PEEP

High TV High PI P

Atelectotrauma Barotrauma Volutrauma

Release of I nflammatory

cytokines

Release of I nflammatory

cytokines

Biotrauma (IL-1β, IL-6, IL-8, TNF-α)

Ventilator-associated lung injury (VALI)

Adapted from Tusman G et al. Curr Opin Anesthesiol 2012

mor

bidy

risk

VT

High VT > 12 ml/kgVery low VT (without PEEP)

AtelectasisAtelectotrauma

AtelectasisAtelectotrauma

VILI

(Ventilator Induced

Lung Injury)

VILI

(Ventilator Induced

Lung Injury)

Opt

imal

VT

Tidal volume (VT) : how much is too much ?

Evolution of Mortality over Time in Patients Receivi ng Mechanical Ventilation

Andrés Esteban1, Fernando Frutos-Vivar1, Alfonso Muriel2, Niall D. Ferguson3, Oscar Peñuelas1, Victor Abraira2, Konstantinos Raymondos4, Fernando Rios5, Nicolas Nin1, Carlos

Apezteguía5, Damian A. Violi6, Arnaud W. Thille7, Laurent Brochard8, Marco González9, Asisclo J. Villagomez10, Javier Hurtado11, Andrew R. Davies12, Bin Du13, Salvatore M.

Maggiore14, Paolo Pelosi15, Luis Soto16, Vinko Tomicic17, Gabriel D’Empaire18, DimitriosMatamis19, Fekri Abroug20, Rui P. Moreno21, Marco Antonio Soares22, Yaseen Arabi23, Freddy Sandi24, Manuel Jibaja25, Pravin Amin26, Younsuck Koh27, Michael A. Kuiper28, Hans-Henrik

Bülow29, Amine Ali Zeggwagh30, and Antonio Anzueto31

AJRCCM Vol. 188, No. 2 (2013), pp. 220-230

Is there a rationale to use lung protective

ventilation in patients with normal lungs ?

Is there a rationale to use lung protective

ventilation in patients with normal lungs ?

Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilationOgnjen Gajic, MD; Saqib I. Dara, MD; Jose L. Mendez, MD; Adebola O. Adesanya, MD; Emir Festic, MD; Sean M. Caples, MD; Rimki Rana, MD; Jennifer L. St. Sauver, PhD; James F. Lymp, PhD; Bekele Afessa, MD; Rolf D. Hubmayr, MD

Gajic O. et al Crit Care Med 2004

A retrospective cohort study of 332 patients with « normal lungs » at the onset of mechanical ventilation and who received mechanical ventilation for ≥24h 4 ICUs of a tertiary referral center

Incidence ALI: N=80 patients (24%)

Ventilation with lower tidal volumes as compared to conventional tidal volumes for patients without acute lung injury - A preventive randomized controlled trialRogier M Determann, Annick Royakkers, Esther K Wolthuis, Alexander P Vlaar, Goda Choi, Frederique Paulus, Jorrit-Jan Hofstra, Mart J de Graaff, Johanna C Korevaar and Marcus J Schultz

10 ml/kg PBW

6 ml/kg PBW

13.5% vs. 2.6%

Determann RM et al. Crit care 2010

Lower Tidal Volumes in Patients without

Preexisting Lung Injury

Serpa Neto A et al , JAMA. 2012 Oct 24;308(16):1651-9


Preexisting Lung Injury

Serpa Neto A et al , JAMA. 2012 Oct 24;308(16):1651-9


Preexisting Lung Injury in ICU: A Metaanalysis

Serpa Neto A et al , Curr Opin Crit Care 2014, 20:25–32


Preexisting Lung Injury in ICU: A Metaanalysis

Serpa Neto A et al , Curr Opin Crit Care 2014, 20:25–32

Courtesy of Prof. Serpa Neto A,

PROTECTIVE VENTILATION IN ICU

LUNG PROTECTIVE VENTILATION WITH LOWER TIDAL VOLUMES TO PREVENT ACUTE RESPIRATORY DISTRESS SYNDROME IN INTENSIVE CARE UNIT PATIENTS UNDER

MECHANICAL VENTILATION: A systematic review and meta-analysis using individual data of 2,184 patien ts

Ary Serpa Neto MD MSc, Sabrine NT Hemmes MD, Carmen SV Barbas MD PhD, Michelle Biehl MD, Rogier M Determann MD PhD, Jonathan Elmer MD PhD,

Gilberto Friedman MD PhD, Ognjen Gajic MD PhD, Rita Linko MD PhD, Roselaine Pinheiro de Oliveira MD PhD, Esther K Wolthuis MD PhD, Marcelo Gama de Abreu

MD PhD, Paolo Pelosi MD, Marcus J Schultz MD PhD

VENTILAÇÃO PROTETORA NA UTIPROTECTIVE VENTILATION IN ICU

Courtesy of Prof. Serpa Neto A, Prof Pelosi







… and in the operating room,

What is the evidence ?

In ICU patients In the OR

Patients with injured lungs

Patients with healthy lungs

Improved morbidityand morality: YES

Improved morbidity: YES

Recommendations:Limit VT < 10 ml/kg PBW

5 < PEEP < 15 cmH2O

Impact on Postoperative outcome: ?

Patients with healthy lungs

Recommendations:VT ?

PEEP ?

Lung Protective Mechanical Ventilation

Low TV and PEEP

Large TV and zero PEEP Low TV and zero PEEP

1963

� Approximately 30% of patients still ventilated with TV ≥10 ml.kg-1 IBW� Female sex and BMI were independently associated with the use of high TV

2161 patients between January and June 2006 in 97 anaesthesia units from 49 hospitals

10

A multicentre observational study of intraoperative ventilatory management during general anaesthesia: tidal volumes and relation to body weight

Jaber S, Coisel et al. Anaesthesia 2012; 67, 999–1008

1-4 cmH2O0 cmH2O

5-8 cmH2O >9 cmH2O

PEEP is “rarely” used during general anesthesia

� A combination of PEEP ≥5 cmH2O and TV <10 ml/kg IBW was used in less than 5% of patients

A multicentre observational study of intraoperative ventilatory management during general anaesthesia: tidal volumes and relation to body weight

Jaber S, Coisel et al. Anaesthesia 2012; 67, 999–1008

� 80% of patients received zero PEEP, and PEEP ≥5 cmH2O in less than 15%

High Tidal Volumes in Mechanically Ventilated PatientsIncrease Organ Dysfunction after Cardiac SurgeryLellouche F et al. Anesthesiology 2012 116:1072-82

Low VT(<10 ml/kg PBW)

High VT(>12 ml/kg PBW)

Retrospective analysis of prospectively collected data in 3434 patients between 2004 and 2006

Postoperative outcomes

0

2

4

6

8

10

12

14

MOF Need for MV > 48 h Renal failure Mortality

VT < 10 ml/kg PBW

VT > 12 ml/kg PBW

Nu

mb

er

(%)

of

pa

tie

nts

P=0.006

P=0.01

P=0.004

P=0.59

Retrospective analysis of prospectively collected data in 3434 patients between 2004 and 2006

High Tidal Volumes in Mechanically Ventilated PatientsIncrease Organ Dysfunction after Cardiac SurgeryLellouche F et al. Anesthesiology 2012 116:1072-82

RCT studiesin the OR

?

High TV group(n = 51)

Low TV group(n = 50)

TV, ml/kg PBW 12.0 ± 2.3 6.7 ± 1.1

PEEP, cmH2O 5 5

Recruitment maneuver 0 0

Minute ventilation, l 6.2 ± 1.9 7.8 ± 2.1

Duration of surgery, h 6.1 ± 2.1 6.1 ± 2.7

Protective Mechanical Ventilation during General An esthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function

Severgnini P. et al. Anesthesiology 2013

56 Patients undergoing elective open abdominal surg ery

STANDARD VENTILATION TV 9 ml/kg PBW

zero PEEP

PROTECTIVE VENTILATIONTV 7 ml/kg PBW

10 cmH2O PEEP + RM VS.

ClinicalTrials.govA service of the U.S. National Institutes of Health

● Protective Ventilation During General Anesthesia for Open Abdominal Surgery (PROVHILO study)

Control group Intervention group

VT 8 ml/kg IBW

PEEP ≤ 2 cmH2O

No Recruitment maneuver

VT 8 ml/kg IBW

PEEP 12 cmH2O

Recruitment maneuvers :

1. After intubation

2. After any disconnection from the ventilator

3. Before detubation

● Intraoperative Protective Ventilation in Abdominal Surgery (IMPROVE Study)

Control group Intervention group

VT 10-12 ml/kg IBW

No PEEP

No Recruitment maneuver

VT 6-8 ml/kg IBW

PEEP 6-8 cmH2O

Recruitment maneuvers :

1. After intubation

2. Repeated every 30-40 min

N = 900

N = 400

Study design

INtraoperative PROtective VEntilation in abdominal surgery

The IMPROVE Trial

Lung-Protective Ventilation

N=200

Non-Protective VentilationN=200

VS.

VT 10 to 12 ml/kg PBWNo PEEPNo Recruitment Maneuver

VT 6 to 8 ml/kg PBWPEEP 6 to 8 cmH2ORecruitment Maneuver

Recruitment maneuver=CPAP 30 cmH2O during 30 sec

After intubation and every 30min thereafter

In both groups:- Plateau pressure <30 cmH2O- Volume-controlled ventilation mode- FiO2 adjusted to maintain SpO2 ≥95% - RR adjusted to maintain ETCO2 between 35 and 40 mmHg

The IMPROVE TrialIntraoperative Protective Ventilation in Abdominal Surgery

A pragmatic multicenter, double-blinded, randomized controlled trial

Inclusion criteria- All adult patients older than 40 years (<90 yrs)- Scheduled for Abdominal laparoscopic or non-laparoscopic surgery- With an expected duration of at least 2 hours- And a preoperative risk index for pulmonary complications ≥2

(Arozullah AM et al. Ann Intern Med 2001)


Non inclusion criteria- Mechanical ventilation of >1H within the last 2 weeks before surgery- Body mass index ≥35 kg/m2

- Acute respiratory failure (pneumonia, ALI or ARDS)- Emergency- Sepsis or septic shock- Progressive neuromuscular illness- Intra-thoracic surgery- Pregnancy- Refusal to participate

Inclusion criteria- All adult patients older than 40 years (<90 yrs)- Scheduled for Abdominal laparoscopic or non-laparoscopic surgery- With an expected duration of at least 2 hours- And a preoperative risk index for pulmonary complications ≥2

(Arozullah AM et al. Ann Intern Med 2001)


Primary outcome measure

A composite of major pulmonary and extra-pulmonary complications to postoperative Day 7

� Pulmonary: Postoperative pneumoniaNeed for NIV or tracheal intubation for ARF

� Extra-pulmonary: Sepsis, Severe sepsis and septic shockPostoperative Death


Secondary outcomes

� Pulmonary complications:- Incidence of all-causes pulmonary complications, scored using a 4 grades scale- Postoperative atelectasis- Postoperative pneumonia- Need for NIV or tracheal intubation for ARF- Postoperative ALI or ARDS

All causes of pulmonary and extra-pulmonary complications to Day 30 after surgery

� Extra-pulmonary complications: - Sepsis, severe sepsis and septic shock- Surgical complications (re-intervention, anastomotic leak)- Need for unexpected ICU admission- Intraoperative ventilation-related adverse events- Duration of ICU and Hospital stay- All cause mortality to Day 30


Results

Characteristics at baseline Non-protective VentilationGroup (n=200)

Lung-protective VentilationGroup (n=200)

Age – yr 63.4±10.0 61.6±11.0

Male sex – no. (%) 121 (60.5) 116 (58.0)

Height – cm 169.5±9.0 169.1±8.8

Actual body weight – kg 71.3±13.9 71.4±14.2

Predicted body weight – kg 63.8±9.9 63.3±9.7

Body mass index – kg/m2 24.7±3.8 24.8±3.8

Preoperative risk index – no. (%)

Class 2 100 (50.0) 101 (50.5)

Class 3 94 (47) 93 (46.5)

Class 4 or more 6 (3.0) 6 (3.0)

Laparoscopic surgery – no. (%) 44 (22.0) 41 (20.5)

Current smoker – no. (%) 50 (25) 51 (25.5)

Alcohol intake – no. (%) 10 (5) 21 (10.5)

COPD – no. (%) 20 (20.0) 20 (20.0)

Weight loss > 10% – no. (%) 44 (22.0) 40 (20)


Intraoperative procedures Non-protective VentilationGroup (n=200)

Lung-protective VentilationGroup (n=200) P Value

Tidal volume – ml 719.0±127.8 406.7±75.6 <0.001

Tidal volume – ml per kg PBW 11.1±1.1 6.4±0.8 <0.001

PEEP – cmH2O – median (IQR)

At baseline 0 (0–0) 6 (6–8) <0.001

End of surgery 0 (0–0) 6 (6–8) <0.001

Recruitment maneuver – median (IQR) 0 (0–0) 9 (6–12) <0.001

Peak pressure – cmH2O

At baseline 20.1±4.9 18.9±3.6 0.04

End of surgery 20.6±4.4 20.0±4.0 0.15

Plateau pressure – cmH2O

At baseline 16.1±4.3 15.2±3.0 0.02

End of surgery 16.6±3.5 15.2±2.6 <0.001

FiO2 – % 47.2±7.6 46.4±7.3 0.27




Epidural use – no. (%) 77 (38.5) 83 (41.5) 0.61

Volume of fluids – median (IQR)

Crystalloids 2.0 (1.3–3.5) 1.5 (2.0–3.0) 0.47

Colloids 0.5 (0.25–1.0) 0.5 (0.5–1.0) 0.97

Duration of surgery – no. (%) 0.95

2-4 hours 76 (39.6) 75 (38.5)

4-6 hours 75 (39.1) 76 (38.9)

>6 hours 41 (21.3) 44 (22.6)

Blood loss – ml – median (IQR) 300 (125–550) 300 (100–500) 0.29

Blood transfusion – no. (%) 37 (18.5) 34 (17.0) 0.79

Need for vasopressor – no. (%) 42 (21.1) 35 (17.7) 0.45

More than 60% of surgical procedures were ≥4 hours




Epidural use – no. (%) 77 (38.5) 83 (41.5) 0.61

Volume of fluids – median (IQR)

Crystalloids 2.0 (1.3–3.5) 1.5 (2.0–3.0) 0.47

Colloids 0.5 (0.25–1.0) 0.5 (0.5–1.0) 0.97

Duration of surgery – no. (%) 0.95

2-4 hours 76 (39.6) 75 (38.5)

4-6 hours 75 (39.1) 76 (38.9)

>6 hours 41 (21.3) 44 (22.6)

Blood loss – ml – median (IQR) 300 (125–550) 300 (100–500) 0.29

Blood transfusion – no. (%) 37 (18.5) 34 (17.0) 0.79

Need for vasopressor – no. (%) 42 (21.1) 35 (17.7) 0.45

No difference in the intraoperative volume of fluids and blood losses


0

5

10

15

20

25

30N

umbe

r of

eve

nts

(%)

Non-protectiveventilation

group (N= 200)

Lung-protectiveventilation

group (N= 200)

27.5 %

10.5 %


Primary Outcome Measure

P<0.001


1 3 7 15 30

0.00

0.

10

0.20

0.

30

0.50

0.

40

Pro

babi

lity

of e

vent

Days since surgery

Non-protective ventilat ion

Lung-protective ventilat ion

Log-rank test, P<0.001

Major Pulmonary and Extra-pulmonary Complications to Postoperative day 30


1 3 7 15 30

0.00

0.

10

0.20

0.

30

0.50

0.

40

Pro

babi

lity

of e

vent

Days since surgery

Non-protective ventilat ion

Lung-protective ventilat ion

Log-rank test, P<0.001

Probability for requiring intubation or non-invasive ventilationfor ARF to Postoperative Day 30

PROVHILO - a worldwide multicenter randomized controlled trial on protective ventilation during

general anesthesia for open abdominal surgery

Hemmes SN et al. LANCET 2014 in press

Vt = 8 ml/kg IBW

PEEP or RM

alone are not

enough !

PEEP 10 cmH2O

RM+PEEPRM+ZEEP

0

10

20

30

40

50

60

70

80

Anesthesia 5 min 20 min 40 min

Com

plia

nce

(ml/c

mH

2O)

0

100

200

300

400

500

600

Awake Anesthesia 5 min 20 min 40 min

PaO

2/F

iO2

(mm

Hg)

Prevention of Atelectasis in Morbidly Obese Patients during General Anesthesia and Paralysis

A Computerized Tomography Study

Henrik Reinius, M.D., Lennart Jonsson, M.D., Sven Gustafsson, M.D., Ph.D., Magnus Sundbom, M.D., Ph.D., Olov Duvernoy, M.D., Ph.D.Paolo Pelosi, M.D., Ph.D., Goran Hedenstierna, M.D., Ph.D., Filip Freden, M.D., Ph.D. Anesthesiology 2009

✱✱

✱

†✱ ✱

✱

✱

✱

✱

RM = CPAP 55 cmH2O for 10 sec AND/OR PEEP=+10 cmH2O

Awake After induction 5 min 20 min

PEEP

RM+PEEP

RM+ZEEP

Quelle est la procédure qui marche le plus et/ou le mieux ?

QUESTION n°2

« petit volume courant »

(6 ml/kg)

PEPouManœuvre de

recrutementou


Réponse (probable) n°2


(6 ml/kg)PEP

Manœuvre de recrutement

ou ou

+ +x x


Réponse (probable) n°2


(6 ml/kg)PEP Manœuvre de

recrutement+ +oux oux

= Association des 3 procédures ++

Serpa Neto ASerpa Neto A

INTRAOPERATIVE VENTILATOR SETTINGS AND POSTOPERATIV E ACUTE RESPIRATORY DISTRESS SYNDROME: An individual data

meta-analysis of 3,659 patients

Ary Serpa Neto MD MSc, Sabrine NT Hemmes MD, Carmen SV Barbas MD PhD, Martin Beiderlinden MD, Michelle Biehl MD, Ana Fernandez-Bustamante MD PhD, Emmanuel Futier MD PhD, Ognjen Gajic MD PhD, Samir Jaber MD PhD , Alf Kozian MD PhD, Marc Licker MD, Wen-Qian Lin MD, Stavros G Memtsoudis MD PhD, Dinis Reis Miranda MD, Pierre Moine MD, Domenico Paparella MD, Marco Ranieri MD PhD, Federica Scavonetto MD, Thomas Schilling

MD PhD DEAA, Gabriele Selmo MD, Paolo Severgnini MD PhD, Juraj Sprung MD PhD, Sugantha Sundar MD, Daniel Talmor MD PhD, Tanja Treschan MD, Gerardo Tusman MD PhD, Mari Carmen Unzueta MD PhD, Toby N Weingarten MD, Esther K Wolthuis MD PhD, Hermann

Wrigge MD PhD, Marcelo Gama de Abreu MD PhD, Paolo Pelosi MD, Marcus J Schultz MD PhD

Intraoperative Mechanical Ventilation

Courtesy of Prof. Serpa Neto A, et al.








Courteesy of Prof. Serpa Neto A, et al.

Conclusion

healthy lungs injured lungs

Objectives in volume-controlled mode (VC)

Initial settings

6 < VT < 7 ml/kg PBW

6 < PEEP < 7 cmH2O

Recruitment maneuvers (repeated every 30-45 min and each derecruitment

procedures (suctioning…) )

12 < RR < 25 breath/min

30% < FiO2 < 50%

Target values and monitoring

Plateau pressure < 25 cmH2O

35 < EtCO2 < 45 mmHg(ABG if presence of EtCO2 > 45 mmHg

SpO2 ≥ 95%

Initial settings

4 < VT ≤ 6 ml/kg PBW

8 < PEEP < 15 cmH2O

Recruitment maneuvers (in selected patients)

15 < RR < 35 breath/min

50% < FiO2 < 80%

Target values and monitoring

Plateau pressure < 30 cmH2O

40 < PaCO2 < 60 mmHg and 7.30 < Ph < 7.40(repeated ABG to optimize)

SpO2 ≥ 92%

A. B.

Many thanks

Montpellier(France)

Documents

Ventilation des patients à poumons sains : Réduire le ...jrur.org/site/wp-content/uploads/2014/02/Samir-Jaber.pdf · Peñuelas 1, Victor Abraira 2, Konstantinos Raymondos 4, Fernando