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Non-ECMO rescue therapies for ARDS

Explore advanced rescue therapies for ARDS management focusing on principles of therapy, avoiding complications, and optimizing lung protective strategies to improve outcomes and survival.

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Non-ECMO rescue therapies for ARDS

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  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

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