LES MODES EN PRESSION ET LA VENTILATION SPONTANNEE:

Transcription

1 LES MODES EN PRESSION ET LA VENTILATION SPONTANNEE: Jean-Christophe M Richard, MD PhD Emergency and Pre-Hospital divisions SAMU 74 INSERM UMR 955 Eq13 REVA: European Network on Mechanical Ventilation ALMS: Medical Advisor

2 CONFLICTS OF INTEREST Part Time: Air Liquide Medical Systems SAU Emergency and ICU department Annecy France Research from our laboratory in Geneva was supported: VYGON MAQUET (NAVA) COVIDIEN (PAV+) DRAGER (SmartCare) GE (FRC)

3 OBJECTIFS Connaître la définition de la ventilation spontanée (VS) Comprendre le rationnel pour la VS au cours du SDRA Risques et bénéfices de la VS Fonctionnement des modes en pression Impact des modes en pression sur la VS Comment favoriser la VS au cours du SDRA

4 DEFINITION Spontaneous Ventilation : meaning what? Spontaneous Ventilation refers to the spontaneous and sustained contraction of respiratory muscles Paw Flow Pes

5 DEFINITION Spontaneous Ventilation : meaning what? Spontaneous Ventilation refers to the spontaneous and sustained contraction of respiratory muscles Paw Flow Pes

6 WHY IS SPONTANEOUS BREATHING DESIRABLE? Preserve Respiratory Muscle Function (avoid VIDD) Improve VA/Q and Regional Ventilation Reduce sedation and days with MV Levine S et al. N Engl J Med 2008 Jaber et al. Am J Respir Crit Care Med 2013 Putensen et al. Am J Respir Crit Care Med 1999 Girard et al. Lancet 2008

7 APRV with 1/1 or 1/2 IE ratio Anesthesiology 2014

8 Am J Respir Crit Care Med 2013: 188;

9 IS SPONTANEOUS VENTILATION AND RELATED VT AFFECTED BY THE MODE OF VENTILATION? APRV (Non inspiratory syncronized) BIPAP (partially i synchronized) PAC (full i synchronized) Intensive Care Med. 2013;39:

10 Different working priciple in pressure regulated modes Spontaneous Breathing (CPAP) PC + CPAP = APRV PAC ventilation

11 VT (ml) VT (ml) VT (ml) BENCH OBSERVATIONS VT change in the presence of spontaneous breaths according to i-synchronization 6ml/kg/IBW No spontaneous breaths Pressure regulated mode time (sec) 10 ml/kg/ibw 6 ml/kg/ibw Spontaneous activity Fully i-synchronized modes PAC 10 ml/kg/ibw 6 ml/kg/ibw 4 ml/kg/ibw Spontaneous Non i-synchronized activity modes Non i-synchronized modes APRV

12 BENCH OBSERVATIONS VT change in the presence of spontaneous breaths according to i-synchronization 10 ml/kg/ibw 6 ml/kg/ibw 4 ml/kg/ibw APRV BIPAP PAC

13 BENCH OBSERVATIONS APRV BIPAP PAC

14 Clinical observations : 4 ARDS Patients successively ventilated with APRV and BIPAP and PAC vt CV APRV - BIPAP (PS= 0) - PAC Intensive Care Med. 2013;39:

15 Intensive Care Med. 2013;39: Clinical observations : 8 ARDS patients under APRV over 5 days 6 ml/pbw

16 TITLE: Effect of different pressure-targeted modes of ventilation on transpulmonary pressure and breathing effort Author(s): N. Rittayamai 1,2,5, F.Beloncle 1,2,6, R.Waheed 1,2, L.Chen 1,2, M.Rauseo 1,2, G. Chen 1,2, E.Goligher 2, JCM. Richard 3, L.Brochard 1,2,4

17 BIRDS Ventilation settings V2 16/01/13 H0 H3: ACV Vt = 6 ml/kg PBW and PEP : pour Pplat = 28 cmh2o ACV BIPAP-APRV Mode : VAC Vt = 6 ml/kg PBW Insp flow. : 50 à 70 L/mn PEP : pour Pplat = 28 cmh2o Mode : APRV Thigh : 1s Tlow : for FR = FR during VAC Plow : idem PEEP en ACV Phigh : for Vt=6ml/kg PBW and Pplat max = 28 cmh2o Principal Investigator: JCM Richard L Brochard A Mercat

18 BIRDS nombre de patients 308 enrolled V2 16/01/ expected enrolled 0 Inclusions / center La Pitié (14/02/14) Foch (13/06/13) Bicetre (22/07/13) Bdx Pel. (24/06/14) Bdx HL (25/02/14) Nantes (25/11/14) Beauvais (06/11/14) Mulhouse (24/06/13) Mondor (10/07/13) St Pierre (24/09/13) Orleans (26/09/13) Lyon (04/02/14) HEGP (19/11/13) Poitiers (24/01/13) Strasbourg (5/02/13) Montpellier (27/06/13) Brest (17/06/13) Tours (06/06/13) Rouen (29/01/13) Angers (12/02/13) Patients 48

19 BIRDS Management of spontaneous ventilation V2 16/01/13 BIPAP-APRV Spontaneous Ventilation = 10 à 50 % of VM tot Check goals (Spontaneous Vent and Vt ) every 8 or 12 h SV < 10% and RASS < -2 SV < 10% and Sedation OK SV > 50% and Sedation OK SV > 50% and RASS > -2 Sedation ph: alcalosys? If yes Tlow RR ph: acidose If yes Tlow RR Si T > 38 C +/- cooling Sedation

20 LES MESSAGES CLEFS La VS pourrait permettre d améliorer les échanges gazeux, protéger le diaphragme, de minimiser l impact hémodynamique de la PEEP, de réduire le temps de sédation La VS peut augmenter la consommation en O2 (VO2), augmenter le travail respiratoire, majorer le risques de grand Vt et PTP Les modes en pression favorisent la VS Le fonctionnement des différents modes en pression affecte la VS et le patern respiratoire (VT, variabilité)