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
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)
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
DEFINITION Spontaneous Ventilation : meaning what? Spontaneous Ventilation refers to the spontaneous and sustained contraction of respiratory muscles Paw Flow Pes
DEFINITION Spontaneous Ventilation : meaning what? Spontaneous Ventilation refers to the spontaneous and sustained contraction of respiratory muscles Paw Flow Pes
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
APRV with 1/1 or 1/2 IE ratio Anesthesiology 2014
Am J Respir Crit Care Med 2013: 188;1420-1427
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;39:2003-10
Different working priciple in pressure regulated modes Spontaneous Breathing (CPAP) PC + CPAP = APRV PAC ventilation
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
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
BENCH OBSERVATIONS APRV BIPAP PAC
Clinical observations : 4 ARDS Patients successively ventilated with APRV and BIPAP and PAC 700 60 600 500 400 300 200 100 50 40 30 20 10 vt CV 0 0 0.5 1 1.5 2 2.5 3 3.5 0 APRV - BIPAP (PS= 0) - PAC Intensive Care Med. 2013;39:2003-10
Intensive Care Med. 2013;39:2003-10 Clinical observations : 8 ARDS patients under APRV over 5 days 6 ml/pbw
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
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
BIRDS nombre de patients 308 enrolled 03 20 2015 V2 16/01/13 350 300 250 200 150 expected 100 50 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) 0 0 1 2 2 4 5 5 7 10 12 13 14 14 16 16 19 32 34 0 5 10 15 20 25 30 35 40 45 50 Patients 48
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
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)