La ventilazione polmonare: protettiva? Razionale e dati ad interim del mrct.

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1 11/12/2015 La ventilazione polmonare: protettiva? Razionale e dati ad interim del mrct. Dr. Nicola Langiano Clinica di Anestesia e Rianimazione Azienda Ospedaliero-Universitaria S.M.M. - Udine Dir. Prof. G. Della Rocca

2 Agenda background and actual MV protective ventilation protective ventilation during OLV Alveolar Recruitment Strategy (ARS) mrct low TV in OLV (ad interim data) conclusions

3 Agenda background and actual MV protective ventilation protective ventilation during OLV Alveolar Recruitment Strategy (ARS) mrct low TV in OLV (ad interim data) conclusions

4 ATELECTASIS

5 Before induction 15-20% collapse lung during GA Atelectasis appear up to 90% of all induced pts. Post intubation Not dependent by sex, age or type of anesthetic drugs administered

6 Pulmonary complications L.O.S. Pro-inflamatory cytokines Bacterial translocation Identify Prevent Treat OLV Up to 50% of lungs can be collapsed even hours after surgery CCH Am J Respir Crit Care Med May 1;169(9):

7 Atelectasis formation Absortion atelectasis Compression atelectasis Loss surfactant function GA MRA Supine FRC Cranial diaphr. movement Loss of negative pressure Not very important for the normal lung Expir. closure Insp. reopening Lateral decubitus Superimposed weight even if General Anesthesia seems to affect it Alveolar GAS FRC absobtion imparement

8 Apnea Tolerance Time

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10 P < No effect on the amount of atelectasis! Prolonged effect! 20 min Short effect!

11 Protective Ventilation ARDS Normal lung Low vt (6 ml/kg) rather than 12 ml/kg mortality ventilatory free-days in pts with ARDS lung injury pulmonary infections mortality LOS in pts without ARDS

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13 Low Tv LRMs PEEP Postop. Lung Injury Pulmonary infections Atelectasis Mortality LOS

14 N=20 CRT Multicentrico TLV: Tv (C/P) 10-12/5-7 ml/kg

15 TLV: Tv (C/P) 12/6 ml/kg N=40 CRT

16 N=447 Retrospective Cohort Study, N=447 Multicentric Study No ALI 332 No ALI 80

17 Prospective Observational Single Center Study N=3434 TLV: High Tv 33-3% Tradit Tv 45-6% Low Tv 21.1%

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24 is there an individual association? PPCs

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29 Agenda background and actual MV protective ventilation protective ventilation during OLV Alveolar Recruitment Strategy (ARS) mrct low TV in OLV (ad interim data) conclusions

30 OLV TLV Collapsed lung Shunt Ischemia/Reperf. Hypoxemia (24%) Surgical trauma Pro-inflamatory cytokines

31 N= 52 OLV: Tv (C/P) 9/5 ml/kg

32 OLV: Tv (C/P) 9/5 ml/kg

33 Retrospective Observational Single Center Study N=170 - VAM - Re-IO - NIV

34 Retrospective Observational Single Center Study N=170

35 Retrospective Cohort Study Single Center Study N=1091 OLV: Tv (C/P) <8/9-12 ml/kg

36 N=100 CRT Conv TLV Vt 10 ml/kg FiO ZEEP Protect TLV Vt 10 ml/kg FiO ZEEP OLV Vt 10 ml/kg FiO ZEEP OLV Vt 6 ml/kg FiO PEEP 5 cm H 2 O OLV: Tv (C/P) 10/6 ml/kg

37 P < 0.05

38 P < 0.05

39 Agenda background and actual MV protective ventilation protective ventilation during OLV Alveolar Recruitment Strategy (ARS) mrct low TV in OLV (ad interim data) conclusions

40 Prospective randomized controlled trial. N=40 Can a lung recruitment manoeuvre applied before OLV decrease dead space? Wich is its effect on arterial oxygenation?

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42 P<0.001 P>0.05 Phys airway P<0.001 P=0.04 Alv EtCO 2

43 P<0.001

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45 Agenda background and actual MV protective ventilation protective ventilation during OLV Alveolar Recruitment Strategy (ARS) mrct low TV in OLV (ad interim data) conclusions

46 47 centers 62 answers

47 Il problema è legato al TV/Peep/LRM e PaO2/FiO2 periop? Oppure, incide sulle complicanze (polmonari) postop?

48 Agenda Background of protective ventilation EBM for protective ventilation EBM for protective ventilation during OLV Alveolar Recruitment Strategy (ARS) mrct ad interim data Conclusions

49 Studio ALI dati ad interim Ventilazione protettiva vs ventilazione convenzionale durante One Lung Ventilation in pazienti da sottoporre a chirurgia toracica elettiva.

50 Obiettivi Primari: Valutazione della differenza nella frequenza di complicanze respiratorie postoperatorie (ALI o ARDS) nei due gruppi di studio con ventilazione convenzionale e protettiva. Obiettivi Secondari: Valutazione della relazione tra insorgenza di complicanze respiratorie postoperatorie (ALI o ARDS) e tecnica chirurgica utilizzata (VATS vs Open). Descrizione degli outcome postoperatori, durata della degenza (ospedaliera e in Terapia Intensiva), complicanze, decessi. Valutazione della relazione esistente tra insorgenza delle complicanze e presenza/assenza di comorbilità preoperatorie e tecnica chirurgica utilizzata.

51 Protocollo di studio TLV TLV Vt 8 ml/kg Ppeak 25 cmh 2 O PEEP 5 cmh 2 O (after lung re-expansion) Vt 8 ml/kg Ppeak 25 cmh 2 O PEEP 5 cmh 2 O (after lung re-expansion) Conv N=1000 OLV Vt 6 ml/kg Ppeak 35 cmh 2 O ZEEP Protect N=1000 OLV Vt 4 ml/kg Ppeak 35 cmh 2 O PEEP 5 cmh 2 O LRM

52 Pazienti arruolati nov 2015 CONVENZIONALE = 191 PROTETTIVA = 208 TOTALE = 399 pz

53 TREND: P/F, PaCO 2, ph T1 T2 T3 T4 T7 T8 1h 24h 48h T1 T2 T3 T4 T7 T8 1h 24h 48h P/F P/F Prot P/F Conv PaCO 2 PaCO2 Prot PaCO2 Conv 7,44 7,42 7,4 7,38 7,36 ph ph Prot ph Conv 7,34 7,32 T1 T2 T3 T4 T7 T8 1h 24h 48h

54 Agenda background and actual MV protective ventilation protective ventilation during OLV Alveolar Recruitment Strategy (ARS) mrct low TV in OLV (ad interim data) conclusions

55 Avoid! Atelectasis Vt ZEEP FRC Inflammation Bacterial translocation PPCs

56 OLV Low Tv EBV supports it but how low is enough? LRM EBV supports it but mcrt are needed! PEEP The individual rule in the protective ventilation strategy during OLV must be clarified. mcrt are needed!

57 One PEEP may not fit all. PEEP that is too high may compromise circulation, too little PEEP may not prevent collapse. An individualized PEEP, may be a better approach! are PPC decreased by an individualized PEEP?.

58 PROTHOR: ESA-EACTA per low TV /PPEP in OLV investigator meeting in Frankfurt January 9, To determine whether individualized ventilatory management combining: low TV, ARM, individually titrated PEEP postop individualized ventilatory support will decrease: postop complications, unplanned ICU readmissions, ICU and hospital LOS mortality compared to a standardized Lung Protective Ventilation (LPV) for all patients at risk.

59 Take home messages Protective MV must be part of a periop lung protective strategy, but the outcome is Low Vt is better than high Vt LRMs must be seriated high PEEP at the moment: no